Case Managers Can Help Non-Cardiac Chest Pain Patients in the ED
The results of a pilot study show case management can help patients with non-cardiac chest pain by addressing their biopsychosocial factors and providing follow-up care management.1
Non-cardiac chest pain is the second most common reason for ED visits in the United States. Each year, there are as many as 7 million ED visits and 27 million office visits for this symptom.
“We were interested in looking at patients with non-cardiac chest pain — those who’d undergone evaluation that found the pain was not related to their heart,” says Elizabeth N. Madva, MD, a psychiatrist and faculty member in the department of psychiatry at Massachusetts General Hospital and Harvard Medical School. “These patients have normal ECGs, normal enzymes. We were interested to see if we could help patients develop something to reduce symptoms and improve quality of life.”
The intervention is led by a nurse case manager. Patients undergo a one-time consultation with a cardiologist for a comprehensive exam, history, and physical to ensure there are no potential cardiac causes of the patient’s chest pain.
“The RN care manager is present for the entirety of the patient’s visit with the cardiologist as well,” Madva says. “The care manager answers questions, explains the next steps, and also talks with patients about the research program.”
Care managers also work with a psychiatrist, creates a biopsychosocial recommendation/plan for the patient. The care manager explains the plan to the patient and shares information with the patient’s primary care provider (PCP). “At the consultation visits, they would introduce this biopsychosocial formulation and set up a plan to have eight weekly phone calls with the expectation they would help reduce the pain,” Madva says.
Chest pain could be the result of reflux or heartburn, musculoskeletal pain, or an upper respiratory infection. It also could be the result of a panic attack and recent stress.
“What we were trying to accomplish with this program and having a cardiologist, psychiatrist, and nurse care manager was to view this holistically and think about all the different factors contributing to the pain,” Madva explains.
Cognitive Behavioral Therapy Helps
The nurse care manager was trained in basic cognitive behavioral therapy (CBT) principles.
Biopsychosocial plans could address any physical causes of chest pain, including musculoskeletal pain and heartburn, and psychological factors such as anxiety, stress, and panic disorder.
“The nurse care manager provided some CBT principles, using strategies for people to think about anxiety and to examine thoughts and behaviors that occur around the time of the patient experiencing those pain symptoms,” she explains. “The nurse care manager also was supportive in checking in with the patient and making sure the patient felt heard and was getting the care they needed.”
Care managers introduced diaphragmatic breathing, showing patients how to keep their hands on their belly and allow the belly to expand and then contract during exhalation.
Some patients began taking an antidepressant if the team identified comorbid depression or anxiety. “That’s where we would send recommendations to the PCP, and we’d recommend they follow-up with the PCP in a couple of weeks,” Madva says. “During those eight weekly phone calls, the nurse care manager would say, ‘Did you see the primary care doctor?’ or ‘Did they make a medication change? How is that going?’”
The pilot study only included three patients, so there are no findings on the intervention’s efficacy. “But we did find it was feasible,” Madva notes. “We were able to make it happen and, overall, all of our study outcome measures trended in the right direction, and patients found it quite helpful. Chest pain severity improved across all participants. The number of emergency department visits also improved, and the mean scores for depression, anxiety, and somatization improved.”
The resources needed for the intervention were fairly minimal. Nurse care managers were trained in breathing and relaxation techniques. The weekly phone calls lasted about 30 minutes on average. These could be shorter or less frequent, depending on the patients’ needs.
“For a primary care provider clinic that already has a social worker or care manager in the practice, this would be a simple thing to introduce,” Madva says.
The next step would be to conduct a randomized, controlled trial with more patients to determine efficacy.
“If it is effective, I believe this kind of intervention can improve chest pain symptoms and psychological symptoms in a population with significant comorbidity — a high comorbidity population, including behavioral health,” Madva says.
- Madva EN, Celano CM, Kim S, et al. A care management intervention for noncardiac chest pain: Treatment development and feasibility assessment. Prim Care Companion CNS Disord 2022;24:21m03045.
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