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Spasmophilia in the Cardiological Outpatient Department: A Retrospective Study of 228 Sub-saharan Africans over 5 Years

Authors:
  • Military medical academy/ HMO
Spasmophilia in the Cardiological Outpatient Department: A Retrospective Study
of 228 Sub-saharan Africans over 5 Years
Ba Djibril Marie*, Sow Mamadou Saidou, Diack Aminata, Diallo Cheikh Omar, Barkire Ismaila, Dieng Fatou Kine and Fall Moussa Daouda
Department of Cardiology and Internal Medicine, Military Hospital of Ouakam, Dakar, Senegal
*Corresponding author: Ba Djibril Marie, Department of cardiology and Internal Medicine. Military Hospital of Ouakam, Dakar, Senegal, Tel: 00221-773338434; E-mail:
gaby.11ba@yahoo.fr
Received date: Oct 27, 2016; Accepted date: July 21, 2017; Published date: July 28, 2017
Copyright: © 2017 Marie BD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Spasmophilia also called latent tetany is a disorder with a very heterogeneous clinical
manifestation which affects particulary young women. Chest pain, constriction of the throat and palpitations are
symptoms common to spasmophilia and ischaemic heart disease (IHD). The objective of this work was to assess
the incidence and to study the epidemiological, clinical features of spasmophilia in patients with symptoms of
ischaemic heart disease.
Methods: This was a retrospective study conducted at the cardiology Department of Military Hospital of Ouakam,
in Dakar, Senegal, from January 1st 2009 to December 31st 2014). We included all patients who were admitted with
manifestation of ischaemic heart disease and who subsequently had a negative evaluation for IHD. We observed the
occurrence of neuromuscular hyperexcitability, assessed with Electromyographic (EMG) test. We collected and
analyzed epidemiological, clinical, and outcomes data of Powered by Editorial Manager® and ProduXion Manager®
from Aries Systems Corporation 228 patients.
Results: The incidence of spasmophilia in patient’s reffered with symptoms of ischaemic heart disease was 20%
and 100% in patients with normal ECG findings. The mean age of patients was 28.70 ± 18 years with a sex ratio
(F/M) of 13.41. The most common presenting symptoms were dominated by chest pain (90%). a history of Insomnia
was found in 31 patients (13.60%), and affective disorders were found in 55 patients (24.12%). Biochemical
investigation revealed decreased serum magnesium in 5.26%. Medical examinations were normal. All patients were
treated with magnesium lactate. 80.60% of patients reported after 3 months complete regression of complaints.
17.20% of patients continued to experience complaints with a significant improvement in terms of reduced frequency
and intensity. No complications were noted in our patients after 12 months follow-up.
Conclusion: Despite its fearly common occurence, spasmophilia is rarely recognized. We recommend to add
EMG test to the algorithm of examinations of patients with chest pain and normal ECG.
Keywords: Spasmophilia; Chest pain; Electromyographical test;
Magnesium deciency
Background
Spasmophilia also called latent tetany and recently referred to as the
central neuronal hyper excitability syndrome (NHS) is a disorder with
a very heterogeneous clinical manifestation. It includes neuromuscular
hyperactivity, decreased attention, fatigue, constant anxiety, chest pain
etc. [1].
Spasmophilia aects particularly young women [2]. A
noncharacteristic clinical picture and the lack of a pathognomonic
symptom, cause that despite of the fearly common occurrence,
spasmophilia is rarely recognized.
Chest pain is the most common reason for referral of patients for
acute medical admission. Prompt and accurate diagnosis is very
important but our ability to dierentiate between the patient with a
life-threatening cardiac condition and someone with non-cardiac
discomfort still depends primarily on clinical acumen plus
interpretation of the ECG and the chest radiograph.
Chest pain, constriction of the throat and palpitations are symptoms
common to spasmophilia and ischemic heart disease (IHD) [3].
Henceforth, it becomes dicult to distinguish between them as there is
considerable overlapping of symptomatology.
e objective of this work was to assess the incidence and to study
the epidemiological, clinical features of spasmophilia in patients with
symptoms of ischemic heart disease presenting in the cardiology
department.
Methods
is was a retrospective study conducted at the cardiology and
Internal medicine Department of Military Hospital of Ouakam, in
Dakar, Senegal, over a period of 5 years (January 1st 2009 to December
31st 2014).
