Non-cardiac chest pain: time to extend the rapid access chest pain clinic?

Authors


  • Disclosures None.

Prof JB Chambers, Cardiothoracic Centre, St Thomas’ Hospital, London SE1 7EH, UK
Tel.: +44 (0)20 7188 1047
Fax: +44 (0)20 7188 0728
Email: john.chambers@gstt.nhs.uk

Summary

Non-cardiac chest pain is common. It has a low risk of coronary events, but causes considerable physical and social disability and inappropriate health-care usage. It is a heterogeneous condition, which may be caused by or associated with gastro-oesophageal, musculoskeletal or psychiatric abnormalities and sustained by psychological factors including catastrophisation, avoidance behaviour and abnormal help-seeking. These may coexist and their relative contributions may vary in different patients or at different times in an individual patient. The absence of a unitary cause probably explains why treatment studies show only moderate success. An individualised biopsychosocial approach takes account of all causative and sustaining processes and has been shown to work in pain syndromes at other sites. We suggest that this approach should be tried for chest pain using a multidisciplinary clinic model including cardiologists, psychologists and nurses linked with a Rapid Access Chest Pain Clinic.

Review criteria

  • All available published studies.

Message for the clinic

  • Non-cardiac chest pain is not a unitary diagnosis. An individualised biopsychosocial approach is likely to be effective.

Rapid Access Chest Pain Clinics (RACPC) were originally developed to manage new-onset angina (1), which has a high early mortality (2). However, about three quarters of patients referred have non-cardiac chest pain (NCCP) (3–5). This is not included in management protocols, so that RACPCs fail to address a source of considerable physical and social disability and high health-care usage. This review discusses what is known about treatment and suggests ways of improving our current models of care.

Outcome of NCCP

NCCP has a population prevalence of around 25–30% (6,7) in the UK, USA, and mainland Europe and 14% in one study from Hong Kong (8). It accounts for 2–5% of all emergency department admissions in Australia and Hong Kong (7,8). NCCP is seen as benign because the incidence of myocardial infarction or premature death is close to zero (4,9,10), but patients remain significantly disabled. About three quarters report residual chest pain (9), while one half continue taking cardiac medication (9). One half remain or become unemployed (11) and absenteeism is common with a mean time off work of 22 days (range 1–240) in 1 year (10). Health-care use is high (11–13), but the monetary cost has not been quantified recently. In the USA in 1989, it was estimated that bed costs alone were $3500 in the year after a normal coronary angiogram (14).

What determines chronicity?

Symptoms continue if an underlying organic non-cardiac source of pain remains untreated or if there is an untreated psychiatric disorder (15,16). It is also associated with stress at home or work, with negative life-events (17) hypochondriasis (18) or a number of psychological processes, such as catastrophisation, avoidance behaviour, a belief that the heart is the source of the pain (11,19–21) and a perceived lack of control over symptoms (17). Chronicity may also be associated with a longer interval before diagnosis (19,22) and is more likely in women (23,24). Repeated help-seeking for NCCP can lead to a temporary reduction in anxiety, but tends to entrench the belief that the pain is a sign of impending disease or threat.

What do we know about treatment?

Non-cardiac pain is not a unifying diagnosis, but a descriptive term for the exclusion of coronary disease after clinical assessment and sometimes non-invasive or invasive tests. Preparing patients for a negative test may make it easier for them to accept simple reassurance from a cardiologist or cardiac nurse (25). Many have a readily identifiable source for pain, either gastrointestinal reflux or musculoskeletal pathology or else have significant underlying psychiatric disorders. These may often respond to specific therapies (26). A proton pump inhibitor has been shown to be effective in a number of small trials in patients with either non-specific NCCP (27) or pain with features suggestive of gastro-oesophageal reflux (4). This leaves a group, often with abnormal breathing patterns or thoracic muscular tension as a mechanism of pain, in whom psychological disorders are dominant. This group has much in common with other functional syndromes, such as irritable bowel, non-specific pelvic pain, fibromyalgia and chronic fatigue, which are currently grouped as Medically Unexplained Syndromes (MUS) (28). The clinical assessment can be expanded into a therapeutic intervention by providing written information that offers unambiguous reassurance and an alternative explanation for the pain (19). This idea of ‘assessment as treatment’ has been used as an effective model for managing physical symptoms in general hospital outpatients (29). However, many patients with NCCP remain unconvinced (17) and anxiety may be increased by a visit to the RACPC (17). For these, cognitive behavioural therapy (CBT) has been moderately successful (Table 1)(30). Most trials have involved between 4 and 12 sessions of individual CBT (31–34), whereas others have found improvements with group CBT (35), or brief interventions of three (36) or even one session (37). Another study (38) found a single session of CBT to be ineffective, probably in part as a result of intervening too early after coronary angiography. Others have shown a positive effect from relaxation training, physical training or breathing exercise (39–41), which are part of a whole CBT package.

