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Eriksson-Liebon M, Westas M, Johansson P, Mourad G. Long-term effects and predictors of change of internet-delivered cognitive behavioural therapy on cardiac anxiety in patients with non-cardiac chest pain: a randomized controlled trial. BMC Psychiatry 2024; 24:216. [PMID: 38504157 PMCID: PMC10953164 DOI: 10.1186/s12888-024-05661-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Approximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain. AIMS To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress. METHODS A longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program (n = 54) in patients with NCCP, compared to psychoeducation (n = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety. RESULTS A total of 85% (n = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life (p = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up. CONCLUSIONS Cardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.
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Affiliation(s)
- Magda Eriksson-Liebon
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
- Department of Emergency Medicine in Norrköping, and, Department of Biomedical and Clinical Sciences, Linköping University, Norrköping, Sweden.
| | - Mats Westas
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Internal Medicine in Norrköping, and, Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Ghassan Mourad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Bahall M, Kissoon S, Islam S, Panchoo S, Bhola-Singh N, Maharaj M, Khan F, Marajh S, Maharaj A, Legall G. Patients With Atypical Chest Pain: Epidemiology and Reported Consequences. Cureus 2024; 16:e53076. [PMID: 38414689 PMCID: PMC10896710 DOI: 10.7759/cureus.53076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Approximately a quarter of the global population experiences chest pain during their lifetime worldwide. Although largely non-life-threatening, many patients experience mental, physical, social, and financial consequences. AIM This study aimed to describe and determine the epidemiology and consequences of patients presenting with atypical chest pain (ACP). Method: Data were obtained from 102 participants, from a desired sample size of 166. The target population was patients who presented with ACP at the Accident and Emergency Department of a Teaching Hospital in Trinidad during a two-year period, from January 2021 to December 2022. The data collection instrument used was a 34-item online questionnaire. Data were analyzed using both descriptive and inferential statistical methods. RESULTS Participants were predominantly women (63.7%; n = 65), between 31 and 50 years of age (74.5%; n = 76), in full-time employment (n = 58; 56.9%), who lived with at least one person (90.2%; n = 92) at the time of the episode. Overall, 61.8% (n = 63) reported having a stressful life. Hypertension (30.4%; n = 31) and diabetes (18.6%; n = 19) were the leading comorbidities. Participants experienced mild to severe anxiety (53.9%; n = 55), moderate to severe depression (25.5%; n = 26), moderate stress (65.7%; n = 67), and loneliness (25.5%; n = 26). A stressful life was associated with, and was a predictor of, both anxiety and loneliness. No sociodemographic variables were associated with depression or stress. The most common self-reported consequences were "fear as a result of the pain" (68.6%; n = 69), "interruptions to daily life" (60.8%; n = 61), "reduction in time spent on hobbies" (62.7%; n = 63), and costly diagnostic/investigative tests (62.7%; n = 64). The majority of patients (52.9%; n = 53) reported reduced quality of life. The most common treatment prescribed was paracetamol (53.9%; n = 55) and exercise (23.5%; n = 24). CONCLUSION The study participants were mainly women, 31-50 years old, who had experienced anxiety, stress, or depression. They mainly experienced fear and self-reported a reduced quality of life.
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Affiliation(s)
- Mandreker Bahall
- Caribbean Center for Health Systems Research and Development, University of the West Indies, St. Augustine Campus, Marabella, TTO
| | - Sherece Kissoon
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Samiha Islam
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Sarah Panchoo
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Naomi Bhola-Singh
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Mitra Maharaj
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Fiyad Khan
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Sathyadeep Marajh
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - Aishwarya Maharaj
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
| | - George Legall
- Faculty of Medical Sciences, University of the West Indies, Eric Williams Medical Sciences Complex, San Juan, TTO
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Chen J, Oshima T, Kondo T, Tomita T, Fukui H, Shinzaki S, Miwa H. Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study. J Neurogastroenterol Motil 2023; 29:446-454. [PMID: 37814435 PMCID: PMC10577468 DOI: 10.5056/jnm22184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 10/11/2023] Open
Abstract
Background/Aims Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population. Methods Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed. Results Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis. Conclusions The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.
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Affiliation(s)
- Junji Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Tadayuki Oshima
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Takashi Kondo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Toshihiko Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hirokazu Fukui
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Shinichiro Shinzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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Eriksson‐Liebon M, Lundgren J, Rytterström P, Johansson P, Mourad G. Experience of internet‐delivered cognitive behavioural therapy among patients with non‐cardiac chest pain. J Clin Nurs 2022. [DOI: 10.1111/jocn.16565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/28/2022] [Accepted: 10/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Magda Eriksson‐Liebon
- Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
- Department of Emergency Medicine in Norrköping, and Department of Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Johan Lundgren
- Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
| | - Patrik Rytterström
- Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
- Department of Internal Medicine in Norrköping, and Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
| | - Ghassan Mourad
- Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
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Mourad G, Eriksson-Liebon M, Karlström P, Johansson P. The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain: Randomized Controlled Trial. J Med Internet Res 2022; 24:e31674. [PMID: 35089153 PMCID: PMC8838599 DOI: 10.2196/31674] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/09/2021] [Accepted: 12/08/2021] [Indexed: 01/19/2023] Open
Abstract
Background Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. Objective This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. Methods Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes. Results No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (≥11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group. Conclusions iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions. Trial Registration ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112
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Affiliation(s)
- Ghassan Mourad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Magda Eriksson-Liebon
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Emergency Medicine in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Patric Karlström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Internal Medicine, Ryhov County Hospital, Region Jönköping County, Jönköping, Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Internal Medicine in Norrköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Barranco-Trabi J, Mank V, Roberts J, Newman DP. Atypical Costochondritis: Complete Resolution of Symptoms After Rib Manipulation and Soft Tissue Mobilization. Cureus 2021; 13:e14369. [PMID: 33976991 PMCID: PMC8106472 DOI: 10.7759/cureus.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Costochondritis is a self-limiting, poorly described, and benign condition that usually manifests as non-cardiac chest pain. The symptoms usually tend to resolve in a couple of weeks. Serious causes of chest pain should be ruled out prior to diagnosing costochondritis, as it is often a diagnosis of exclusion. Costochondritis that does not self-resolve is referred to as atypical costochondritis and is associated with high medical expenses and psychological burden on the patient. In this report, we discuss the case of a 37-year-old healthy male patient who presented with a two-year history of intermittent pain along the right anterolateral rib cage without any history of trauma. After extensive diagnostic work-up by Cardiology and Gastroenterology, Physical Medicine and Rehabilitation (PM&R) got involved. The initial diagnosis of chest pain evolved into atypical costochondritis given the time course, physical examination findings of focal tenderness, along with normal laboratory values, electrocardiogram, and imaging studies. A multimodal approach was adopted for the treatment of this patient, including manipulative therapy to determine if regional interdependence was present, followed by instrument-assisted soft tissue mobilization (IASTM) and stretching to address the potential myofascial pain generators. After three appointments, there was complete resolution of morning pain and there was no pain upon examination. This case highlights how osteopathic manipulation techniques (OMT) can be useful in the treatment of rib dysfunction, especially in atypical costochondritis. Further studies are required to expand our knowledge of costochondritis and physical therapy (PT) techniques, which would allow for early identification and effective treatment of the condition.
