In over 50% of the people investigated for chest pain, coronary heart disease is excluded (Mayou et al. 1999, Esler & Bock 2004), yet very little is written about those in whom a diagnosis cannot be made; these are the people with unexplained chest pain. Within the nursing literature there are few references to this problem, yet nurses in emergency departments and chest pain clinics will often be the main professionals encountered during the patient's repeated presentations. For this reason, Jerlock et al.’s paper (2005) is a welcome addition to the sparse literature on the experience of living with unexplained chest pain.
Mayou et al. (1999) reported on a follow-up of 133 patients with unexplained chest pain. They found that one third of the patients (usually with milder symptoms) improved following reassurance and negative results from assessments. However, those people who continue to experience unexplained chest pain are regarded as difficult to treat.
Patients in Jerlock et al.’s study described their experience of pain, and how it intruded into everyday life. The descriptions are very typical of the experience of people with chronic pain. Many people with chronic pain develop hypervigilance, in which they continually scan their bodies for signs of pain (this was also reported by Jerlock et al.). When signs of pain are observed, the patient may then catastrophize (Asmundson et al. 2004) – that is, they will think of the worst-case scenario; so for people who experience repeated chest pain they may believe that they are suffering from myocardial infarction (demonstrated by the participant in Jerlock et al.’s study who reported ‘I feel very frightened, I don't want to die’). Patients with unexplained chest pain who are repeatedly reassured that their coronary arteries are normal are still likely to suffer from significant disability in later years (Fleet et al. 1994, Mayou et al. 1999). Asmundson et al. (2004) explain the link between report of chronic pain (with or without apparent cause) and disability in the ‘fear – anxiety – avoidance’ model of chronic pain. In this model, when people interpret their perceptions of pain as catastrophic (e.g. ‘it's a heart attack, I'm going to die’), they become very anxious and fearful, which leads to avoidance of anything that may precipitate the pain in future. In the study by Jerlock et al., participants ‘did not know much they dared to exert themselves’ and avoided many activities. Avoidance is a poor coping strategy as it leads to loss of fitness, contraction of social life and a consequent reduction in quality of life. This response to fear of heart disease is similar to that found in people who are newly diagnosed with angina (Lewin 1997, Furze et al. 2003). However, people with non-cardiac chest pain have greater fear of pain, avoid activities more, are more anxious than people with heart disease, and they use the same amount of medical care (Esler & Bock 2004). These findings, which Jerlock et al.’s study adds depth to, suggest that interventions designed to reduce the psychological distress and subsequent disability are overdue. As Esler and Bock (2004) state, being told that there is nothing wrong does not reassure or help these patients.
In their conclusion to the paper, Jerlock et al. suggest that specialist nurse intervention ‘would probably result in fewer visits to the emergency department’. There have been interventions for people with unexplained chest pain, but results have been mixed. Sanders et al. (1997) report a study of patients who received a diagnosis of non-cardiac chest pain following coronary angiography. Only 57 (40% of possible sample) patients agreed to participate and were randomized to receive either a brief intervention and phone follow-up from a cardiac nurse or usual care. The intervention was not successful, perhaps because the intervention focussed on the effects of psychological aspects at a time when people were only just coming to terms with being told that they did not have heart disease, despite many months of treatment for this. The patients were not receptive to the switch from a medical to a psychological focus at this time. Esler and Bock (2004) have argued that such all-or-nothing attributional approaches (either psychological or medical) are counter-productive, and a bio-psychosocial approach, which incorporates medical care and cognitive behaviour treatments, would be more acceptable. Esler et al. (2003) found that giving a brief intervention in the emergency department was able to reduce frequency of chest pain at three-month follow-up, but had no effect on avoidance coping or quality of life.
Mayou et al. (1999) suggest a stepped approach to care: after seeing a cardiologist and receiving a diagnosis of non-cardiac chest pain, the patient should be seen by a nurse specialist who has received extra training in the delivery of brief education and psychological interventions and follow-up. All patients should receive a review appointment with their nurse or GP to identify those with recurrent or persistent symptoms, as these may require referral to psychiatric or psychological services. A problem with this approach is the lack of detail and evidence for the brief intervention delivered by the nurse specialist.
Jerlock et al. have described the poor experience and quality of life of a group of people who could be helped by nurses within emergency rooms and chest pain clinics. As they suggest, nurses could talk to patients to elicit their illness narratives in order to have a deeper understanding of the patient experience. What is also needed is the development and testing of different models of care for these patients to find out what works. In that way successful, evidence-based practice can be incorporated into different points of the patient pathway.