Attitudes and referral patterns of primary care physicians when evaluating subjects with noncardiac chest pain--a national survey

Relevance of early management by proton-pump inhibitor in acute upper gastro-intestinal tract disorder: A scoping review

BACKGROUND

Proton-pump inhibitors (PPI) are frequently used in the emergency and general practice settings in several clinical presentations linked to acute upper gastro-intestinal tract disorders as abdominal or chest pain without recommendations.

OBJECTIVE

The aim of this scoping review was to assess pain reduction, diagnostic performance, and safety in the first 24 h-management in primary care or emergency medicine.

METHODS

Search was realized by 2 independent reviewers in PubMed, Embase, and Web of Science following PRISMA-ScR guidelines. Only original articles or systematic reviews in English were included. Studies about chronic and/or bleeding conditions, therapeutic cocktails and studies without pain evaluation were excluded. Two methodologies were used for bias estimation.

RESULTS

From 4442 titles, 79 full-text articles were assessed, and 9 were included. There is no strong evidence supporting the use of PPI as a first line analgesic or diagnostic test in acute syndromes linked to acute upper gastro-intestinal tract disorder. A small effect in pain reduction was retrieved in patients with low pain scores. A poor additional value in patients with gastric reflux, and a low specificity compared to other diagnostic tests were observed. A short-term PPI administration appears to be safe with low risk of serious allergic reactions, and poor adverse effects (moderate evidence).

CONCLUSION

Although PPIs may contribute to the multimodal analgesia in acute settings, with few and/or minor side effects, no recommendation can be drawn for their use as a primary analgesic. Data regarding the relevance of the PPI test are much less clear, no data regarding care pathways are available.

Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study

Background/Aims

Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population.

Methods

Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed.

Results

Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis.

Conclusions

The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.

Heart-focused anxiety and health care seeking in patients with non-cardiac chest pain: A prospective study

OBJECTIVES

This study aimed to estimate the incidence of medical consultations six months after an emergency department (ED) consultation for non-cardiac chest pain (NCCP). It also investigated the role of heart-focused anxiety (HFA) and other factors in predicting an increased healthcare utilization in these patients.

METHOD

This was a prospective study of 428 patients who came to an ED with NCCP. Patients completed an interview and questionnaires assessing HFA, psychological distress, the characteristics of NCCP, and comorbidities. Their medical consultations were assessed by telephone interview six months later. The contribution of each factor was assessed using a binomial negative regression.

RESULTS

Eighty-three percent of patients reported at least one medical consultation (mean=3.1, standard deviation=3.9). HFA (incident rate ratio 1.01; 95% CI, 1.00-1.02), the presence of a medical condition (2.14; 1.51-3.03), NCCP frequency (1.49; 1.16-1.91) and NCCP-related interference (1.08; 1.04-1.13) were predictive of further medical consultations.

CONCLUSIONS

A significant proportion of patients with NCCP are at risk of multiple medical consultations following discharge from the ED. HFA appears as a determinant of medical consultations after controlling for multiple confounding factors.

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

BACKGROUND

Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers.

METHODS

We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP.

RESULTS

We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions.

CONCLUSIONS

Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

Noncardiac chest pain: diagnostic evaluation

Noncardiac chest pain (NCCP) is a common and challenging clinical problem. It is estimated that more than 70 million Americans (23% of the population) suffer from this condition yearly. Patients with NCCP represent a diagnostic dilemma. Their chest pain is often indistinguishable from cardiac pain leading to extensive and expensive evaluations. Once coronary artery disease and other cardiac and pulmonary sources of chest pain are excluded, patients are frequently referred to gastroenterologists to look primarily for esophageal sources of pain. A variety of diagnostic tests are available to the practicing clinician to identify the origin of pain, including ambulatory pH testing, esophageal motility, upper endoscopy, provocative testing and even therapeutic trials.

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.

Patients dismissed from the hospital with a diagnosis of noncardiac chest pain: cardiac outcomes and health care utilization

OBJECTIVE

To determine the proportion of patients with noncardiac chest pain (NCCP) who see a gastroenterologist, the type and frequency of gastrointestinal (GI) and cardiac tests performed, and the frequency of cardiac death.

