Clinical symptoms in young adults with atypical chest pain attending the emergency department

Unexplained acute chest pain in young adults: disease patterns and medication use 25 years later

BACKGROUND

Patients with unexplained chest pain are commonly revisiting an emergency department with various symptoms, but comprehensive long-term studies are lacking.

METHODS

A total of 150 young adults (aged 18-40 years) with unexplained chest pain who presented at an emergency unit for 16 weeks in mid-1980s were included in a prospective cohort study. An age- and sex-matched control group was randomly selected from the same area. Data were retrieved from registers that recorded death, income, education, country of birth, diagnoses, hospitalizations, outpatient visits, and medications dispensed.

RESULTS

Patients with unexplained acute chest pain had lower levels of education and income and were more often immigrants. Long-term mortality rates did not differ between cases (4%) and controls (5%) during 25 years of follow-up, nor were there differences in diagnosis of ischemic heart disease. Patients with unexplained acute chest pain had more outpatient visits (median, 5 versus 2; p < .0001) and had more often been hospitalized (61.6% ever versus 41.8%; p < .001) during the follow-up period. Several disorders were more common among patients 20 to 25 years later, including atrial fibrillation, esophageal/gastric disorders, chest pain, palpitations, abdominal discomfort, musculoskeletal symptoms, sleeping disturbance, and stress reactions (p values < .05). More patients had been given antihypertensives, anticoagulants, antidepressants, analgesics, and hypnotics/tranquilizers (p values < .05).

CONCLUSIONS

Young patients admitted to the emergency department with unexplained acute chest pain showed no increased risk of mortality or ischemic heart disease during 25 years of follow-up, but they had higher incidence of a wide range of disorders and used more medications. Early identification and preventive interventions may improve health outcomes in these patients.

Swedish general practitioners' practice behaviour in hypertension care

OBJECTIVE

To examine care organization and practice behaviour in hypertension care among Swedish general practitioners.

DESIGN

A postal questionnaire followed by a structured interview, in a two-step study design.

SETTING

Uppsala-Orebro region in mid-Sweden (population 1.9 mill.)

PARTICIPANTS

General practitioners employed by counties, according to a register maintained by the Swedish Medical Association (N = 489).

MAIN OUTCOME MEASURE

Practice behaviour score compared with a gold standard.

RESULTS

392 general practitioners returned the questionnaire, and the interview was accomplished with 222 of 232 who agreed to participate. Non-responder studies were carried out in both steps. Every fifth GP had access to a special hypertension clinic at their health centre, and 29% had specially trained nurses for hypertension care. 31% reported use of written guidelines. 47% declared they accepted higher BP-levels than recommended, although 78% agreed with official guidelines. The mean practice behaviour score was 8,77 (range 5-12, maximum score 12).

CONCLUSION

Although a majority of GPs agree with official guidelines, there is a considerable variation in care organization and practice behaviour in hypertension care.

Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain

STUDY OBJECTIVES

To determine the feasibility, safety, and reliability of emergency cardiac treadmill exercise stress testing (CTEST) in the evaluation of emergency department patients with atypical chest pain.

DESIGN

Thirty-two patients with atypical chest pain, normal ECGs, and risk factor stratification having low-probability of coronary artery disease were evaluated prospectively using outpatient, emergency CTEST. Study patients were compared with a retrospectively selected sample of admitted patients diagnosed with atypical chest pain who met the study criteria and were evaluated with CTEST as inpatients. All patients had follow-up at three and six months after evaluation.

SETTING

University-affiliated community teaching hospital with 65,000 annual ED visits.

RESULTS

All patients had normal CTEST. No patient had evidence of coronary artery disease, myocardial infarction, or sudden death during the follow-up period. The average length of stay was 5.5 hours for emergency CTEST patients versus two days for inpatients. The average patient charge was $467 for ED evaluation with emergency CTEST versus $2,340 for inpatient evaluation.

CONCLUSION

Emergency CTEST is a safe, efficient, cost-effective, and practical method of evaluating selected ED patients with chest pain. It is a useful aid for clinical decision making and may help to prevent unnecessary hospital admissions.

Five-year follow-up of young adults visiting an emergency unit because of atypical chest pain

A five-year follow-up, by means of a personal interview, was performed on patients below the age of 40 years with acute chest pain without obvious organic cause (n = 64). They had been consecutively admitted to the emergency unit over a period of 8 weeks, and had all been subjected to a thorough medical and psychosocial investigation with feedback soon after the initial consultation (investigation patient group, IP). For comparison, a non-investigation patient (NIP) group (n = 51) was recruited over a period of 8 separate weeks. Half of the patients in each group reported at the follow-up that they continued to suffer from chest pain. Compared to normal subjects, they reported more depression. This means that the initial research programme performed in the investigation group had no sustained therapeutic effect compared to routine care at the emergency unit. Tension, anxiety and number of consultations with a physician, as reported in the initial investigation, were negatively correlated with the outcome at follow-up. We conclude that acute chest pain without obvious organic cause in young adults is a condition with an excellent prognosis in strictly physical terms. However, a high proportion of the patients continue to suffer from chest pain for several years, and many of them continue to be consumers of medical resources. We therefore suggest that therapeutic programmes should be developed, particularly for those who report psychological symptoms and those with a history of many consultations with physicians.