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Affiliation(s)
| | - Victoria Mank
- Department of Internal Medicine, Tripler Army Medical Center, Honolulu, USA
| | - Jefferson Roberts
- Department of Rheumatology, Tripler Army Medical Center, Honolulu, USA
| | - David P Newman
- Pain Management-Physiotherapy, Tripler Army Medical Center, Honolulu, USA
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Madanchi M, Cioffi GM, Kobza R, Cuculi F, Bossard M. The Importance of Defining the Coronary Anatomy in Suspected Myopericarditis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929009. [PMID: 33780431 PMCID: PMC8019837 DOI: 10.12659/ajcr.929009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/21/2021] [Accepted: 01/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND It is challenging to distinguish between acute coronary syndrome (ACS) and myocardial injury due to alternative causes (eg myopericarditis, coronary vasospasm, and pulmonary embolism), as they often share similar presentations, especially in young patients. Coronary computerized tomography angiography (CCTA) is increasingly recognized as a fast and safe diagnostic tool for rapid assessment of the coronary anatomy among patients with a low to intermediate cardiovascular risk profile and/or atypical chest pain. However, its utility among patients with possible ACS is still debated. CASE REPORT A 36-year-old man presented to our institution with intermittent pleuritic chest pain and malaise over the preceding 7 days. He was a smoker and his father had ACS at the age of 45 years. The patient had unspecific electrocardiographic changes and elevated troponin values. The initial transthoracic echocardiogram indicated a normal ejection fraction without any wall motion abnormalities. Presuming a very low chance of coronary artery disease due to his age and atypical symptoms, we ordered a CCTA, which identified a thrombotic lesion in the right coronary artery (RCA). An invasive coronary angiography, including an optical coherence tomography, confirmed the presence of a thrombotic lesion located at the level of the proximal RCA, which was consequently treated with 1 drug-eluting stent. CONCLUSIONS Physicians should always eliminate underlying coronary artery disease among patients with unclear myocardial injury, irrespective of a patient's presentation, age, and estimated cardiovascular risk. In this context, CCTA represents a safe and simple tool to rapidly assess the coronary anatomy, especially in younger patients.
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Newman DP, Jansen BJ, Scozzafava A, Smith R, Mclean BC. Rib Mediated Non-Cardiac Chest Pain: A Case Report. Cureus 2020; 12:e10831. [PMID: 33173637 PMCID: PMC7645301 DOI: 10.7759/cureus.10831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Non-cardiac chest pain (NCCP) is a very common and functionally limiting pain complaint that vexes patients and medical providers leading to time-consuming and expensive diagnostic work-ups as well as significant disability and lost productivity. Despite extensive debate and research, there is no definitive treatment recommendation or high-level evidence to support a conservative care treatment approach, or interventional management procedures for the diagnosis and alleviation of NCCP. In patients presenting with chest pain, after ruling out life-threatening causes, the diagnosis of NCCP is made. This process is a diagnosis of exclusion rather than a specific etiology with a defined treatment plan. This results in specialty consultation, advanced diagnostic testing, and delayed definitive care. A better triage process may include the incorporation of diagnostic maneuvers at the primary care and emergency room to justify referral to a musculoskeletal specialist in lieu of or during advanced diagnostic work-up. After the diagnosis of NCCP is made in our young and active patient population, we have seen significant success in the application of manipulation and a functional restoration program similar to the presented case. To our knowledge, this treatment approach has not been previously described. While this management strategy may be taught in physiotherapy courses, we provide the case to illustrate a multimodal treatment approach that seems to be unknown or underutilized based on the number of referrals and prevalence of this condition.
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Affiliation(s)
- David P Newman
- Interdisciplinary Pain Management Clinic, Tripler Army Medical Center, Honolulu, USA
| | | | | | - Ryan Smith
- Cardiology, Adventist Health System, Kailua, USA
| | - Brian C Mclean
- Pain Management, Landstuhl Regional Medical Center, Landstuhl, DEU
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Teragawa H, Oshita C, Orita Y. Is Noncardiac Chest Pain Truly Noncardiac? CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820918903. [PMID: 32595282 PMCID: PMC7297489 DOI: 10.1177/1179546820918903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/15/2020] [Indexed: 11/16/2022]
Abstract
Many causes of noncardiac chest pain (NCCP) have been studied and gastroesophageal reflux disease is considered to be the major cause. However, studies have reported that treatment with a proton pump inhibitor does not effectively provide relief for NCCP-related symptoms, and these symptoms frequently recur. These findings suggest that patients with cardiac disease may be excluded completely from the NCCP group. Several examinations can be conducted to verify the presence of cardiac disease. Such examinations include the assessment of biochemical markers, rest and exercise electrocardiogram, echocardiography, cardiac computed tomography, stress myocardial perfusion imaging, cardiac magnetic resonance imaging, and coronary angiography (CAG). However, the presence of functional coronary artery diseases (CADs), such as vasospastic angina and/or microvascular angina, cannot be detected using these modalities. These functional CADs can be diagnosed by CAG with spasm-provocation testing and/or physiological coronary measurement. Thus, when a patient who is suspected of having NCCP takes a proton pump inhibitor and does not respond well, further examination-including assessment for possible functional CADs-may be needed.
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Affiliation(s)
- Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Chikage Oshita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Yuichi Orita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
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Pardue CM, White KS, Gervino EV. The Role of Disease Conviction: Exploring Its Effects on Chest Pain and Anxiety-Related Models of Non-cardiac Chest Pain. J Clin Psychol Med Settings 2020; 26:131-141. [PMID: 29948646 DOI: 10.1007/s10880-018-9572-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The aim of this study was to investigate the role of disease conviction in the chest pain and life interference of patients with non-cardiac chest pain (NCCP), after controlling for anxiety sensitivity and body vigilance. While all three psychological constructs are theoretically implicated and empirically associated with the experience of NCCP, no research has examined the influence of disease conviction in the context of other relevant constructs. The sample included 229 participants with NCCP who were recruited after a medical evaluation failed to elicit an organic explanation for their chest pain. Hierarchical regression analyses revealed that while anxiety sensitivity significantly predicted chest pain severity and interference, only body vigilance contributed significant additional variance to chest pain severity, and only disease conviction contributed significant additional variance to chest pain interference. While anxiety sensitivity, body vigilance, and disease conviction all appear to affect those with NCCP, it seems that their impact is manifest in different domains (i.e., pain perception vs. psychosocial impairment).
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Affiliation(s)
- Caleb M Pardue
- Department of Psychological Sciences, University of Missouri-St Louis, One University Blvd., St. Louis, MO, 63121, USA.
| | - Kamila S White
- Department of Psychological Sciences, University of Missouri-St Louis, One University Blvd., St. Louis, MO, 63121, USA
| | - Ernest V Gervino
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Mourad G, Alwin J, Jaarsma T, Strömberg A, Johansson P. The associations between psychological distress and health-related quality of life in patients with non-cardiac chest pain. Health Qual Life Outcomes 2020; 18:68. [PMID: 32160887 PMCID: PMC7066800 DOI: 10.1186/s12955-020-01297-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/13/2020] [Indexed: 12/21/2022] Open
Abstract
Background Recurrent chest pain episodes with no clear explanation may affect patients’ psychological wellbeing and health-related quality of life (HRQoL) negatively. Despite the fact that a significant amount of patients with non-cardiac chest pain (NCCP) might have a history of Cardiac Disease (CD), there is today a lack of knowledge on how CD influences the association between psychological wellbeing and HRQoL in patients with NCCP. Therefore, the aim of this study is to describe HRQoL in patients with NCCP, with or without history of CD, and to explore the association between HRQoL and cardiac anxiety, depressive symptoms, fear of body sensations and somatization. Methods Five hundred fifty-two patients discharged with NCCP from four hospitals in Southeast Sweden completed the EQ-5D, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9, Body Sensations Questionnaire, and Patient Health Questionnaire-15. Results Fifty precent reported at least moderate problems regarding pain/discomfort and 25% reported at least moderate problems in the HRQoL dimensions mobility, usual activities, and anxiety/depression. Patients with NCCP and history of CD reported significantly lower HRQoL (p ≤ 0.05) compared to patients with NCCP without CD. In the total study population, cardiac anxiety, depressive symptoms, and somatization had weak significant negative associations (beta = 0.187–0.284, p < 0.001) with HRQoL. In patients with history of CD, the association between depressive symptoms and HRQoL was moderate (beta = − 0.339, p < 0.001), compared to weak association in patients without CD (beta = − 0.193, p < 0.001). On the other hand, the association between cardiac anxiety and HRQoL was weak in both patients with history of CD (beta = − 0.156, p = 0.05), and in those without (beta = − 0.229, p < 0.001). Conclusions Patients with NCCP, in particular those with history of CD, reported low levels of HRQoL, which was associated with psychological distress. This should be considered when developing psychological interventions aiming to improve HRQoL in patients with NCCP.
