Schwartz and Bourassa et al used an algorithm to evaluate a patient with chest pain and normal coronary angiography. The authors are from the University of Toronto and University of Montreal.


Patient selection: chest pain with normal coronary angiogram



(1) Are the angiograms truly normal on review?

(2) Is there a noncoronary cardiac explanation for chest pain?

(3) Is there a noncardiac explanation for chest pain?


Coronary lesions that may be missed on initial review:

(1) large vessel spasm

(2) missed (small lesion, obscured view, other)

(3) congenital anomaly

(4) myocardial bridge (segment of left anterior descending artery that courses from the subepicardial surface into the myocardium and then back out)


Noncoronary cardiac lesions that can cause chest pain:

(1) aortic valve disease

(2) hypertrophic cardiomyopathy

(3) dilated cardiomyopathy

(4) hypertension (hypertensive cardiomyopathy)


Noncardiac explanations for chest pain:

(1) esophageal disease

(2) musculoskeletal disorder



• Another noncardiac explanation explanation for chest pain would be referred pain.


If the responses to all 3 questions is "No", then the patient may have "syndrome X" (cardiac ischemia with normal coronary artery angiography).


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