We include all patients who were admitted with manifestation of
ischemic heart disease such: chest pain, constriction of throat,
palpitation and dyspnea and who subsequently had a negative
evaluation for IHD. A metabolic cause of tetany was ruled out.
Journal of Thrombosis and
Circulation Open Access Marie et al., J Thrombo Cir 2017, 3:3
DOI: 10.4172/2572-9462.1000121
Research Article OMICS International
J rombo Cir, an open access journal
ISSN:2572-9462
Volume 3 • Issue 3 • 1000121
We observed the occurrence of neuromuscular hyper excitability,
assessed with Electromyographic (EMG) recordings of the rst
interosseous muscle on the right arm. e test was considered positive
when, aer the strap of the sphygmanometer had been loosened,
spontaneous motor unit discharges in sequences of triplets and
multiplets waves were observed. e test was considered negative when
a silent electromographical trace was recorded.
We collected and analyzed epidemiological, clinical, paraclinical and
outcomes data of patients.
We studied data on age, gender, psychological factors. We also noted
the time delay between the onset of symptoms and nal diagnosis. All
patients had a complete physical examination and a laboratory
assessment with emphasis on the level of serum magnesium and
calcium.
On the ECG we looked for suggestive electrocardiographic changes,
rhythm and conduction abnormalities. Doppler echocardiography was
performed for all patients to evaluate the le ventricle (LV) wall
motion, LV ejection fraction and pericardial involvement. We also
looked for rib fractures, pleural eusion and signs of venous stasis on
the chest X-ray. Salt magnesium, calcium and anxiolytics therapy were
evaluated.
e studied parameters were entered into an electronic
questionnaire using Epi info version 6.0 of the World Health
Organization. Data analysis was performed using SPSS (Statistical
Package for Social Sciences). Quantitative data were expressed as mean
± standard deviation. Qualitative data were expressed as percentage.
ese hormones have been shown to increase the occurrence of cell
death via apoptosis in germ cells located at specic stages of the
seminiferous epithelial cycle.
Results
We included 228 patients. 211 patients (92.54%) were females and
17 patients (7.46%) were males giving a sex ratio (F/M) of 13/41.
e mean age of patients was 28.7 ± 18 years with a range of 6 and
59 years. In women, the mean age was 28 years and among men it
was 34 years. Most of patients (58.77%) were under 30 years.
EMG test was positive for all patients.
e Diagnosis latency i.e., the interval from the onset of symptoms
to the denite diagnosis of latent tetany was 6.4 months.
e most common presenting symptoms (Table 1) were dominated
by chest pain (90%), palpitations (81%) and shortness of breath
(42.9%) Association of chest pain and palpitations was found in 92
patients (40.35%).
Symptoms Number %
Chest pain 205 90
palpitations 184 81
Shortness of breath 98 42.9
Muscle crumps 60 26.3
headaches 28 12.3
Loss of consciousness 5 2.2
Table 1: Symptoms found in our patients.
A history of Insomnia was found in 31 patients (13.60%) and panic
attacks in 5 patients (2.19%).
Mood and aective disorders were found in 55 patients (24.12%).
Biochemical investigation with emphasis on the level of serum
magnesium and calcium revealed a decreased serum magnesium
and calcium respectively in 5.26% and 1.31%.
Successive ECG was normal. Echocardiography and chest X-ray
were normal for all patients. Exercise tests and coronarography
were performed in 5 patients with typical chest pain and cardiac
risk factors with a negative outcome examination. ECG holter
recording, performed in all patients with palpitations, was normal.
All patients were treated with magnesium lactate and calcium by
the oral route. Anxiolytics were given to patients with sleep and
mood disorders.
Psychological evaluation and psychotherapy were designated for
patients with panic attacks.
80.6% of patients reported aer 3 months complete regression of
complaints. is favorable outcome was higher (79.2%) in the
group of patient diagnosed as spasmophilic before 6 months from
the onset of symptoms versus 40% in those with late diagnosis.
17.2% of patients continued to experience complaints with a
signicant improvement in terms of reduced frequency and
intensity.
5 patients (2.2%) were sent for treatment in a psychiatric
outpatient unit.
No complications were noted in our patients aer 12 months
follow-up.