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Affiliation(s)
- Ghassan Mourad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Jenny Alwin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez R, Remes-Troche J, Abreu-Abreu A, Cerda-Contreras E, Gómez-Castaños P, González-Martínez M, Huerta-Iga F, Ibarra-Palomino J, Icaza-Chávez M, López-Colombo A, Márquez-Murillo M, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez J, Torres-Barrera G, Valdovinos-García L, Valdovinos-Díaz M, Vázquez-Elizondo G, Villar-Chávez A, Zavala-Solares M, Achem S. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2019. [DOI: 10.1016/j.rgmxen.2019.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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13
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Gómez-Escudero O, Coss-Adame E, Amieva-Balmori M, Carmona-Sánchez RI, Remes-Troche JM, Abreu Y Abreu AT, Cerda-Contreras E, Gómez-Castaños PC, González-Martínez MA, Huerta-Iga FM, Ibarra-Palomino J, Icaza-Chávez ME, López-Colombo A, Márquez-Murillo MF, Mejía-Rivas M, Morales-Arámbula M, Rodríguez-Chávez JL, Torres-Barrera G, Valdovinos-García LR, Valdovinos-Díaz MA, Vázquez-Elizondo G, Villar-Chávez AS, Zavala-Solares M, Achem SR. The Mexican consensus on non-cardiac chest pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 84:372-397. [PMID: 31213326 DOI: 10.1016/j.rgmx.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/22/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.
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Affiliation(s)
- O Gómez-Escudero
- Clínica de Gastroenterología, Endoscopia Digestiva y Motilidad Gastrointestinal «Endoneurogastro», Hospital Ángeles Puebla, Puebla, Puebla, México
| | - E Coss-Adame
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México.
| | - M Amieva-Balmori
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - R I Carmona-Sánchez
- Unidad de Medicina Ambulatoria Christus Muguerza, San Luis Potosí, S.L.P., México
| | - J M Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, Veracruz, México
| | - A T Abreu Y Abreu
- Gastroenterología y Fisiología Digestiva, Hospital Ángeles del Pedregal, Ciudad de México, México
| | - E Cerda-Contreras
- Medicina Interna, Gastroenterología y Motilidad Gastrointestinal, Hospital Médica Sur, Profesor de Medicina ITESM, Ciudad de México, México
| | | | - M A González-Martínez
- Departamento de Endoscopia, Laboratorio de Motilidad Gastrointestinal, Hospital de Especialidades CMN Siglo XXI IMSS, Ciudad de México, México
| | - F M Huerta-Iga
- Jefe de Endoscopia y Fisiología Digestiva, Hospital Ángeles Torreón, Torreón, Coahuila, México
| | - J Ibarra-Palomino
- Laboratorio de Motilidad Gastrointestinal, Área de Gastroenterología, Hospital Ángeles del Carmen, Guadalajara, Jalisco, México
| | - M E Icaza-Chávez
- Hospital Star Médica de Mérida, Profesora de Gastroenterología de la UNIMAYAB, Mérida, Yucatán, México
| | - A López-Colombo
- Dirección de Educación e Investigación en Salud, UMAE Hospital de Especialidades del Centro Médico Nacional «Manuel Ávila Camacho», Instituto Mexicano del Seguro Social, Puebla, Puebla, México
| | - M F Márquez-Murillo
- Cardiólogo Electrofisiólogo, Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - M Mejía-Rivas
- Gastroenterología, Endoscopia, Neurogastroenterología, Hospital «Vivien Pellas», Managua, Nicaragua
| | | | - J L Rodríguez-Chávez
- Gastroenterología y Neurogastroenterología, Hospital Puerta de Hierro, Guadalajara, Jalisco, México
| | - G Torres-Barrera
- Departamento de Gastroenterología, Hospital Universitario, Universidad Autónoma de Nuevo León, Profesor de cátedra, ITESM, Monterrey, Nuevo León, México
| | - L R Valdovinos-García
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología y Laboratorio de Motilidad Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición «Salvador Zubirán», Ciudad de México, México
| | - G Vázquez-Elizondo
- Escuela de Medicina y Ciencias de la Salud, Tecnológico de Monterrey, OnCare Group, Monterrey, Nuevo León, México
| | - A S Villar-Chávez
- Gastroenterología y Motilidad Gastrointestinal, Hospital Ángeles Acoxpa, Ciudad de México, México
| | - M Zavala-Solares
- Unidad de Motilidad Gastrointestinal, Servicio de Gastroenterología, Hospital General de México «Dr. Eduardo Liceaga», Ciudad de México, México
| | - S R Achem
- Profesor de Medicina Interna y Gastroenterología, Facultad de Medicina, Mayo College of Medicine, Mayo Clinic, Jacksonville, Florida, Estados Unidos de América
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Park JY, Oh S, Han YM, Lee J, Kim JS, Jung HC, Hong KS. There might be a distinctive clinical phenotype of constipation with non-cardiac chest pain which responds to combination laxatives: A retrospective, longitudinal symptom analysis. Medicine (Baltimore) 2019; 98:e15884. [PMID: 31261496 PMCID: PMC6617427 DOI: 10.1097/md.0000000000015884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Proton pump inhibitor (PPI)-refractory non-cardiac chest pain (NCCP) is often resolved when constipation was relieved. This study aimed to investigate the clinical features of patients with both NCCP and constipated functional bowel disorders (FBD).Among 692 consecutive patients diagnosed with functional constipation or irritable bowel syndrome with constipation and underwent anorectal manometry (ARM) in our hospital, PPI-refractory NCCP was present in 37. The clinical course of various torso symptoms including NCCP and ARM findings were retrospectively evaluated.The mean age was lower in the NCCP than in the non-NCCP group (57.4 vs 61.3 years, respectively, P = .042). Back pain (16.2% vs 2.0%, P < .001) and sharp abdominal pain (13.5% vs 0.9%, P < .001) were more common in the NCCP group. Increased resting pressure (16.2% vs 6.9%, P = .036) and squeezing pressure (62.2% vs 50.7%, P = .049) of the anal sphincter, increased urgency volume (40.5% vs 23.2%, P = .004), and maximal volume (25.7% vs 15.0%, P = .032) for rectal sensation were more frequently observed in the NCCP group. After taking laxatives for 1 to 3 months, 81.1% of patients with NCCP reported improvement.Subjects with NCCP showed decreased rectal sensation more frequently at anorectal manometry. Majority of patients with NCCP reported improvement of symptom upon relief of constipation. Constipation might be a therapeutic target in patients with NCCP related to constipated functional bowel disorders.
