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A Persistent Pain in the Chest
Abstract & commentary
By Allan J. Wilke, MD, MA, Professor and Chair, Department of Integrative Medicine, Ross University (Bahamas) Limited, Freeport, Grand Bahama, The Bahamas. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Nonspecific chest pain is a persistent illness and patients with it are subject to overly extensive work-ups.
Source: Glombiewski JA, et al. The course of nonspecific chest pain in primary care: Symptom persistence and health care usage. Arch Intern Med 2010;170:251-255.
Patients presenting with chest pain in primary care offices pose a dilemma. If the pain is acute, the course of action is clear: Give the patient an aspirin and a sublingual nitroglycerin and call 911. When it is obviously not an acute myocardial infarction, the decision-making becomes murkier. These investigators from Germany set out to answer three questions: 1) How many patients with nonspecific chest pain, presenting to a primary care physician, will be symptomatic 6 months hence? 2) How many of these patients are "over-investigated"? 3) How many of these patients receive mental health referrals? They went to 209 general practitioners (GPs) to ask if they would participate in the study; 74 agreed. Of 190,000 adults, these GPs recruited 1355, age 35 or older, who had a complaint of chest pain. The age cutoff was chosen to increase the probability that at least some of these cases would eventually be determined to be cardiac in origin. If the pain had resolved more than a month before presentation, if it had previously been investigated, or if the visit was for follow-up of chest pain, the patient was excluded. The patients underwent a standardized history and physical and were followed prospectively. The GPs chose treatment and referral. At 6 weeks and 6 months, the patients were called and asked, "Do you have chest pain at present?" At 6 months, each patient's record was reviewed by a panel made up of a cardiologist, a GP, and one of the investigators to sort the patients into three groups: those who needed immediate hospitalization, those with coronary heart disease (CHD) not requiring hospitalization, and those with a non-CHD diagnosis not requiring hospitalization. This third group included patients with diagnoses such as chest wall syndrome, gastroesophageal reflux disease, benign stomach problems, and neck or shoulder disorders. The third group's diagnoses were further subdivided into psychologically caused nonspecific chest pain (NSCP) and potentially somatically caused NSCP.
After proper exclusion (patients not meeting inclusion criteria, refusal, lack of follow-up, etc.), 1212 patients remained. Four hundred five (405) patients were adjudicated to have unambiguous medical diagnoses, 692 had probably somatically caused NSCP, and 115 had psychologically caused NSCP. The researchers focused on the last two groups (807 patients in total). The average age was 58 years, and there was a female predominance (60%). At 6 months, of the 755 patients who had data available, 419 (55%) still complained of chest pain. Women were more likely to be persistently symptomatic (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.08-1.81). There was no age predilection. Patients with psychologically caused NSCP were more likely to report pain at 6 months than patients with probably somatically caused NSCP (OR, 1.19; 95% CI, 0.79-1.79). This finding was not statistically significant.
To these researchers, "over-investigation" of NSCP meant 1 visit to a cardiologist or 2 cardiac diagnostic investigations (ECG, angiography, echocardiography, chest X-ray, etc.) in the 6 months after the initial visit. Sixty (14%) of the 419 patients saw a cardiologist at least once and 161 (38%) had at least one cardiac test. Forty-five (11%) patients met their definition for over-investigation. These patients were more likely to receive a diagnosis of psychologically caused NSCP than patients appropriately referred to cardiac and imaging services (OR, 2.2; 95% CI, 1.07-4.53).
Of course, cardiologists are not the only specialists to whom a GP could refer a NSCP patient. In this study, 219 of 419 (52%) patients were referred to a medical specialist. Referrals were counted even if the patients did not make the appointments. Only 6 visits were to a psychiatrist or a psychologist. Cardiologists were visited twice as often by patients with psychologically caused NSCP than were patients with potentially somatically caused NSCP (OR, 2.15; 95% CI, 1.01-4.15). This was just barely statistically significant.
This study has several strengths. The numbers were large and there was little dropout. It studied patients in primary care settings that are probably similar to the ones that we practice in, and it followed them long enough for any cardiac disease to manifest. It has some limitations. Were these German patients demographically similar to ours? Were the patients in the practices that declined to participate different than the ones here? Are patients who do not present to GP offices with chest pain different from the ones that do? (The authors point out that there is far less use of emergency departments in Germany than in the United States.) Was the chest pain that the patients reported at 6 months the same they presented with? The article did not contain all of the data in tables, so the odds ratios could not be confirmed.
One interpretation of the over-investigation of patients with psychologically caused NSCP is that they needed a more thorough investigation before the physicians could make that diagnosis. Perhaps the patients themselves were not accepting of a psychological diagnosis and demanded these investigations. The "elephant in the middle of the room" is the question of why there was such an imbalance between "medical" referrals and "mental health" referrals. The study recorded referrals whether the patients showed or not. Did the GPs not recognize that the NSCP could have a psychological basis? Did they doubt that their patients would benefit from a psychological evaluation/intervention? The evidence for the effectiveness of psychological intervention in NSCP is mixed at best,1-4 but because of the prolonged nature of the problem, for our patients' sake, we should give it the benefit of the doubt. Unlike in the United States, it was not out of concern that their patients couldn't afford the visit: Germany has universal health care.
1. van Peski-Oosterbaan AS, et al. Cognitive-behavioral therapy for noncardiac chest pain: A randomized trial. Am J Med 1999;106:424-429.
2. Arnold IA, et al. Medically unexplained physical symptoms in primary care: A controlled study on the effectiveness of cognitive-behavioral treatment by the family physician. Psychosomatics 2009;50:515-524.
3. Mayou RA, et al. Management of non-cardiac chest pain: From research to clinical practice. Heart 1999;81:387-392.
4. Esler JL, Bock BC. Psychological treatments for noncardiac chest pain: Recommendations for a new approach. J Psychosom Res 2004;56:263-269.