PATIENTS AND METHODS

A cohort of Olmsted County, Minnesota, residents presenting to the emergency department (ED) with chest pain between January 1, 1985, and December 31, 1992, was identified through the Rochester Epidemiology Project. We assessed the frequency of ED, cardiology, and gastroenterology visits and corresponding tests after a diagnosis of NCCP (n=320). We also assessed the frequency of cardiac events.

RESULTS

During follow-up, 49% of patients sought care in the ED, 42% had repeated cardiology evaluations, and 15% were seen by a gastroenterologist. Thirty-eight percent underwent esophagogastroduodenoscopy, but very few underwent manometry or a pH probe. Patients with NCCP of unknown origin had 3 times the rate of GI consultations as their counterparts with a GI disorder. Survival free of cardiac death in the subset with NCCP with a GI disorder was 90.2% at 10 years and 84.8% at 20 years, compared with 93.7% at 10 years and 88.1% at 20 years for the subset with NCCP of unknown origin.

CONCLUSION

The frequency of health care utilization in NCCP patients is high, but relatively few GI consultations and even fewer GI tests are performed. Patients dismissed from the hospital with NCCP continue to experience cardiac events, which may highlight a need for more aggressive cardiovascular risk factor management in this population.

[Non-cardiac chest pain]

CONTEXT

Non-cardiac chest pain or functional chest pain is a syndrome with high prevalence in occidental world. Findings on 15%-30% of coronary angiograms performed in patients with chest pain are normal. Causes significant impact in quality of life of patients and is associated with increased use of the health care facilities.

DATA SOURCES

To this review the following data base were accessed: Medline, the Cochrane Library, LILACS. The limit was the last 5 years publications and were selected relevant original articles, reviews, consensus, guidelines and meta-analysis.

RESULTS

Forty-four papers were selected, 28 original articles, 12 reviews, 2 guidelines, 1 consensus and 1 meta-analysis.

CONCLUSIONS

Exclusion of cardiac disease is of crucial importance. On the other hand non-cardiac chest pain could be related to gastrointestinal, muscular and respiratory causes and/or psychological disturbances. Treatment aims to attack mechanism generator in order to relieve or to eliminate symptoms. Drugs are the cornerstone of treatment, exception to achalasia patients because those have better response to dilation of the esophagus or surgery, and to those who need intensive psychological therapy. The most important drugs used are proton pump inhibitors and tricyclic antidepressants, the latter, to modulate central signal process (visceral hypersensitivity) and autonomic response. Recently, new diagnostic facilities, and also therapeutic modalities, such as esophageal botulin toxin injection and hypnosis are under investigations. In the near future, maybe some of them would take a place in the therapeutic scenario of these patients.

Origin of and therapeutic approach to cardiac syndrome X: Results of the proton pump inhibitor therapy for angina-like lingering pain trial (PITFALL trial)

AIM: To investigate the frequency of gastroen-terological diseases in the etiology and the efficacy of proton pump inhibitors (PPIs) in the treatment of cardiac syndrome X (CSX) as a subform of non-cardiac chest pain (NCCP).

METHODS: We investigated 114 patients with CSX using symptom questionnaires. A subgroup of these patients were investigated regarding upper gastrointestinal disorders (GIs) and treated with PPI. Patients not willing to participate in investigation and treatment served as control group.

RESULTS: Thirty-six patients denied any residual symptoms and were not further evaluated. After informed consent in 27 of the remaining 78 patients, we determined the prevalence of disorders of the upper GI tract and quantified the effect of treatment with pantoprazole. We found a high prevalence of gastroenterological pathologies (26/27 patients, 97%) with gastritis, gastroesophageal reflux disease (GERD) and acid reflux as the most common associated disorders. If treated according to the study protocol, these patients showed a significant improvement in the symptom score. Patients treated by primary care physicians, not according to the study protocol had a minor response to treatment (n = 19, -43%), while patients not treated at all (n = 26) had no improvement of symptoms (-0%).

