Noncardiac Chest Pain After Acute MI Common and ‘Just as Scary’: Why Cardiologists Should Care

One out of 10 patients who survive an acute myocardial infarction returns to the hospital with chest pain within 12 months of their MI, new data suggest, and in one-third of these cases, the chest pain is not cardiac in nature.

Researchers say cardiologists should sit up and notice the fact that, for patients, the negative impact on quality of life is more or less equal between those experiencing noncardiac chest pain and those found to have problems that were cardiac in nature.

“Before I did this work I counted myself among the group of interventionalists who probably didn’t think about this very much,” senior author Adam Salisbury, MD (Saint Luke’s Mid America Heart Institute, Saint Louis, MO), admitted to TCTMD. “But the health-status impact of the noncardiac symptoms was of the exact same magnitude as the cardiac chest pain symptoms, so this was really impactful for patients’ quality of life, and as impactful as the chest pain that we spend a lot of resources and a lot of time becoming more concerned about.

“So this deserves at least some attention from the cardiovascular community to make sure these patients are treated effectively and that the appropriate diagnostic tests are done,” he said. Salisbury, with lead author Mohammed Qintar, MD (Saint Luke’s Mid America Heart Institute), and colleagues, recently reported the findings in an early online publication in the American Heart Journal.

The Job Not Done

The study reviewed cardiac and noncardiac chest pain hospitalizations in the first year following acute MI among patients included in the TRIUMPH registry, a 24-center study funded in part by the National Heart, Lung, and Blood Institute. In all, 3,099 patients initially hospitalized for acute MI consented to be included in the follow-up study and 318 (10.3%) were ultimately rehospitalized with chest pain over the next 12 months. Of these, 28.9% were found to have noncardiac chest pain, most commonly with gastrointestinal or musculoskeletal diagnoses.

Before I did this work I counted myself among the group of interventionalists who probably didn’t think about this very much. Adam Salisbury

Importantly, mortality at 1 and 2 years after acute MI was numerically lower among the cardiac chest-pain patients but not statistically different. There were also no differences in self-reported health status—the primary focus of this study—using different quality-of-life questionnaires.

While the incidence of noncardiac chest pain admissions following acute MI has been previously studied, Qintar et al believe their study may be the first to illuminate the clinical implications and quality-of-life impact of chest pain admissions that are not cardiac in nature.

According to Salisbury, cardiologists may need to think differently about their role in caring for acute MI patients—their job does not end when they’ve ruled out cardiac causes. For the patients, their noncardiac chest pain may be “essentially just as scary” as the chest pain that sent them to the cath lab in the first place.

“The standard cardiologist approach is to follow our diagnostic pathways to determine whether [the chest pain] is cardiac. And if it’s cardiac, they get a lot of attention, they get procedures, they get testing, they get a clear description of where their pain is coming from and hopefully the source of the pain is eliminated,” Salisbury said. “But if it’s noncardiac the way we typically handle that is to say, well, we’re done. Go see your primary doctor in a month, and I hope you do well. But for many patients that’s really an inadequate response.”

Potential Cost Savings

When patients come back to the clinic for follow-up, said Salisbury, ideally within the first week or so after their initial hospitalization, this is the time to discuss chest pain symptoms. “This can really stave off some very expensive inpatient evaluations,” he said, and potentially set up referrals to noncardiac specialists, particularly gastroneurologists, who can help patients understand or get to the bottom of their symptoms.

“The thing that these patients need to be reassured about the most is that most of these noncardiac causes of chest pain, while disturbing, are benign and not prognostically significant,” Salisbury said. “If we can identify those symptoms and start that diagnostic pathway as an outpatient, we’re likely to save money and also improve quality of life.”

Commenting on the study for TCTMD, Guy Reeder, MD (Mayo Clinic, Rochester, MN), pointed out that patients with recurring chest pain, particularly when a diagnosis is not easily made, become “frequent fliers” in cardiac cath labs, receiving repeat diagnostic caths and potentially stent procedures “that may or may not have been related to the initial symptoms. But the expectation is that, the next time they have that chest pain, they need to come back and get another stent.”

Patients are explicitly told when they’re discharged from hospital the first time that if they feel any chest pain, they should come to the emergency room or call 9-1-1, Reeder pointed out. “That’s kind of engrained in them when they leave, so there’s this heightened awareness to possible symptoms that they might not have otherwise had.”

One of the ideas proposed by Qintar et al is a predictive model that could help identify patients more likely to return to hospital, an idea that Reeder says is worth exploring. As hospitalizations following acute MI grow shorter and shorter, however, the current study is a reminder to physicians to take the time with patients to understand their concerns and anxiety.

“We’re all facing kind of a time crunch,” Reeder said, adding, “Time with the patient is something we could all do better at.”