Discussion
In our study, the incidence of spasmophilia in patients referred with
symptoms of ischemic heart disease was 20% and 100% in patients
with normal ECG ndings. Data on the incidence of spasmophilia are
rare in Africa. In the literature there is a lack of precise data concerned
which most probably results from its underestimation.
e mean age of patients was 28.7 ± 18 years with a range of 6 and
59 years. In women, the mean age was 28 years and among men it was
34 years. In Japan, 508 patients were reported to range in age from
5-85 years. Spasmophilia was particularly prevalent among women in
their late teens and among men in their twenties [4]. e young age of
patients with spasmophilia was also reported by Torunska [5].
Our study conrms female predominance as has been emphasized
in previous works [3-6].
Chest pain was found to be the main symptoms. Although chest
pain is a common clinical syndrome, there is a paucity of African
studies describing the causes, prevalence and disposition of patients
with chest pain. However Geyser, in a study conducted in the
emergency department (ED) of a regional hospital in Pretoria found
that most of patients with chest pain of non-cardiac origin were black
Africans (75%). In this study, regarding age, patients with
cardiovascular disease tend to be older than the average, with a mean
age of 55.07 years while patients with psychological disorders were
younger than the average, with a mean age of 29.86 years and such
patients were most oen females (85.71%) [7]. Sullivan found that the
diagnosis of normal coronary artery in patients referred with chest
pain, was ve times more common in women than men [8]. In Czech,
Sovova found that 50% of patients referred for chest pain with negative
coronarography ndings had spasmophilia [3].
Citation: Marie BD, Saidou SM, Aminata D, Omar DC, Ismaila B, et al. (2017) Spasmophilia in the Cardiological Outpatient Department: A
Retrospective Study of 228 Sub-saharan Africans over 5 Years. J Thrombo Cir 3: 121. doi:10.4172/2572-9462.1000121
Page 2 of 4
J rombo Cir, an open access journal
ISSN:2572-9462
Volume 3 • Issue 3 • 1000121
In our study, all patients with chest pain had normal ECG ndings.
Despite the fact that studies of several decades ago reported a 3% to
10% incidence of acute myocardial infarction in patients presenting to
the ED with chest pain and a normal ECG [9,10], it seems that such
patients have low rates of mortality and cardiac complications [11].
Clinically, spasmophilia in Africans does not appear much dierent
from that of European countries [3,5,12,13].
In our study, shortness of breath was found in 42.9% of patients.
Shortness of breath in patients with spasmophilia is related to
hyperventilation syndrome (HVS) which is characterized by functional
hyperventilation attacks with no underlying organic abnormality. HVS
is particularly prevalent among young women [4]. Traditionally, it has
been considered that hyperventilation attacks spontaneously disappear
regardless of their severity. In our study, we encountered ve patients
with HVS who experienced apnea and loss of consciousness.
Spontaneous respiration re-started without treatment within one
minute.
Apnea and loss of consciousness in patients with HVS have been
reported by Munemoto [14], Inagaki [15] and MacDonald [16] and
were related to post hyperventilation apnea (PHA). In most cases,
patients spontaneously recover from PHA within one or two minutes
without any clinical problems, but cases with prolonged PHA was
reported as an example of near fatal instance of PHA [16]. PHA has
been reported to be due to a decreased PaCO2. Hypocapnia caused by
hyperventilation presents the condition of alkalosis in which, reduced
hydrogen acting on the chemoreceptors lead to the suppression of
breathing [17].
Indeed, most works on the occurrence spasmophilia have a disease
pattern dominated by the absence of organic abnormalities. is is
reected in our work where medical examinations including chest X-
ray, ECG, echography, excise testing; holter ECG and coronarography
were normal.
e pathophysiological basis of spasmophilia is frequently
magnesium deciency and the therapeutic administration of
magnesium salts has usually a favorable eect. However the parameters
of magnesium balance are not always consistent with the results of
electromyography.
Vizinova found in his study that in 72% of patients there was
agreement of the positivity of the EMG and magnesium deciency (i.e.
reduced values of ery-Mg and U-Mg), positivity of EMG combined
with normal parameters of the Mg balance was recorded in 18% [18].
Mazzotta, in his study, found that the majority of migraine patients
(93.30%) with neuromuscular hyper excitability had red blood cell
levels of magnesium below the norm [19].