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Affiliation(s)
- Jae Yong Park
- Department of Internal Medicine, Chung-Ang University Hospital
| | - Sooyeon Oh
- Chaum Life Center, CHA Medical University
| | - Yoo Min Han
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center
| | - Jooyoung Lee
- Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center
| | - Joo Sung Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Hyun Chae Jung
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul
| | - Kyoung Sup Hong
- Department of Gastroenterology, Mediplex Sejong Hospital, Incheon, South Korea
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History of gastroesophageal reflux disease in patients with suspected coronary artery disease. Heart Vessels 2019; 34:1631-1638. [PMID: 30993440 DOI: 10.1007/s00380-019-01413-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 04/12/2019] [Indexed: 12/15/2022]
Abstract
It is well known that patients with gastroesophageal reflux disease (GERD) experience GERD-related chest pain, but little is known about the relationship between GERD and coronary artery disease (CAD). We evaluated medical history of GERD in patients with suspected CAD and its association with types of CAD. We enrolled 236 patients who underwent coronary angiography (CAG). We assessed past medical history of each patient, making note of esophageal or stomach diseases such as GERD including reflux esophagitis and non-erosive reflux disease. The patients were divided into the following three subgroups based on the CAG results. Group I, patients with o-CAD (> 50% stenosis with ischemic findings, n = 141); Group II, patients with vasospastic angina (VSA, with positive spasm provocation test without organic coronary stenosis, n = 52); and Group III, patients without organic coronary stenosis or VSA (n = 43). Group I included more men than women (p < 0.001) and the frequencies of smoking, lipid disorders, and diabetes mellitus in this group were higher than those in the other groups (p < 0.01). The frequency of medical history of GERD was significantly higher in Group II (21%) than in Group I (3%) or Group III (7%, p < 0.0001). Logistic regression analysis showed that a medical history of GERD (OR 7.8; p < 0.01) was one of the factors associated with the presence of VSA. Our findings showed that a medical history of GERD was frequently observed in approximately one-fifth of patients with VSA, indicating that VSA may be present in patients with chest pain and a medical history of GERD.
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Wertli MM, Dangma TD, Müller SE, Gort LM, Klauser BS, Melzer L, Held U, Steurer J, Hasler S, Burgstaller JM. Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study. PLoS One 2019; 14:e0211615. [PMID: 30707725 PMCID: PMC6358153 DOI: 10.1371/journal.pone.0211615] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 01/17/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out. OBJECTIVE To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED). METHODS Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing. RESULTS In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation. CONCLUSION In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.
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Affiliation(s)
- Maria M. Wertli
- Division of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Tenzin D. Dangma
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Sarah E. Müller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Laura M. Gort
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Benjamin S. Klauser
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Lina Melzer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
| | - Susann Hasler
- Kantonsspital Winterthur, Department of General Internal Medicine Outpatient Clinic, Winterthur, Switzerland
| | - Jakob M. Burgstaller
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Zurich, Switzerland
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Mol KA, Smoczynska A, Rahel BM, Meeder JG, Janssen L, Doevendans PA, Cramer MJ. Non-cardiac chest pain: prognosis and secondary healthcare utilisation. Open Heart 2018; 5:e000859. [PMID: 30364505 PMCID: PMC6196943 DOI: 10.1136/openhrt-2018-000859] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 12/31/2022] Open
Abstract
Objective Presentations of non-cardiac chest pain (NCCP) to the emergency department (ED) are increasing. More knowledge of prognosis and healthcare utilisation of patients with NCCP is necessary to optimise their management. Methods This study is a prospective, observational, prevalence-based cohort study conducted from September 2015 to February 2016 with 1-year follow-up including all patients 18 years and older referred to the ED with chest pain. Discharge diagnoses, mortality, major adverse cardiac events (MACE), re-presentations to the ED, hospitalisations, cardiac interventions and outpatient monitoring were assessed. Results More than 60% of the 1239 patients presenting with chest pain were discharged with NCCP. The all-cause 1-year mortality rate of patients with NCCP was 2.3% compared with 7.2% in patients with cardiac chest pain (CCP) (p<0.001) and the occurrence of MACE was 5.1% vs 8.3%, respectively (p=0.026). Previous history of coronary artery disease (CAD) in patients with NCCP was identified as a predictive factor for MACE (OR 4.30 (95% CI 1.24 to 14.89), p=0.021). Patients with NCCP had more non-invasive interventions than patients with CCP (proportion of 0.225 vs 0.165 per patient, p<0.001) and 13.7% of patients with NCCP re-presented at the ED within 1 year. Conclusion The majority of patients referred to the ED with chest pain are discharged with NCCP. The prognosis of patients with NCCP is better than patients with CCP; however, they are at risk for MACE due to a history of CAD. Patients with NCCP moreover use a substantial amount of medical resources, stressing the importance of good triage to minimise unnecessary healthcare utilisation while still preventing MACE.
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Affiliation(s)
- Karen Anne Mol
- Department of Cardiology, University Medical Centre, Utrecht, The Netherlands
| | | | | | - Joan Gerard Meeder
- Department of Cardiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Loes Janssen
- Department of Clinical Epidemiology, VieCuri Medical Center, Venlo, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Centre, Utrecht, The Netherlands
| | - Maarten-Jan Cramer
- Department of Cardiology, University Medical Centre, Utrecht, The Netherlands
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Abstract
Background Non-cardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected (in this order) at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life due to NCCP is comparable, and partially even higher, to that caused by cardiac chest pain. Reasons for psychological strain are symptom recurrence in approximately 50%, nonspecific diagnosis with resulting uncertainty, and insufficient integration of other medical disciplines in the diagnostic workup. Methods and Results The management of patients with chest pain has to be multidisciplinary because non-cardiac causes may be frequently encountered. Especially gastroenterological expertise is required since the cause of chest pain is gastroesophageal reflux disease (GERD) in 50-60%, hypercontractile esophageal motility disorders with nutcracker/jackhammer esophagus or diffuse esophageal spasm or achalasia in 15-18%, and other esophageal alterations (e.g., infectious esophageal inflammation, drug-induced ulcers, rings, webs, eosinophilic esophagitis) in 32-35%. Conclusion This review highlights the importance of regular interdisciplinary ward rounds and management of chest pain units.
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Affiliation(s)
- Thomas Frieling
- Department of Gastroenterology, Hepatology, Infectiology, Neurogastroenterology, Hematology, Oncology, and Palliative Medicine, HELIOS-Clinic Krefeld, Krefeld, Germany
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Heart-focused anxiety and health care seeking in patients with non-cardiac chest pain: A prospective study. Gen Hosp Psychiatry 2018; 50:83-89. [PMID: 29120733 DOI: 10.1016/j.genhosppsych.2017.10.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/20/2017] [Accepted: 10/26/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES This study aimed to estimate the incidence of medical consultations six months after an emergency department (ED) consultation for non-cardiac chest pain (NCCP). It also investigated the role of heart-focused anxiety (HFA) and other factors in predicting an increased healthcare utilization in these patients. METHOD This was a prospective study of 428 patients who came to an ED with NCCP. Patients completed an interview and questionnaires assessing HFA, psychological distress, the characteristics of NCCP, and comorbidities. Their medical consultations were assessed by telephone interview six months later. The contribution of each factor was assessed using a binomial negative regression. RESULTS Eighty-three percent of patients reported at least one medical consultation (mean=3.1, standard deviation=3.9). HFA (incident rate ratio 1.01; 95% CI, 1.00-1.02), the presence of a medical condition (2.14; 1.51-3.03), NCCP frequency (1.49; 1.16-1.91) and NCCP-related interference (1.08; 1.04-1.13) were predictive of further medical consultations. CONCLUSIONS A significant proportion of patients with NCCP are at risk of multiple medical consultations following discharge from the ED. HFA appears as a determinant of medical consultations after controlling for multiple confounding factors.
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Roche TE, Gardner G, Jack L. The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study. BMC Health Serv Res 2017; 17:445. [PMID: 28655309 PMCID: PMC5488347 DOI: 10.1186/s12913-017-2395-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 06/16/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities. METHODS This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care. RESULTS The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models. CONCLUSIONS There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).
