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Previous Volume 330:1411-1417 May 19, 1994 Number 20 Next

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ABSTRACT

Background Ten to 30 percent of patients undergoing cardiac catheterization because of chest pain are found to have normal coronary angiograms. Because these patients may have a visceral pain syndrome unrelated to myocardial ischemia, we investigated whether drugs that are useful in chronic pain syndromes might also be beneficial in such patients.

Methods Sixty consecutive patients underwent cardiac, esophageal, psychiatric, and pain-sensitivity testing and then participated in a randomized, double-blind, placebo-controlled three-week trial of clonidine at a dose of 0.1 mg twice daily (20 patients), imipramine at a dose of 50 mg nightly with a morning placebo (20 patients), or placebo twice daily (20 patients); this treatment phase was compared with an identical period of twice-daily placebo for all patients (placebo phase).

Results Thirteen (22 percent) of the 60 patients had ischemic-appearing electrocardiographic responses to exercise, 22 of the 54 tested (41 percent) had abnormal esophageal motility, 38 of 60 (63 percent) had one or more psychiatric disorders, and 52 of 60 (87 percent) had their characteristic chest pain provoked by right ventricular electrical stimulation or intracoronary infusion of adenosine. During the treatment phase, the imipramine group had a mean (±SD) reduction of 52 ±25 percent in episodes of chest pain, the clonidine group had a reduction of 39 ±51 percent, and the placebo group a reduction of 1 ±86 percent, all as compared with the placebo phase of the trial. Only the improvement with imipramine was statistically significant (P = 0.03). Repeat assessment of sensitivity to cardiac pain while the patients were receiving treatment showed significant improvement only in the imipramine group (P = 0.01). The response to imipramine did not depend on the results of cardiac, esophageal, or psychiatric testing at base line, or on the change in the psychiatric profile during the course of the study, which generally improved in all three study groups.

Conclusions Imipramine improved the symptoms of patients with chest pain and normal coronary angiograms, possibly through a visceral analgesic effect.

Source Information

From the Cardiology Branch (R.O.C., A.A.Q., R.M., A.M.S.) and the Biostatistics Research Branch (M.A.W.), National Heart, Lung, and Blood Institute; the Neurobiology and Anesthesiology Branch, National Institute of Dental Research (R.H.G, W.B.S.); and the Section on Anxiety and Affective Disorders, National Institute of Mental Health (M.F.G., B.C.B., T.W.U.) -- all at the National Institutes of Health, Bethesda, Md.; and the Division of Gastroenterology, Georgetown University Hospital, Washington, D.C. (K.M., S.B.B.). Presented in part at the 57th Scientific Meeting, American College of Gastroenterology, Miami Beach, Fla., October 26, 1992, and at the 42nd Scientific Session, American College of Cardiology, Anaheim, Calif., March 18, 1993.

Address reprint requests to Dr. Cannon at Bldg. 10, Rm. 7B-15, National Institutes of Health, Bethesda, MD 20892.

Full Text of this Article

Related Letters:

Imipramine in Patients with Chest Pain Despite Normal Coronary Angiograms
Hare D. L., Venes D. J., Cannon R. O.
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N Engl J Med 1994; 331:882-883, Sep 29, 1994. Correspondence

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