CONCLUSION: Disorders of the upper GI tract are a frequent origin of CSX in a German population and can be treated with pantoprazole if given for a longer period.

Noncardiac chest pain

Noncardiac chest pain (NCCP) affects approximately 1 quarter of the adult population in the United States. The pathophysiology of the disorder remains to be fully elucidated. Identified underlying mechanisms for esophageal pain include gastroesophageal reflux disease (GERD), esophageal dysmotility, and visceral hypersensitivity. Aggressive antireflux treatment has been the main therapeutic strategy for GERD-related NCCP. NCCP patients with or without spastic esophageal motor disorders are responsive to pain modulators. The value of botulinum toxin injection, endoscopic treatment for GERD, and antireflux surgery in alleviating NCCP symptoms is limited.

Noncardiac chest pain--an Asia-Pacific survey on the views of primary care physicians

Noncardiac chest pain (NCCP) is common and has a significant impact on health care. Primary care physicians (PCPs)' attitudes, clinical approach, preference of diagnostic tests, referral patterns, and comfort in managing patients with NCCP in the Asia-Pacific region are not known. Consequently, we performed this survey in the Asia-Pacific region. The self-completed questionnaire was sent to PCPs in the Asia-Pacific region. A 28-item questionnaire contained questions on demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, treatment plans, and opinion on Helicobacter pylori and NCCP. A total of 108 (74%) PCPs returned the questionnaire. A mean of 18% of the patients were diagnosed with NCCP by PCPs in the past 6 months. Ninety-four percent of PCPs had treated NCCP patients in the last 6 months. Only 38% of the PCPs were comfortable in diagnosing NCCP but 85.2% believed that they should manage NCCP patients. PCPs in Malaysia and Philippines were more likely to refer patients to subspecialists. Fifty-seven and four-tenths percent of PCPs believed that H. pylori infection plays a role in the development of NCCP. The study demonstrates clearly that the understanding, diagnostic strategies, and treatment strategies of NCCP in the Asia-Pacific region are suboptimal and thus highlights the importance of educational and training programs tailored for PCPs in NCCP.

The view of gastroenterologists on non-cardiac chest pain in Asia

BACKGROUND

Non-cardiac chest pain is an important disorder in Asia. The practice and views of gastroenterologists on non-cardiac chest pain in this region are not known.

AIMS

To determine the current understanding, diagnostic practice and treatment strategies among gastroenterologists on the management of non-cardiac chest pain in Asia.

METHODS

A 24-item questionnaire was sent to gastroenterologists in Mainland China, Hong Kong, Malaysia, Indonesia, Philippines, Singapore, Taiwan and Thailand.

RESULTS

186 gastroenterologists participated with a response rate of 74%. 98% of gastroenterologists managed patients with non-cardiac chest pain over the last 6 months. 64% felt that the number of non-cardiac chest pain patients was increasing and 85% believed that the most common cause of non-cardiac chest pain was GERD. 94% of the gastroenterologists believed that they should manage non-cardiac chest pain patients, but only 41% were comfortable in diagnosing non-cardiac chest pain. The average number of investigations performed was four in non-cardiac chest pain patients, and oesophago-gastro-duodenoscopy was the most commonly used initial test. A proton pump inhibitor was considered the first-line treatment in non-cardiac chest pain and was reported as the most effective treatment by the gastroenterologists.

CONCLUSION

Most gastroenterologists were practicing evidence-based medicine, but frequent use of investigations and a lack of awareness of the role of visceral hypersensitivity in non-cardiac chest pain patients were noted.