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Affiliation(s)
- Tina E. Roche
- School of Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059 Australia
- Queensland University of Technology, Institute of Health and Biomedical Innovation Victoria Park Road, Victoria Park Road, Kelvin Grove, QLD 4059 Australia
- Emergency Department, Stanthorpe Health Services, PO Box 273, Stanthorpe, QLD 4380 Australia
| | - Glenn Gardner
- Queensland University of Technology, Institute of Health and Biomedical Innovation Victoria Park Road, Victoria Park Road, Kelvin Grove, QLD 4059 Australia
- Emergency Department, Stanthorpe Health Services, PO Box 273, Stanthorpe, QLD 4380 Australia
| | - Leanne Jack
- Queensland University of Technology, School of Nursing Victoria Park Road, Kelvin Grove, QLD 4059 Australia
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A Mixed-Methods Study of Patient Views on Reflux Symptoms and Medication Routines. J Voice 2017; 31:381.e15-381.e25. [DOI: 10.1016/j.jvoice.2016.06.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 12/19/2022]
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Campbell KA, Madva EN, Villegas AC, Beale EE, Beach SR, Wasfy JH, Albanese AM, Huffman JC. Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist. PSYCHOSOMATICS 2017; 58:252-265. [PMID: 28196622 PMCID: PMC5526698 DOI: 10.1016/j.psym.2016.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers. METHODS We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP. RESULTS We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions. CONCLUSIONS Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.
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Affiliation(s)
- Kirsti A Campbell
- Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Elizabeth N Madva
- Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ana C Villegas
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Eleanor E Beale
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Scott R Beach
- Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Jason H Wasfy
- Harvard Medical School, Boston, MA; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Ariana M Albanese
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Jeff C Huffman
- Harvard Medical School, Boston, MA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
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Qintar M, Spertus JA, Tang Y, Buchanan DM, Chan PS, Amin AP, Salisbury AC. Noncardiac chest pain after acute myocardial infarction: Frequency and association with health status outcomes. Am Heart J 2017; 186:1-11. [PMID: 28454822 DOI: 10.1016/j.ahj.2017.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/01/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The frequency of noncardiac chest pain (CP) hospitalization after acute myocardial infarction (AMI) is unknown, and its significance from patients' perspectives is not studied. OBJECTIVES To assess the frequency of noncardiac CP admissions after AMI and its association with patients' self-reported health status. METHODS We identified cardiac and noncardiac CP hospitalizations in the year after AMI from the 24-center TRIUMPH registry. Hierarchical repeated-measures regression was used to identify the association of these hospitalizations with patients' self-reported health status using the Seattle Angina Questionnaire Quality of Life domain (SAQ QoL) and Short Form 12 (SF-12) physical (PCS) and mental (MCS) component summary scores. RESULTS Of 3,099 patients, 318 (10.3%) were hospitalized with CP, of whom 92 (28.9%) were hospitalized for noncardiac CP. Compared with patients not hospitalized with CP, noncardiac CP hospitalization was associated with poorer health status (SAQ QoL-adjusted differences: -8.9 points [95% CI -12.1 to -5.6]; SF-12 PCS: -2.5 points [95% CI -4.2 to -0.8] and SF-12 MCS: -3.5 points [95% CI -5.1 to -1.9]). The SAQ QoL for patients hospitalized with noncardiac CP was similar to patients hospitalized with cardiac CP (adjusted difference: 0.6 points [95% CI -3.2 to 4.5]; SF-12 PCS (0.9 points [95% CI -1.1 to 2.9]), but was worse with regard to SF-12 MCS (adjusted difference: -2.0 points [95% CI -3.9 to -0.2]). CONCLUSIONS Noncardiac CP accounted for a third of CP hospitalizations within 1 year of AMI and was associated with similar disease-specific QoL as well as general physical and mental health status impairment compared with cardiac CP hospitalization.
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Affiliation(s)
- Mohammed Qintar
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO
| | - Yuanyuan Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Donna M Buchanan
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO
| | - Amit P Amin
- Washington University School of Medicine, Saint Louis, MO
| | - Adam C Salisbury
- Saint Luke's Mid America Heart Institute, Kansas City, MO; University of Missouri-Kansas City, Kansas City, MO.
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Abstract
The Rome IV diagnostic criteria delineates 5 functional esophageal disorders which include functional chest pain, functional heartburn, reflux hypersensitivity, globus, and functional dysphagia. These are a heterogenous group of disorders which, despite having characteristic symptom profiles attributable to esophageal pathology, fail to demonstrate any structural, motility or inflammatory abnormalities on standard clinical testing. These disorders are associated with a marked reduction in patient quality of life, not least considerable healthcare resources. Furthermore, the pathophysiology of these disorders is incompletely understood. In this narrative review we provide the reader with an introductory primer to the structure and function of esophageal perception, including nociception that forms the basis of the putative mechanisms that may give rise to symptoms in functional esophageal disorders. We also discuss the provocative techniques and outcome measures by which esophageal hypersensitivity can be established.
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Musey PI, Kline JA. Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety. J Emerg Med 2016; 52:273-279. [PMID: 27998631 DOI: 10.1016/j.jemermed.2016.11.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/02/2016] [Accepted: 11/05/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. OBJECTIVE Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. METHODS Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. RESULTS Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to "stress" or "anxiety"; their mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. CONCLUSIONS Without prompting, 8% of patients self-identified "stress" or "anxiety" as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes.
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Affiliation(s)
- Paul I Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Mol K, Rahel B, Meeder J, van Casteren B, Doevendans P, Cramer M. Delays in the treatment of patients with acute coronary syndrome: Focus on pre-hospital delays and non-ST-elevated myocardial infarction. Int J Cardiol 2016; 221:1061-6. [DOI: 10.1016/j.ijcard.2016.07.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
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Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain - a pilot randomized controlled study. Trials 2016; 17:352. [PMID: 27456689 PMCID: PMC4960843 DOI: 10.1186/s13063-016-1491-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/22/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care. METHODS A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22-76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention. RESULTS Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups. CONCLUSIONS The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period. TRIAL REGISTRATION Clinicaltrials.gov NCT02336880 . Registered on 8 January 2015.
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Tylee A, Barley EA, Walters P, Achilla E, Borschmann R, Leese M, McCrone P, Palacios J, Smith A, Simmonds R, Rose D, Murray J, van Marwijk H, Williams P, Mann A. UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients. PROGRAMME GRANTS FOR APPLIED RESEARCH 2016. [DOI: 10.3310/pgfar04080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- André Tylee
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Elizabeth A Barley
- Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
| | - Paul Walters
- Weymouth and Portland Community Mental Health Team, Dorset HealthCare University NHS Foundation Trust and Bournemouth University, Dorset, UK
| | - Evanthia Achilla
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rohan Borschmann
- Centre of Adolescent Health, The Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Morven Leese
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jorge Palacios
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Alison Smith
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Rosemary Simmonds
- Academic Unit of Primary Health Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Diana Rose
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Joanna Murray
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Harm van Marwijk
- Department of General Practice and Elderly Care Medicine, VU University Medical Centre, Amsterdam, the Netherlands
| | - Paul Williams
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Anthony Mann
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Webster R, Thompson AR, Norman P, Goodacre S. The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain. PSYCHOL HEALTH MED 2016; 22:1-11. [PMID: 26924523 PMCID: PMC5105082 DOI: 10.1080/13548506.2016.1144891] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.
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Affiliation(s)
- Rosie Webster
- a Research Department of Primary Care and Population Health , University College London , Royal Free Campus, Rowland Hill Street, London , NW3 2PF , UK.,b Department of Psychology , University of Sheffield , UK
| | - Andrew Robert Thompson
- c Department of Psychology , University of Sheffield , Western Bank, Sheffield , S10 2TN , UK
| | - Paul Norman
- d Department of Psychology , University of Sheffield , UK
| | - Steve Goodacre
- e School of Health and Related Research , University of Sheffield , UK
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Israel JI, White KS, Gervino EV. Illness perceptions, negative emotions, and pain in patients with noncardiac chest pain. J Clin Psychol Med Settings 2015; 22:77-89. [PMID: 25609578 DOI: 10.1007/s10880-015-9419-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and pain-related life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development.
