Natural history and predictors of outcome for non-cardiac chest pain: a prospective 4-year cohort study

A randomized clinical trial of chiropractic treatment and self-management in patients with acute musculoskeletal chest pain: 1-year follow-up

OBJECTIVE

We have previously reported short-term follow-up from a pragmatic randomized clinical trial comparing 2 treatments for acute musculoskeletal chest pain: (1) chiropractic treatment and (2) self-management. Results indicated a positive effect in favor of the chiropractic treatment after 4 and 12 weeks. The current article investigates the hypothesis that the advantage observed at 4 and 12 weeks would be sustained after 1 year. In addition, we describe self-reported consequences of acute musculoskeletal chest pain at 1-year follow-up.

METHODS

In a nonblinded, randomized controlled trial undertaken at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain of musculoskeletal origin were included. After the baseline evaluation, patients were randomized to 4 weeks of either chiropractic treatment or self-management, with posttreatment questionnaire follow-up 52 weeks later. The primary outcome measures were change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale).

RESULTS

Both groups experienced decreases in pain, positive global, self-perceived treatment effect, and increases in the 36-Item Short Form Health Survey scores. No statistically significant differences were observed between groups at the 1-year follow-up, and we could not deduce a common trend in favor of either intervention.

CONCLUSIONS

At the 1-year follow-up, we found no difference between groups in terms of pain intensity and self-perceived change in chest pain in the first randomized clinical trial assessing chiropractic treatment vs minimal intervention for patients with acute musculoskeletal chest pain. Further research into health care utilization and use of prescriptive medication is warranted.

Management of noncardiac chest pain in women

Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, especially those of middle age, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; however other esophageal pathology including esophageal hypersensitivity, neuromuscular disease and eosinophilic esophagitis may also cause NCCP. Proton pump inhibitors are commonly used initially to manage NCCP, although patients who do not respond to this therapy require further investigation and differing treatment regimes. This article will focus on current knowledge regarding GI tract-related NCCP management strategies.

Suicidality and panic in emergency department patients with unexplained chest pain

OBJECTIVES

The present study aims to document the problem of suicidality in emergency department (ED) patients with unexplained chest pain and to assess the strength and independence of the relationship between panic and suicidal ideation (SI) in this population.

METHOD

This cross-sectional study included 572 ED patients with unexplained chest pain. SI, history of suicide attempts, history of SI and the presence of thoughts about how to commit suicide were assessed. Logistic regression analyses were used to quantify the relationship between current SI and panic.

RESULTS

Approximately 15% [95% confidence interval (CI), 12%-18%] of patients reported current SI, and 33% (95% CI, 29%-37%) reported history of SI. Nearly 19% (95% CI, 16%-22%) of patients had thought about a method to commit suicide, and 33% (95% CI, 29%-37%) had a history of a suicide attempt. Panic attacks were diagnosed in 42% (95% CI, 38%-46%) of patients, and 45% (95% CI, 39%-51%) of those had panic disorder. Panic increased the crude likelihood of current SI [odds ratio (OR)=2.53, 1.4-4.5]. This increase in SI risk remained significant after controlling for confounding factors (OR=1.70, 95% CI, 1.0-2.9).

CONCLUSIONS

Suicidality and SI were common and often severe in our sample of ED patients with unexplained chest pain.

The impact of perceived stress and perceived control on anxiety and mood disorders in noncardiac chest pain

Chest pain without detectable heart disease, noncardiac chest pain (NCCP), is linked with anxiety and depression. Theory posits stress and perceived control may relate to NCCP. We hypothesized stress would have direct and mediated effects via perceived control on anxiety and mood disorders in NCCP. Patients ( N = 113) completed questionnaires and a structured diagnostic interview. Stress and perceived control were associated with anxiety and mood disorder severity. Perceived control fully mediated the relation between stress and mood disorder severity but not anxiety disorder severity. Results are partially supportive of anxiety-based theories of NCCP.

Chiropractic treatment vs self-management in patients with acute chest pain: a randomized controlled trial of patients without acute coronary syndrome

OBJECTIVE

The musculoskeletal system is a common but often overlooked cause of chest pain. The purpose of the present study is to evaluate the relative effectiveness of 2 treatment approaches for acute musculoskeletal chest pain: (1) chiropractic treatment that included spinal manipulation and (2) self-management as an example of minimal intervention.

METHODS

In a nonblinded, randomized, controlled trial set at an emergency cardiology department and 4 outpatient chiropractic clinics, 115 consecutive patients with acute chest pain and no clear medical diagnosis at initial presentation were included. After a baseline evaluation, patients with musculoskeletal chest pain were randomized to 4 weeks of chiropractic treatment or self-management, with posttreatment questionnaire follow-up 4 and 12 weeks later. Primary outcome measures were numeric change in pain intensity (11-point box numerical rating scale) and self-perceived change in pain (7-point ordinal scale).