In our study, there was no relationship between serum magnesium
level and positivity of the EMG.
is dierence is probably due to the superiority of the
determination of Mg++ levels in erythrocytes not only as a sensitive
indicator of magnesium nutritional status, but also as an indirect
marker of muscular excitability, compared to the magnesium
concentration in other body compartments such as mononuclear cells
and particularly serum [1,20,21].
Spasmophilia, demonstrated by positive results of EMG tests was
associated in previous research with high levels of mood disturbances
[22,23]. In our study, mood and aective disorders were present in
21.12% of patients. Panic attack was found in 2.19%. e symptoms of
panic disorder according to the diagnostic criteria DSM-III [24] are,
except a few, virtually identical with those of spasmophilia. In a group
of 20 patients treated for panic disorder, Taborska found a concomitant
incidence of latent tetany with known etiology and decreased levels of
intracellular magnesium in 18 (90%) [25].
Despite its common occurrence, it happens that spasmophilia is
diagnosed too late and therefore insuciently cured as noted in our
study where diagnosis latency was 6.4 months.
e impact of therapy with magnesium salts on improvement of
spasmophilic patients, as noted in our work, has been emphasized by
most of authors.
Conclusion
Spasmophilia is a disorder with a very heterogeneous clinical
manifestation. A noncharacteristic clinical picture and the lack of a
pathognomonic symptom, cause that despite of the fearly common
occurrence, spasmophilia is rarely recognized.
Electromyography examination is regarded as the most sensitive
method in the diagnostic spectra at disposal and with regard to the
high rate of positive EMG tests in patients with a history of chest pain
and a negative evaluation for IHD, we recommend to add this simple
test to the algorithm of examinations of these patients particularly in
young women.
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Citation: Marie BD, Saidou SM, Aminata D, Omar DC, Ismaila B, et al. (2017) Spasmophilia in the Cardiological Outpatient Department: A
Retrospective Study of 228 Sub-saharan Africans over 5 Years. J Thrombo Cir 3: 121. doi:10.4172/2572-9462.1000121
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Volume 3 • Issue 3 • 1000121
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Citation: Marie BD, Saidou SM, Aminata D, Omar DC, Ismaila B, et al. (2017) Spasmophilia in the Cardiological Outpatient Department: A
Retrospective Study of 228 Sub-saharan Africans over 5 Years. J Thrombo Cir 3: 121. doi:10.4172/2572-9462.1000121
Page 4 of 4
J rombo Cir, an open access journal
ISSN:2572-9462
Volume 3 • Issue 3 • 1000121
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To determine the prevalence and characteristics of acute myocardial infarction (AMI) patients who present to emergency departments with normal or nonspecific electrocardiograms (ECGs), data were analyzed from 7,115 consecutive patients in the Multicenter Chest Pain Study. AMI patients with normal or nonspecific initial ECGs (n = 107) were less likely to have a past history of coronary artery disease or to be diaphoretic on presentation (p less than 0.01) than AMI patients with initial ECGs highly suggestive of AMI (n = 811). The overall probability of AMI among patients with chest pain and initially normal or nonspecific ECGs was 3%, but ranged from less than 1 to 17% depending on the patient's age and sex and whether the patient had pressure-type pain or pain radiating to the shoulder, neck or arms. Among initially admitted patients, the time elapsed between onset of pain and presentation was similar in both groups. However, the time between onset of pain and definitive diagnosis of AMI by enzymes or clinical course was longer in patients with initially normal or nonspecific electrocardiograms (8.3 vs 7.5 hours, p less than 0.05), their peak creatine kinase levels were lower (mean 643 vs 1,032 mg/dl, p less than 0.001) and their mortality was slightly lower (6 vs 12%, p = 0.10). These findings suggest that AMI patients with initially normal or nonspecific ECGs may have a less severe short-term clinical outcome.
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For many years, the symptoms grouped under the label "spasmophilia" have been differently evaluated in France by psychiatrists, who ascribe them to hysteria or anxiety, and by endocrinologists and general practitioners for whom they are all due to neuromuscular hyperexcitability, the cause of which must be sought in the biochemistry of calcium. Recent studies on anxiety should reduce the gap between these discordant views. The concept of anxiety itself has changed owing to the discriminant effects of psychotropic drugs and to a classification based on precise diagnostic criteria without theoretical presuppositions. Since anxiety can be biochemically induced, the hypotheses put forward by "spasmophilologists", such as disorders of calcium metabolism or hyperventilation, can now be tested in the laboratory.