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Affiliation(s)
- Jared I Israel
- Department of Psychology, University of Missouri-St. Louis, One University Boulevard, 325 Stadler Hall, St. Louis, MO, 63121, USA,
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Bahremand M, Saeidi M, Komasi S. Non-Coronary Patients with Severe Chest Pain Show More Irrational Beliefs Compared to Patients with Mild Pain. Korean J Fam Med 2015. [PMID: 26217482 PMCID: PMC4515511 DOI: 10.4082/kjfm.2015.36.4.180] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Despite providing insufficient medical evidence of the existence of a real cardiac condition, patients with non-coronary chest pain still interpret their pain incorrectly. The present study, therefore, sought to compare the irrational beliefs in non-coronary patients with mild chest pain against those with severe chest pain. Methods A cross-sectional design was used. The statistical population comprised non-coronary patients who presented to the Heart Emergency Center of Kermanshah city, Iran. Using a matching method, 96 participants were selected and studied in two groups of 48. The instruments used were the Comorbidity Index, Brief Pain Index, and the Jones Irrational Beliefs Test (short-form). The multivariate analysis of variance, chi-square test, and t-test were used for data analysis. Results Controlling for the effects of age and comorbid conditions, the severity of three types of irrational beliefs, including emotional irresponsibility (P<0.001), hopelessness changes (P<0.001), and problem avoiding (P=0.002) was higher among patients with severe chest pain (according to effect level). However, in terms of demand for approval, no difference was seen between the two groups (P=0.180). Conclusion Non-coronary patients with severe chest pain showed a greater number of irrational beliefs in comparison to patients with mild pain. Irrational beliefs are common mental occurrences in patients with non-coronary chest pain, and they should be attended to by health professionals, especially in severe non-coronary chest pain. Further investigation to determine the association between irrational beliefs and non-coronary chest pain is necessary.
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Affiliation(s)
- Mostafa Bahremand
- Interventional Cardiologist, Assistant Professor of Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mozhgan Saeidi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeid Komasi
- Master of Clinical Psychology, Cardiac Rehabilitation Center, Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Kisely SR, Campbell LA, Yelland MJ, Paydar A. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev 2015; 2015:CD004101. [PMID: 26123045 PMCID: PMC6599861 DOI: 10.1002/14651858.cd004101.pub5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients. OBJECTIVES To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain. SEARCH METHODS We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors. SELECTION CRITERIA Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs. MAIN RESULTS We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies. AUTHORS' CONCLUSIONS This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.
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Affiliation(s)
- Steve R Kisely
- School of Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia, QLD 4102
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Webster R, Thompson AR, Norman P. 'Everything's fine, so why does it happen?' A qualitative investigation of patients' perceptions of noncardiac chest pain. J Clin Nurs 2015; 24:1936-45. [PMID: 25988506 PMCID: PMC4959531 DOI: 10.1111/jocn.12841] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/30/2022]
Abstract
Aims and objectives To examine patients' perceptions and experiences of noncardiac chest pain, within the framework of the common sense model. Background Patients with noncardiac chest pain have good physical prognosis, but frequently suffer prolonged pain and psychological distress. The common sense model may provide a good framework for examining outcomes in patients with noncardiac chest pain. Design Qualitative thematic analysis with semi‐structured interviews. Methods In 2010, participants recruited from an emergency department (N = 7) with persistent noncardiac chest pain and distress were interviewed using a semi‐structured schedule, and data were analysed using thematic analysis. Results Seven themes were identified; six of which mapped onto core dimensions of the common sense model (identity, cause, timeline, consequences, personal control, treatment control). Contrary to previous research on medically unexplained symptoms, most participants perceived psychological factors to play a causal role in their chest pain. Participants' perceptions largely mapped onto the common sense model, although there was a lack of coherence across dimensions, particularly with regard to cause. Conclusion Patients with noncardiac chest pain lack understanding with regard to their condition and may be accepting of psychological causes of their pain. Relevance to clinical practice Brief psychological interventions aimed at improving understanding of the causes of noncardiac chest pain and providing techniques for managing pain and stress may be useful for patients with noncardiac chest pain.
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Affiliation(s)
- Rosie Webster
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Andrew R Thompson
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Paul Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
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Chambers JB, Marks EM, Hunter MS. The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed? Heart 2015; 101:1240-9. [PMID: 25882503 DOI: 10.1136/heartjnl-2014-306277] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 03/08/2015] [Indexed: 12/20/2022] Open
Affiliation(s)
- J B Chambers
- Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK
| | - E M Marks
- Cardiothoracic Centre, Guy's and St Thomas Hospital, London, UK Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - M S Hunter
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Depressive Symptoms, Cardiac Anxiety, and Fear of Body Sensations in Patients with Non-Cardiac Chest Pain, and Their Relation to Healthcare-Seeking Behavior: A Cross-Sectional Study. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2015; 9:69-77. [DOI: 10.1007/s40271-015-0125-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Joseph S Alpert
- Professor of Medicine, University of Arizona College of Medicine, Tucson
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Atluri DK, Chandar AK, Fass R, Falck-Ytter Y. Systematic review with meta-analysis: selective serotonin reuptake inhibitors for noncardiac chest pain. Aliment Pharmacol Ther 2015; 41:167-76. [PMID: 25412947 DOI: 10.1111/apt.13015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 07/17/2014] [Accepted: 10/14/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Selective serotonin reuptake inhibitors (SSRIs) are used to treat noncardiac chest pain (NCCP) symptoms, however, data regarding their efficacy remains inconclusive. AIM To conduct a meta-analysis of randomised controlled trials (RCT) comparing SSRIs to placebo in patients with NCCP, and rate the quality of evidence. METHODS Electronic databases were searched using the terms 'noncardiac chest pain', 'atypical chest pain' and 'selective serotonin reuptake inhibitors'. Data were extracted from RCTs of ≥8 weeks. Standardised mean differences (SMD), weighted mean differences (WMD) or risk ratios (RR) were used as summary statistics for pooled outcomes. GRADE methodology was used to rate the quality of evidence. RESULTS Four RCTs (184 patients) met the inclusion criteria. Compared to placebo, patients on SSRIs showed a nonsignificant change in chest pain of 3½ points decrease on a 100 mm visual analogue scale (184 patients, 95% CI, -9.5 to 2.5; I(2) = 0%). Change in depression scores was not significantly different between the two groups (88 patients; WMD = 0.7; 95% CI, -1.81 to 3.20; I(2) = 64%). Treatment discontinuations were not significantly different between groups (154 patients, RR = 2.08; 95% CI, 0.77-5.60; I(2) = 0%). The quality of evidence was rated as moderate for change in chest pain symptoms, low for change in depression scores and moderate for treatment discontinuation due to adverse events. CONCLUSIONS Selective serotonin reuptake inhibitors are not superior to placebo in improving chest pain or depression symptoms in patients with noncardiac chest pain. Larger trials with longer follow-up periods are necessary to assess the benefits and drawbacks of SSRIs for the treatment of noncardiac chest pain.