RESULTS

Both groups experienced decreases in pain, self-perceived positive changes, and increases in Medical Outcomes Study Short Form 36-Item Health Survey scores. Observed between-group significant differences were in favor of chiropractic treatment at 4 weeks regarding the primary outcome of self-perceived change in chest pain and at 12 weeks with respect to the primary outcome of numeric change in pain intensity.

CONCLUSIONS

To the best of our knowledge, this is the first randomized trial assessing chiropractic treatment vs minimal intervention in patients without acute coronary syndrome but with musculoskeletal chest pain. Results suggest that chiropractic treatment might be useful; but further research in relation to patient selection, standardization of interventions, and identification of potentially active ingredients is needed.

Alexithymia and anxiety sensitivity in patients with non-cardiac chest pain

The aim of this study was to examine independent and combined influences of alexithymia and anxiety sensitivity on chest pain and life interference in patients with non-cardiac chest pain (NCCP). Theories of NCCP posit a central role for emotion in the experience of chest pain, however, studies have not examined how alexithymia characterized by a difficulty identifying or verbalizing emotions, may influence this relationship. This study examined 231 patients (56% females, M age=50 years) with chest pain seeking cardiac evaluation, who showed no abnormalities during exercise tolerance testing. Forty percent (40%) scored at or above the moderate range of alexithymia. Whereas health care utilization was associated with elevated alexithymia among men, health care utilization was associated with elevated anxiety sensitivity among women. Hierarchical regression analyses revealed that alexithymia and anxiety sensitivity were both uniquely and independently associated with pain severity and life interference due to pain. Alexithymia-pain links were stronger for men compared to women. Secondary analyses conducted with a subsample suggest that alexithymia may be increasingly stable over time (i.e., 18-month follow-up). Findings are largely congruent with theoretical models of NCCP showing that personality and emotional factors are important in this medically unexplained syndrome.

Noncardiac chest pain: epidemiology, natural course and pathogenesis

Noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause. Noncardiac chest pain is a prevalent disorder resulting in high healthcare utilization and significant work absenteeism. However, despite its chronic nature, noncardiac chest pain has no impact on patients' mortality. The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. Esophageal dysmotility affects only the minority of noncardiac chest pain patients. Esophageal hypersensitivity may be present in non-GERD-related noncardiac chest pain patients regardless if esophageal dysmotility is present or absent. Psychological co-morbidities such as panic disorder, anxiety, and depression are also common in noncardiac chest pain patients and often modulate patients' perception of disease severity.

A cognitive behavior intervention program in women with unexplained chest pain--a pilot study

BACKGROUND

Unexplained chest pain (UCP) affects everyday life, causing fear and anxiety. Patients often have difficulty understanding their symptoms.

AIM

To test a cognitive behavior group intervention program designed for women with UCP, and investigate its effects in terms of participants' ideas and perceptions of the program as well as their pain experience.

METHOD

Nine women aged 44-69 participated in the pilot study, which included six group sessions. Three months after the intervention, interviews were conducted, followed by content analysis.

RESULTS

Narrating and sharing experiences led to awareness and understanding of what may affect chest pain. Knowledge about how stress affects the body and an understanding of one's own situation and what may affect the pain changed participants' patterns of thinking. The treatment provided tools to take control over beginning reactions to stress and thus prevent chest pain. Fewer pain attacks were reported but there was no pronounced decrease in pain intensity.

CONCLUSION

This pilot study shows that it is possible, through a cognitive behavior group intervention program, to generate positive experiences of managing stress and inner pressure and to change thinking patterns. The possibility to use these strategies and techniques to improve sleeping problems and alleviate pain is also presented.

Epidemiology and risk factors of pediatric chest pain: a systematic review

The epidemiology and associated risk factors of pediatric chest pain are not well described. Several studies report the prevalence of chest pain types among children and adolescents; however, detailed prospective studies that aim to determine continued morbidity, mortality, health-care seeking behaviors, continued medication use, and quality of life are lacking. A greater understanding of pediatric chest pain epidemiology and risk factors is required.

Exercise-provoked esophageal motility disorder in patients with recurrent chest pain

AIM: To investigate the relationship between exercise-provoked esophageal motility disorders and the prognosis for patients with chest pain.

METHODS: The study involved 63 subjects with recurrent angina-like chest pain non-responsive to empirical therapy with proton pump inhibitor (PPI). In all, a coronary artery angiography, panendoscopy, 24-h esophageal pH-metry and manometry, as well as a treadmill stress test with simultaneous esophageal pH-metry and manometry monitoring, were performed. Thirty-five subjects had no significant coronary artery lesions, and 28 had more than 50% coronary artery narrowing. In patients with hypertensive esophageal motility disorders, a calcium antagonist was recommended. The average follow-up period was 977 ± 249 d.