Table 1. Trials of cognitive behavioural therapy in non-cardiac chest pain
Trial N InterventionControlImprovementOutcome improved
Esler et al. (2003)(37)361-hour CBT (psychoeducation, cognitive restructuring & breathing exercises)Information, clinically prescribed medication+Chest pain frequency, anxiety sensitivity and fear of cardiac symptoms
Jonsbu et al. (2011)(36)403-hourly sessions of manualized CBT with one physical activity exposure sessionUsual treatment+Fear of bodily sensations, avoidance of physical activity, depression and some domains of QOL
Klimes et al. (1990)(31)29Individual CBT up to 11 sessions over 3 months (cognitive restructuring, problem-solving, relaxation, breathing exercises)Explanation+Chest pain, limitations of daily life, autonomic symptoms and psychological distress
Mayou et al., 1997(32)37Individual CBT up to 12 sessions (cognitive restructuring, problem-solving, relaxation, breathing exercises)Assessment only+Symptoms, mood and activity at 3 months, fewer differences at 6 months
Potts et al. (1999)(35)566 sessions of group CBT (education, cognitive restructuring, relaxation, breathing exercises, graded exposure and light physical exercise) +Frequency of chest pain, anxiety and depression and total disability score and exercise tolerance
Sanders et al. (1997)(38)41Nurse-delivered single 1-h information and discussion session (relaxation, breathing, education and graded exposure, booklet and audio cassette) plus telephone follow upNo interventionNone
Spinhoven et al. (2010)(33)58Up to 6 sessions of psychologist-delivered CBT (breathing and relaxation techniques, cognitive restructuring and behavioural experiments)Placebo or paroxetine+Frequency of chest pain (compared with placebo or paroxetine)
Van Peski-Oosterbaan et al. (1999)(34)63Individual CBT up to 12 sessions (cognitive restructuring, problem solving, relaxation, breathing exercises)Usual care+Chest pain frequency and intensity
De Guire et al. (1996) (39)416 individual sessions over 3 weeks based on guided breathing retrainingNo treatment+End-tidal carbon dioxide level, respiratory rate, frequency of non-cardiac symptoms
Tyni-Lenne et al. 2002(4)21Relaxation training twice weekly for 8 weeks or Endurance training for 8 weeksNo treatment+Tolerated exertion and QOL (relaxation or endurance) work rate and distance (endurance)
Asbury et al. (2007; 2009)(41)53Weekly group autogenic training supported by individual home programme and symptom diary for 8 weeksSymptom diary alone+Symptom frequency and severity

The biopsychosocial model

It is important to broaden our management of patients with NCCP beyond simply excluding coronary disease. In many patients, underlying physical causes of pain may interact with psychological processes (13). In others, the abnormality may be predominantly psychological, but with no unitary aetiology or process. A biopsychosocial approach assumes that biological, social and psychological factors are inter-related and are relevant to all patient presentations (28). It assesses the relative contributions of these factors and offers an individual a holistic approach rather than a unitary treatment for all patients. Management could include:

  • • An explanation for the symptom and its likely determinants with reassurance tailored to the patients fears and concerns (42).
  • • Medication as clinically indicated for gastro-oesophageal reflux, musculoskeletal pain, insomnia, constipation or depression.
  • • Breathing and relaxation exercises (35).
  • • Supported return to normal exercise and activities.
  • • Arranging contacts for help with social problems.
  • • Discussion of disordered cognitive processes including CBT.
  • • Referral to specialist mental health services.

This approach has already been shown to be effective for chronic pain in other sites (43) and the various components have individually been tested in small randomised trials.

Conclusion

As we develop focused pathways for treating coronary disease, we must not forget the far more numerous group with NCCP. These patients feel equally or more disabled and are a major drain on health-care resources, yet can be treated with inexpensive low-technology methods. Multidisciplinary clinics are effective for other chronic pain syndromes and are likely to be useful for chest pain. These clinics should include a cardiologist, psychologist and cardiac nurse and should be linked with and ideally based within the same geographical area as the Rapid Access Chest Pain Clinic. This setting and composition avoids the negative effects of the ‘mind-body’ dualism, which commonly leaves the patient feeling misunderstood with persistent worries about their health.

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