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Affiliation(s)
- D K Atluri
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Gümüşer F, Altinbaş K, Çağlar İM, Ungan İ. Comparison of Temperamental Features, Anxiety, and Depression Levels Between Non-Cardiac Angina and Acute Coronary Syndrome. Noro Psikiyatr Ars 2014; 51:363-367. [PMID: 28360655 DOI: 10.5152/npa.2014.6789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 04/13/2013] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In many studies that are aimed to determine the psychological profile of patients admitted to the emergency unit with non-cardiac angina (NCA), it was indicated that psychiatric problems, less effective problem-solving, and alexithymia are more common in NCA compared with acute coronary syndrome (ACS) patients. In this study, aiming to find predictive psychological clinical features, we compared the temperament, anxiety, and depression scores of patients with NCA and ACS. METHODS Sociodemographic variables of 63 patients (n=41 NCA, n=22 ACS) who were admitted to the emergency unit with chest pain were recorded. TEMPS-A scale was used for defining temperamental features, and Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression levels of patients in both groups. Sociodemographic variables and TEMPS-A and HADS scores were compared with χ2 and independent-groups t-test between the NCA and ACS groups. RESULTS The NCA and ACS groups were similar in terms of sociodemographic variables. There was no statistical difference between groups in HDS (p=.12) and HAS (p=.39) scores and TEMPS-A scale depressive (p=.41), cyclothymic (p=.08), hyperthymic (p=.06), and anxious (p=.29) temperament scores. But, irritable temperament scores were significantly higher in the NCS group (p=.04). CONCLUSION We believe that our findings will provide a basis for further studies in the diagnosis and treatment of NCA by contributing to the definition of NCA patients' psychological profiles.
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Affiliation(s)
- Fatih Gümüşer
- Clinic of Cardiology, Private Acıbadem Hospital, İstanbul, Turkey
| | - Kürşat Altinbaş
- Department of Psychiatry, Çanakkale Onsekiz Mart University, Faculty of Medicine, Çanakkale, Turkey
| | - İlker Murat Çağlar
- Clinic of Cardiology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - İsmail Ungan
- Clinic of Cardiology, Bakırköy Dr. Sadi Konuk Training and Research Hospital, İstanbul, Turkey
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Deary V, Metcalfe L, Wilson JA. Persistent (unexplained) physical symptoms: evidence-based highlights. Br J Hosp Med (Lond) 2014; 75:564-7. [DOI: 10.12968/hmed.2014.75.10.564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Vincent Deary
- Senior Lecturer in Health Psychology, Northumbria University
| | - Louise Metcalfe
- Assistant Psychologist, Northumberland Tyne and Wear NHS Foundation Trust
| | - Janet A Wilson
- Professor of Otolaryngology Head and Neck Surgery, Newcastle University and Department of Otolaryngology Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne NE7 7DN
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The Relevance of Accuracy of Heartbeat Perception in Noncardiac and Cardiac Chest Pain. Int J Behav Med 2014; 22:258-67. [DOI: 10.1007/s12529-014-9433-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Burgstaller JM, Jenni BF, Steurer J, Held U, Wertli MM. Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis. PLoS One 2014; 9:e104722. [PMID: 25111147 PMCID: PMC4128723 DOI: 10.1371/journal.pone.0104722] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 07/12/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment. OBJECTIVES To summarize treatment efficacy for patients presenting with NCCP. METHODS Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group). RESULTS Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions. LIMITATIONS Only a small number of studies were available. CONCLUSIONS Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.
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Affiliation(s)
- Jakob M. Burgstaller
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Boris F. Jenni
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Johann Steurer
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
| | - Maria M. Wertli
- Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland
- Cantonal Hospital Winterthur, Winterthur, Switzerland
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Webster R, Norman P, Goodacre S, Thompson A, McEachan R. Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department. Psychol Health 2014; 29:1265-82. [PMID: 24831735 PMCID: PMC4192860 DOI: 10.1080/08870446.2014.923885] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 05/07/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Many patients who attend an emergency department (ED) with chest pain receive a diagnosis of non-cardiac chest pain (NCCP), and often suffer poor psychological outcomes and continued pain. This study assessed the role of illness representations in explaining psychological distress and continued chest pain in patients attending an ED. METHODS ED NCCP patients (N = 138) completed measures assessing illness representations, anxiety, depression and quality of life (QoL) at baseline, and chest pain at one month. RESULTS Illness representations explained significant amounts of the variance in anxiety (Adj. R² = .38), depression (Adj. R² = .18) and mental QoL (Adj. R² = .36). A belief in psychological causes had the strongest associations with outcomes. At one month, 28.7% of participants reported experiencing frequent pain, 13.2% infrequent pain and 58.1% no pain. Anxiety, depression and poor QoL, but not illness representations, were associated with continued chest pain. CONCLUSIONS The findings suggest that (i) continued chest pain is related to psychological distress and poor QoL, (ii) interventions should be aimed at reducing psychological distress and improving QoL and (iii) given the associations between perceived psychological causes and psychological distress/QoL, NCCP patients in the ED might benefit from psychological therapies to manage their chest pain.
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Affiliation(s)
- R. Webster
- Department of Psychology, University of Sheffield, Sheffield, UK
- e-Health Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - P. Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - S. Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - A.R. Thompson
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - R.R.C. McEachan
- Bradford Institute for Health Research, Bradford Teaching Hopsitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, UK
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Marks EM, Chambers JB, Russell V, Bryan L, Hunter MS. The rapid access chest pain clinic: unmet distress and disability. QJM 2014; 107:429-34. [PMID: 24448381 DOI: 10.1093/qjmed/hcu009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital. METHODS A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period. RESULTS There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60, OR = 1.05) and reported 'atypical' pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower 'illness coherence' (a patient's belief that the illness 'makes sense') (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05). CONCLUSION Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.
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Affiliation(s)
- E M Marks
- From the Cardiothoracic Centre, Guy's and St Thomas Hospital, London, SE1 9RT and Institute of Psychiatry, Department of Psychology King's College London, London, SE1 9RT, UKFrom the Cardiothoracic Centre, Guy's and St Thomas Hospital, London, SE1 9RT and Institute of Psychiatry, Department of Psychology King's College London, London, SE1 9RT, UK
| | - J B Chambers
- From the Cardiothoracic Centre, Guy's and St Thomas Hospital, London, SE1 9RT and Institute of Psychiatry, Department of Psychology King's College London, London, SE1 9RT, UK
| | - V Russell
- From the Cardiothoracic Centre, Guy's and St Thomas Hospital, London, SE1 9RT and Institute of Psychiatry, Department of Psychology King's College London, London, SE1 9RT, UK
| | - L Bryan
- From the Cardiothoracic Centre, Guy's and St Thomas Hospital, London, SE1 9RT and Institute of Psychiatry, Department of Psychology King's College London, London, SE1 9RT, UK
| | - M S Hunter
- From the Cardiothoracic Centre, Guy's and St Thomas Hospital, London, SE1 9RT and Institute of Psychiatry, Department of Psychology King's College London, London, SE1 9RT, UK
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Lee G, Dix S, Mitra B, Coleridge J, Cameron P. The efficacy and safety of a chest pain protocol for short stay unit patients: A one year follow-up. Eur J Cardiovasc Nurs 2014; 14:416-22. [PMID: 24867877 DOI: 10.1177/1474515114537944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Alfred Emergency Short Stay Unit initiated a chest pain protocol for patients presenting with chest pain to risk stratify for acute coronary syndrome (ACS). A 30-day follow-up of patients discharged with low-or-intermediate risk of ACS demonstrated no deaths or ACS. AIMS The purpose of this study was to evaluate the long-term safety of the chest pain protocol, a one year follow-up was undertaken. METHODS A questionnaire was designed for the one-year follow-up and it was administered via a telephone interview by emergency nurses to document adverse cardiac events and health care utilisation. RESULTS From 297 patients, 224 (75%) were contacted 12 months following discharge. There was one death from stroke (0.4%; 95% confidence interval (CI): 0.01-2.5%) and another from an unknown cause. Five patients had been diagnosed with atrial fibrillation (2.2%; 95% CI: 0.7-5.1%), two patients had an acute myocardial infarction (0.9%; 95% CI: 0.03-2.1%) and four were diagnosed with angina (1.8%; 95% CI: 0.9-3.2%). Nearly half (n=103, 46%; 95% CI: 39.5-52.5%) had returned to the emergency department (ED) for various conditions including 42 patients with further chest pain. Ninety-six patients (43%; 95% CI: 39.3-52.7%) had specialist referrals and 124 investigations were performed. Thirty-four patients had cardiology referrals (15%; 95% CI: 10.7-20.5%) and 25 patients had gastroenterology referrals (11%; 95% CI: 7.3-16.0%). Diagnostic cardiac tests were performed on 38 patients: coronary angiography (n=10), 24-hour Holter monitoring (n=17), 24-hour blood pressure (BP) monitoring (n=4), thallium scans (n=5), exercise stress test (n=1) and CT scan (n=1). CONCLUSION Patients had a low risk of adverse events 12 months after discharge but substantial continuing health care utilization was observed. Complete assessment by health care professionals prior to discharge may help mitigate representations.