RESULTS: The prevalence of esophageal disorders, such as gastroesophageal reflux or diffuse esophageal spasm, was similar in patients both with and without significant coronary artery narrowing. Exercise prompted esophageal motility disorders, such as a decrease in the percentage of peristaltic and effective contractions and their amplitude, as well as an increase in the percentage of simultaneous and non-effective contractions. In 14 (22%) patients the percentage of simultaneous contractions during the treadmill stress test exceeded the value of 55%. Using Kaplan-Meier analysis and the proportional hazard Cox regression model, it was shown that the administration of a calcium channel antagonist in patients with such an esophageal motility disorder significantly decreased the risk of hospitalization as a result of a suspicion of acute coronary syndrome after the 2.7-year follow-up period.

CONCLUSION: In patients with chest pain non-responsive to PPIs, a diagnosis of exercise-provoked esophageal spasm may have the effect of lowering the risk of the next hospitalization.

Exertional esophageal pH-metry and manometry in recurrent chest pain

AIM: To investigate the diagnostic efficacy of 24-h and exertional esophageal pH-metry and manometry in patients with recurrent chest pain.

METHODS: The study included 111 patients (54% male) with recurrent angina-like chest pain, non-responsive to therapy with proton pump inhibitors. Sixty-five (59%) had non-obstructive lesions in coronary artery angiography, and in 46 (41%) significant coronary artery narrowing was found. In all patients, 24-h esophageal pH-metry and manometry, and treadmill stress tests with simultaneous esophageal pH-metry and manometry monitoring were performed. During a 24-h examination the percentage of spontaneous chest pain (sCP) episodes associated with acid reflux or dysmotility (symptom index, SI) was calculated. Patients with SI > 50% for acid gastroesophageal reflux (GER) were classified as having GER-related sCP. The remaining symptomatic individuals were determined as having non-GER-related sCP. During the stress test, the occurrence of chest pain, episodes of esophageal acidification (pH < 4 for 10 s) and esophageal spasm with more than 55% of simultaneous contractions (exercise-provoked esophageal spasm or EPES) were noted.

RESULTS: Sixty-eight (61%) individuals reported sCP during 24-h esophageal function monitoring. Eleven of these (16%) were classified as having GER-related sCP and 53/68 (84%) as having non-GER-related sCP. The exercise-provoked chest pain during a stress test occurred in 13/111 (12%) subjects. In order to compare the clinical usefulness of 24-h esophageal function monitoring and its examination limited only to the treadmill stress test, the standard parameters of diagnostic test evaluation were determined. The occurrence of GER-related or non-GER-related sCP was assumed as a “gold standard”. Afterwards, accuracy, sensitivity and specificity were calculated. These parameters expressed a prediction of GER-related or non-GER-related sCP occurrence by the presence of chest pain, esophageal acidification and EPES. Accuracy, sensitivity and specificity of chest pain during the stress test predicting any sCP occurrence were 28%, 35% and 80%, respectively, predicting GER-related sCP were 42%, 0% and 83%, respectively, and predicting non-GER-related sCP were 57%, 36% and 83%, respectively. Similar values were obtained for exercise-related acidification with pH < 4 longer than 10 s in the prediction of GER-related sCP (44%, 36% and 92%, respectively) and EPES in relation to non-GER-related sCP (48%, 23% and 84%, respectively).

CONCLUSION: The presence of chest pain, esophageal acidification and EPES had greater than 80% specificity to exclude the GER-related and non-GER-related causes of recurrent chest pain.

Chest pain in focal musculoskeletal disorders

The musculoskeletal system is a recognized source of chest pain. However, despite the apparently benign origin, patients with musculoskeletal chest pain remain under-diagnosed, untreated, and potentially continuously disabled in terms of anxiety, depression, and activities of daily living. Several overlapping conditions and syndromes of focal disorders, including Tietze syndrome, costochondritis, chest wall syndrome, muscle tenderness, slipping rib, cervical angina, and segmental dysfunction of the cervical and thoracic spine, have been reported to cause pain. For most of these syndromes, evidence arises mainly from case stories and empiric knowledge. For segmental dysfunction, clinical features of musculoskeletal chest pain have been characterized in a few clinical trials. This article summarizes the most commonly encountered syndromes of focal musculoskeletal disorders in clinical practice.

Future developments in chest pain diagnosis and management

Much of the focus of research on patients with chest pain is directed at technological advances in the diagnosis and management of acute coronary syndrome (ACS), pulmonary embolism (PE), and acute aortic dissection (AAD), despite there being no significant difference at 4 years as regards mortality, ongoing chest pain, and quality of life between patients presenting to the emergency department with noncardiac chest pain and those with cardiac chest pain. This article examines future developments in the diagnosis and management of patients with suspected ACS, PE, AAD, gastrointestinal disease, and musculoskeletal chest pain.