New frontiers for the treatment of noncardiac chest pain: the adenosine receptors

Emerging data suggest that noncardiac chest pain (NCCP) is a very common disorder of international proportions. In the United States alone, an estimated 69 million patients suffer from NCCP. The clinical spectrum of patients with NCCP being referred to gastroenterologists seems to be changing to those failing to respond acid inhibition therapy or those who may not have gastroesophageal reflux (GER) in the first place. For these individuals there is an important need to find effective therapeutic options. These patients are the subject of the study that appears in this issue of The American Journal of Gastroenterology (Rao et al.,). Rao et al. report data from their tertiary center on consecutive patients with recurrent NCCP failing an 8-wk therapeutic trial of double-dose PPI or lacking evidence of GER on 24-h pH testing. They found that theophylline--a nonspecific adenosine receptor antagonist--when compared with placebo, improved the biomechanical and sensory properties of the esophageal wall and chest pain frequency, severity, and duration. This study underscores the potential role of adenosine receptors in visceral pain.

Non-cardiac chest pain: an update

Non-cardiac chest pain (NCCP) is very common, affecting up to a quarter of the USA adult population. Recent studies have shown that the disorder has a profound impact on patient's quality of life and is associated with marked increase in utilization of healthcare resources. Non-cardiac chest pain is a heterogeneous disorder with gastrointestinal and non-gastrointestinal causes. After excluding a cardiac cause, most NCCP patients are treated by cardiologists or primary care physicians and only the minority are referred to a gastroenterologist for further work-up. Gastro-oesophageal reflux disease (GORD) is the most common cause for NCCP. The role of oesophageal dysmotility in NCCP has been discounted in recent years. However, visceral hyperalgesia has been shown to play an important role in symptom generation of non-GORD-related NCCP. The main therapeutic interventions in GORD-related NCCP patients are potent antireflux modalities and pain modulators in those with non-GORD-related NCCP.

Noncardiac chest pain: the role of the cardiologist--a national survey

BACKGROUND

The current assumption is that noncardiac chest pain (NCCP) patients diagnosed by a cardiologist are commonly referred to a gastroenterologist for further evaluation. Thus far, there are no studies that assess the clinical approach and referral patterns of cardiologists when evaluating subjects with NCCP.

AIM

To determine the extent of involvement of cardiologists in the management of NCCP patients.

METHODS

Cardiologists were randomly selected from the American College of Cardiology national membership list and sent a 20-item questionnaire that included demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, and treatment plans.

RESULTS

A total of 246 (33%) cardiologists returned the questionnaire. A mean of 12.6% of patients were diagnosed with NCCP and 45.5% were treated by a cardiologist in the past 6 months. Of the NCCP patients that were referred, most ended up in the primary care physician clinic (45.9%) followed by gastroenterologist clinic (29.3%). Most cardiologists are either comfortable (35%) or very comfortable (43.1%) in diagnosing NCCP. Proton pump inhibitors (44.9%), lifestyle modifications (28.7%), and H2 blockers (11.8%) are the three most commonly used therapeutic modalities for NCCP.

CONCLUSION

Cardiologists manage about half of the diagnosed NCCP patients by themselves. Of those NCCP patients that are referred, cardiologists prefer to send them to a primary care physician rather than a gastroenterologist.

Diagnosis and treatment of noncardiac chest pain

Chest pain is common: one in four of the population have an episode annually. Of those who present to hospital, nearly two-thirds have noncardiac chest pain. More than half of these cases might have gastroesophageal reflux disease. Opinion differs over what is the most appropriate application of current investigatory methods. Evidence suggests that, once cardiac disease is ruled unlikely, empiric use of a proton pump inhibitor is an option; if acid suppression fails, detailed investigations as clinically indicated can be considered. A range of esophageal investigations is available, including 24-hour or 48-hour esophageal pH testing and esophageal manometry, as well as provocative tests, but there is no consensus as to which methods are the most useful. Psychiatric evaluation is not routine, but psychiatric or psychological disorders are common. Musculoskeletal disorders are also common, but are frequently overlooked. It is possible to subject patients to a comprehensive set of investigations before empiric therapy, but recent studies have failed to demonstrate an improved outcome using this exhaustive approach. A new tactic is required, with less attention spent on absolute diagnostic accuracy and more emphasis on optimizing the long-term clinical outcome in patients with noncardiac chest pain. It is possible that the targeted use of multiple drug trials in a policy of 'therapy as investigation' might be a superior methodology.