Approximately half of all patients who present to a primary care physician with nonspecific chest pain report still having pain 6 months later, according to a study in the February 8, 2010, issue of Archives of Internal Medicine.
Julia Anna Glombiewski, PhD, of Philipps-University of Marburg (Marburg, Germany), and colleagues conducted a prospective, general physician-based cohort study of approximately 190,000 consecutive patients who visited general physicians from October 1, 2005, to July 31, 2006. Of these, 807 were judged to have nonspecific chest pain. Clinicians recorded preliminary diagnoses along with any investigations and treatments related to their patients’ chest pain. The investigators then followed up via telephone call at 6 weeks and again at 6 months after the initial office visit.
Data were available for 755 of the 807 patients at 6 months. The majority of patients (60.5%) were women and the most common diagnosis was chest wall syndrome followed by psychological or gastrointestinal issues (table 1).
Table 1. Diagnoses in Patients with Non-Specific Chest Pain
Chest Wall Syndrome
|
70.0%
|
Psychological Cause
|
14.3%
|
Gastroesophageal Reflux Disease
|
5.2%
|
Benign Stomach Problem
|
3.2%
|
Neck/Shoulder Disorders
|
0.2%
|
Other Nonspecific Somatic
Diseases or No Diagnosis
|
7.1%
|
Unresolved Pain Tied to More Healthcare Usage
At 6-month follow-up, 419 patients (55.5%) still had chest pain. Patients with persistent pain were more likely to be female (OR 1.35; 95% CI 1.08-1.81) but did not differ significantly with regard to age. Patients whose chest pain was diagnosed as having a psychological cause more often reported persistent pain at 6-month follow-up (OR 1.19; 95% CI 0.79-1.79) than patients whose chest pain was thought to have a somatic cause.
Among those with persistent pain at 6 months, 38.4% underwent testing for heart disease and 14.3% visited a cardiologist. They also underwent various tests, including
- Holter electrocardiography, 6.7%
- Angiography, 4.5%
- Echocardiography, 19.8%
- Stress electrocardiography, 23.2%
- Chest X-ray, 13.6%
- Nuclear imaging, 1.2%
Overall, 10.7% of persistent chest pain patients were categorized as using health care in an inappropriate manner compared with 7.1% of patients whose chest pain had resolved at 6 months. Interestingly, those who were found to use health care inappropriately were more likely to have been diagnosed with a psychological cause than those who used health care in an appropriate manner (OR 2.2; 95% CI 1.07-4.53). The groups did not differ by gender or age.
Underutilization of Psych Referrals or Not Enough Investigation?
Despite the fact that 14.3% of patients were judged by their physicians to have a probable psychological cause for their chest pain, only 6 of 115 patients (1.7%) consulted a psychiatrist or psychologist.
“This finding is surprising, because psychological factors are known to contribute to the development of chronic pain, and psychological consultations are covered by the health care system in Germany,” the authors write. “Patients, GPs, or both seem to be hesitant to involve psychological interventions. Future research should investigate the development of effective interventions for nonspecific chest pain and their implementation within healthcare systems.”
Patients with a suspected psychological cause for their chest pain visited cardiologists twice as often (OR 2.15; 95% CI 1.01-4.51) as patients with somatically caused nonspecific chest pain. Whether those patients should have been referred for psychological assessment alone is debatable, though, said Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY).
“In my experience, once you prove to these types of patients that you’ve ruled out all the bad stuff, they are reassured and tend to not be as bothered by the pain,” he told TCTMD in a telephone interview. “That’s not true for everybody, but I think it’s true for a lot of people with this type of pain with no known cause. Reassurance that their heart is OK through a routine treadmill test, for example, may be all that is necessary instead of a psych referral.”
Women May Fall Through the Cracks
Maria Rosa Costanzo, MD, of Midwest Heart Specialists (Naperville, IL), said for the most part, she found the study vague and the methods ill defined.
“First of all, it’s not really clear how they made the diagnoses and how they excluded other conditions that could result in chest pain,” Dr. Costanzo said in a telephone interview with TCTMD. “But the thing I find most troubling is that we know the presence of coronary artery disease in women is underdiagnosed.”
Chest pain in women that may indicate the presence of CAD is labeled as nonspecific or atypical primarily because most of the studies describing angina have been done in middle-aged males, she said. “This is one of the main messages we are trying to send to women and to primary care physicians through the American Heart Association’s Red Dress Initiative,” Dr. Costanzo added. “[Physicians] should not ignore chest pain in women, even if they perceive it as atypical or nonspecific. In young women with severe pulmonary hypertension, very often nonspecific chest pain can be the only clue to their diagnosis.”
Study Details
Inappropriate healthcare usage was defined as ≥ 2 visits to a cardiologist or ≥ 3 cardiac diagnostic evaluations—including angiograms and electrocardiograms—within 6 months.
Source:
Glombiewski JA, Rief W, Bösner S, et al. The course of nonspecific chest pain in primary care: Symptom persistence and health care usage.
Arch Intern Med. 2010;170:251-255.
Disclosures:
- The study was funded by a grant from the German Federal Ministry of Education and Research.
- Drs. Glombiewski, Kirtane, and Costanzo report no relevant conflicts of interest.
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