Anxiety and hypervigilance to cardiopulmonary sensations in non-cardiac chest pain patients with and without psychiatric disorders

We investigated body vigilance, cardiac anxiety, and the mediating role of interoceptive fear on pain in patients with non-cardiac chest pain (NCCP; a syndrome of chest pain in the absence of identifiable organic etiology). Patients were more attentive to cardiac-congruent sensations than cardiac-incongruent sensations (e.g., gastrointestinal, cognitive dyscontrol; p's < .001). Patients with a DSM-IV Axis I anxiety or mood disorder were more body vigilant compared to patients who did not have a disorder (p's < .05). Patients with anxiety disorders were particularly vigilant to and fearful of cardiac sensations relative to patients without anxiety disorders. Latent variable path models examined the extent that interoceptive fear mediated the association between body vigilance and cardiac anxiety on chest pain. Within each model, diagnostic status, body vigilance, and cardiac anxiety were exogenous and predicted interoceptive fear that in turn predicted pain. Separate models examined body vigilance and cardiac anxiety, and both models fit the data well. Findings showed partial mediation for the body vigilance factor, and full mediation for the cardiac anxiety factor. Interoceptive fear played a mediating role in both models. The syndrome of NCCP may persist partly due to conscious hypervigilance to and fear of cardiac-congruent body sensations, particularly among anxious patients.

Non-cardiac chest pain: the long-term natural history and comparison with gastroesophageal reflux disease

OBJECTIVES

The source of most cases of non-cardiac chest pain (NCCP) is thought to be the esophagus. We reasoned that if the origin of NCCP is truly esophageal and not cardiac, the characteristics and survival of individuals with NCCP should be similar to those of individuals with benign esophageal disease, such as gastroesophageal reflux disease (GERD). The aim of this study was to compare the characteristics, natural history, and long-term survival of two well-defined groups, NCCP patients and GERD patients.

METHODS

From 1984 to 1996, patients with NCCP were referred for endoscopy by the cardiology service after a coronary angiography done for chest pain was reported by the cardiologist as negative. Patients with GERD were referred for endoscopy for one of the usual symptoms of acid reflux. The baseline endoscopy and referrals occurred in the pre-proton pump inhibitor (PPI) era, before and during the availability of only the histamine receptor antagonists (HRAs). Thus, the endoscopic findings reflected the untreated natural state of the gastrointestinal mucosa. Endoscopic exams, esophageal biopsy, endoscopic anatomy mapping, and data verification were carried out in the endoscopy lab by one of three endoscopists using predefined criteria. All results were recorded both by hand and by entry into a database storage program. Patients were followed by their primary care providers in their usual outpatient general medicine clinics. The Veterans Affairs Decentralized Hospital Computer Program (VA DHCP) storage system provided access to mortality data as well as details of all prescriptions filled since 1985.

RESULTS

During the 12-year enrollment period, 1,218 patients in the GERD group and 161 in the NCCP group were referred for endoscopy. The follow-up period ranged from 1-22 years (mean 9.8 years). The groups were similar in age, gender, smoking and alcohol habits, and use of aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) (P=NS), but there was a greater proportion of blacks in the NCCP group (P<0.003). In every parameter, NCCP patients had a significantly lower prevalence of GERD-related findings such as endoscopic esophagitis (P<0.0001), Barrett's metaplasia (P=0.02), the development of esophageal adenocarcinoma, and hiatal hernia presence (P=0.0001). In patients with hiatal hernia, the size of the hernia was similar in both groups (P=0.94). In the NCCP group compared with the GERD group, there was a significantly higher prevalence of cardiac factors, such as coronary artery disease (P=0.03), and there was a trend toward greater cardiac clinic enrollment (P=0.08) and cardiac medication usage (P=0.06). The amount and duration of anti-GERD therapy, such as HRAs and PPIs, were significantly less in the NCCP group (P=0.0001 for PPIs and P=0.0002 for HRAs). The diagnosis of NCCP disappeared from the electronic hospital record in 96% of patients within 2 years of follow-up. There was no significant difference in survival between the GERD and NCCP groups (hazard ratio=1.1; CI=0.8-1.5); however, longer duration of follow-up in those with a greater number of events may make a difference in survival.

CONCLUSIONS

NCCP in most patients seems to be a short-lived event requiring extensive medical evaluation and having clinical characteristics significantly different from those associated with GERD. Patients with NCCP, confirmed by the absence of angiogram-documented coronary artery disease, who are referred for diagnostic endoscopy, have an excellent long-term benign prognosis, similar to patients with GERD.