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Quality of life in patients with non-CAD chest pain: associations to fear of pain and psychiatric disorder severity. J Clin Psychol Med Settings 2014; 20:284-93. [PMID: 23338745 DOI: 10.1007/s10880-012-9347-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Chest pain in the absence of identified cardiac cause, or non-cardiac chest pain (NCCP), is a common condition that may result in impaired quality of life. Theories of NCCP put forward that patients who react to cardiopulmonary sensations with fear may avoid activities that elicit cardiac sensations. Co-morbid psychiatric disorders, which are prevalent in this population, may predispose individuals to be more vigilant to physiological sensations, including cardiac-related symptoms. The daily impact of avoiding cardiopulmonary cues may limit quality of life. This study examined psychiatric disorders, fear of pain, and quality of life in 30 non-coronary artery disease (CAD) chest pain patients. Psychiatric disorder severity was independently associated with mental health related quality of life and fear of pain was independently associated with physical health related quality of life. This research adds understanding to contributory factors to impaired quality of life among patients with non-CAD chest pain.
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Do patients with functional chest pain have neuroplastic reorganization of the pain matrix? A diffusion tensor imaging study. Scand J Pain 2014; 5:85-90. [DOI: 10.1016/j.sjpain.2013.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 11/25/2013] [Indexed: 02/08/2023]
Abstract
Abstract
Background and aims
In functional chest pain (FCP) of presumed esophageal origin central nervous system hyperexcitability is generally believed to play an important role in pain pathogenesis. However, this theory has recently been challenged. Using magnetic resonance diffusion tensor imaging, the aim was to characterize any microstructural reorganization of the pain neuromatrix in FCP patients.
Methods
13 FCP patients and 20 matched healthy controls were studied in a 3T MR scanner. Inclusion criteria were relevant chest pain, normal coronary angiogram and normal upper gastrointestinal evaluation. Apparent diffusion coefficient (ADC) (i.e. mean diffusivity of water) and fractional anisotropy (FA) (i.e. directionality of water diffusion as a measure of fiber organization) values were assessed in the secondary sensory cortex, cingulate cortex, insula, prefrontal cortex, and amygdala.
Results
Overall, including all regions, no difference in ADC and FA values was found between the patients and controls (P = 0.79 and P = 0.23, respectively). Post-hoc tests revealed no difference in ADC and FA values of the individual regions. However, a trend of patients having increased ADC in the mid insula grey matter and increased FA in the mid insula white matter was observed (both P = 0.065).
Conclusions
This explorative study suggests that microstructural reorganization of the central pain neuromatrix may not be present in well-characterized FCP patients.
Implications
This finding, together with recent neurophysiologal evidence, challenges the theory of visceral hypersensitivity due to changes in the central nervous system in FCP patients.
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Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis. BMC Med 2013; 11:239. [PMID: 24207111 PMCID: PMC4226211 DOI: 10.1186/1741-7015-11-239] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 10/15/2013] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP. METHODS A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model. RESULTS Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa. CONCLUSIONS In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.
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Hoff DAL, Krarup AL, Lelic D, Olesen SS, Dimcevski G, Hansen TM, Brock C, Hatlebakk JG, Drewes AM. Central response to painful electrical esophageal stimulation in well-defined patients suffering from functional chest pain. Neurogastroenterol Motil 2013; 25:e718-27. [PMID: 23965033 DOI: 10.1111/nmo.12196] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/03/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Functional chest pain (FCP) of presumed esophageal origin is considered a common cause for chest pain in which central nervous system hyperexcitability is thought to play an important role. We aimed to compare cerebral responses with painful esophageal stimuli between FCP patients and healthy subjects (HS). METHODS Thirteen patients with FCP (seven females, mean age 50.4 ± 7.5 years) and 15 HS (eight females, mean age 49.1 ± 12.9 years) were enrolled. Inclusion criteria consisted of typical chest pain, normal coronary angiogram, and normal upper gastrointestinal evaluation. Electrical stimulations evoking the pain threshold were applied in the distal esophagus, while cortical evoked potentials were recorded from the scalp. Pain scores, resting electroencephalogram (EEG), evoked potential characteristics and brain electrical sources to pain stimulation were compared between groups. KEY RESULTS No differences were seen between patients and HS regarding (i) pain thresholds (patients: 20.1 ± 7.4 mA vs HS: 22.4 ± 8.3 mA, all P > 0.05), (ii) resting-EEG (P > 0.05), (iii) evoked brain potential latencies (N2: patients 181.7 ± 25.7 mS vs HS 182.2 ± 25.8 mS, all P > 0.05) and amplitudes (N2P2: patients 8.2 ± 7.2 μV vs HS: 10.1 ± 3.4 μV, all P > 0.05), (iv) topography (P > 0.05), and (v) brain source location (P > 0.05). CONCLUSIONS & INFERENCES No differences in activation of brain areas to painful esophageal stimulation were seen in this group of well characterized patients with FCP compared with sex- and age-matched HS. The mechanism of pain in FCP and whether it originates in the esophagus remains unsolved.
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Affiliation(s)
- D A L Hoff
- Department of Medicine, Division of Gastroenterology and Hepatology, Aalesund Hospital, Aalesund, Norway
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Foldes-Busque G, Denis I, Poitras J, Fleet RP, Archambault P, Dionne CE. A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department. BMJ Open 2013; 3:e003877. [PMID: 24163208 PMCID: PMC3808760 DOI: 10.1136/bmjopen-2013-003877] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain. METHODS AND ANALYSIS The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument. ETHICS AND DISSEMINATION This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.
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Affiliation(s)
- Guillaume Foldes-Busque
- École de psychologie, Faculté des sciences sociales, Université Laval, Québec, Québec, Canada
- Centre de santé et de services sociaux Alphonse-Desjardins, Research Centre of the University-Affiliated Hospital of Lévis, Québec, Québec, Canada
| | - Isabelle Denis
- Centre de santé et de services sociaux Alphonse-Desjardins, Research Centre of the University-Affiliated Hospital of Lévis, Québec, Québec, Canada
| | - Julien Poitras
- Centre de santé et de services sociaux Alphonse-Desjardins, Research Centre of the University-Affiliated Hospital of Lévis, Québec, Québec, Canada
- Department of Family and Emergency Medicine, Faculté de médecine, Université Laval, Québec, Québec, Canada
| | - Richard P Fleet
- Centre de santé et de services sociaux Alphonse-Desjardins, Research Centre of the University-Affiliated Hospital of Lévis, Québec, Québec, Canada
- Department of Family and Emergency Medicine, Faculté de médecine, Université Laval, Québec, Québec, Canada
| | - Patrick Archambault
- Centre de santé et de services sociaux Alphonse-Desjardins, Research Centre of the University-Affiliated Hospital of Lévis, Québec, Québec, Canada
- Department of Family and Emergency Medicine, Faculté de médecine, Université Laval, Québec, Québec, Canada
| | - Clermont E Dionne
- Centre de recherche FRQS du Centre hospitalier universitaire (CHU) de Québec, Hôpital du St-Sacrement, Québec, Québec, Canada
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