Chest pain of cardiac and noncardiac origin

Computed tomography myocardial perfusion imaging to detect myocardial ischemia in patients with anxiety and obstructive coronary heart disease post-exposure to mental stressors

This study aims to measure myocardial blood flow (MBF) using dynamic CT- myocardial perfusion imaging (CT-MPI) combined with mental stressors in patients with obstructive coronary artery disease (OCAD) and in patients with anxiety and no obstructive coronary artery disease (ANOCAD). A total of 30 patients with OCAD with 30 patients with ANOCAD were included in this analysis. Using the 17-segment model, the rest and stress phase MBF of major coronary arteries in participants were recorded respectively. Compared with ANOCAD patients, OCAD patients were more likely to have localized reduction of MBF (p < 0.05). For patients with ANOCAD, both global MBF and MBF of the main coronary arteries in the stress phase were lower than those in the rest phase (all p < 0.05), but there was no significant difference in MBF among the main coronary arteries in the rest or stress phase (p = 0.25, p = 0.15). For patients with OCAD, the MBF of the target area was lower than that of the non-target area in both the rest and stress phase, and the MBF of the target area in the stress phase was lower than that in the rest phase (all p < 0.05). However, there was no significant difference in MBF between the rest or stress phase in the non-target area (p = 0.73). Under mental stress, the decrease in MBF in ANOCAD patients was diffuse, while the decrease in MBF in OCAD patients was localized. Dynamic CT-MPI combined with mental stressors can be used to detect MBF changes in anxiety patients.

Associations of triglyceride-glucose (TyG) index with chest pain incidence and mortality among the U.S. population

BACKGROUND

The triglyceride and glucose (TyG) index, a simple surrogate marker of insulin resistance, is related to cardiovascular disease. However, there is a lack of evidence for the relationship between the TyG index and chest pain. This study aimed to investigate the association of the TyG index with chest pain and to evaluate the relationship between the TyG index and all-cause mortality in participants with or without chest pain.

METHODS

The present study utilized data from the 2001-2012 National Health and Nutrition Examination Survey (NHANES), employing a combination of cross-sectional and cohort study designs. The association between the TyG index and chest pain was investigated using weighted logistic regression models. Weighted Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) for all-cause mortality. Restricted cubic spline analysis was used to explore linear or nonlinear relationships between the TyG index and chest pain or all-cause mortality.

RESULTS

The findings revealed a positive correlation between the TyG index and chest pain, even after adjusting for potential confounding factors (quartile 4 versus quartile 1, odds ratio [OR] 1.42, 95% confidence interval [CI] 1.14-1.77, P = 0.002). During a mean follow-up time of 139 months, a total of 2286 individuals (27.43%) experienced mortality. Weighted multivariate Cox regression models indicated that for each one-unit increase in the TyG index, the adjusted hazard ratio (HR) for mortality was 1.14 (95% CI = 0.94-1.37) for participants with chest pain and 1.25 (95% CI = 1.09-1.43) for those without chest pain. Furthermore, restricted cubic spline analysis revealed a linear relationship between the TyG index and chest pain (P for nonlinearity = 0.902), whereas a nonlinear relationship was shown between the TyG index and all-cause mortality among populations regardless of chest pain (all P for nonlinearity < 0.01).

CONCLUSION

The TyG index was positively linked to a higher incidence of chest pain. Moreover, the TyG index was associated with all-cause mortality not only in participants with chest pain but also in those without chest pain.

Long-term effects and predictors of change of internet-delivered cognitive behavioural therapy on cardiac anxiety in patients with non-cardiac chest pain: a randomized controlled trial

BACKGROUND

Approximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain.

AIMS

To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress.

METHODS

A longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program (n = 54) in patients with NCCP, compared to psychoeducation (n = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety.

RESULTS

A total of 85% (n = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life (p = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up.

CONCLUSIONS

Cardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.

Non-Typical Clinical Presentation of COVID-19 Patients in Association with Disease Severity and Length of Hospital Stay

BACKGROUND

This study aimed to investigate the incidence of non-typical symptoms in ambulatory patients with mild-to-moderate COVID-19 infection and their potential association with disease progression.

MATERIALS AND METHODS

Data on the symptomatology of COVID-19 patients presenting to the fast-track emergency department were collected between March 2020 and March 2021. Fever, cough, shortness of breath, and fatigue-weakness were defined as "typical" symptoms, whereas all other symptoms such as nasal congestion, rhinorrhea, gastrointestinal symptoms, etc., were defined as "non-typical".

RESULTS

A total of 570 COVID-19 patients with a mean age of 42.25 years were included, the majority of whom were male (61.3%; N = 349), and were divided according to their symptoms into two groups. The mean length of hospital stay was found to be 9.5 days. A higher proportion of patients without non-typical symptoms were admitted to the hospital (p = 0.001) and the ICU (p = 0.048) as well. No significant differences were observed between non-typical symptoms and outcome (p = 0.685). Patients who did not demonstrate at least one non-typical symptom had an extended length of stay (p = 0.041). No statistically significant differences in length of hospital stay were associated with individual symptoms.

CONCLUSION

With the possible exception of gastrointestinal symptoms, non-typical symptoms of COVID-19 at baseline appear to predispose to a milder disease.

Evaluation of the Practice Guideline Used for Rule-Out of Myocardial Infarction at a Tertiary Cardiology Center

INTRODUCTION

With the current high burden on the healthcare system and limited resources, the efficient utilization of facilities is of utmost importance. We sought to present the practice guideline used at a high prevalence tertiary cardiology center and compare its safety and efficacy performance with the single high-sensitivity cardiac troponin T strategy, conventional and modified HEART score.

METHODS

In this prospective cohort study, consecutive patients presenting to the emergency department with chest pain or an angina equivalent were recruited. The primary endpoints consisted of major adverse cardiac events at index visits and 30-day follow-up. Patients were managed according to the practice guideline, and sensitivity and negative predictive values were compared.

RESULTS

Of the total 1548 patients, the mean age was 50.4 ± 15.7 years. Ninety-nine (10.9%) patients were admitted at the index visit, and 89 patients were consequently diagnosed with acute coronary symptoms. Six (0.007%) patients experienced major adverse cardiac events within the 30-day follow-up among discharged patients. Among 911 patients with at least 1 troponin, using single high-sensitivity cardiac troponin T, HEART score, and modified HEART score would have further admitted 805, 450, and 609 patients, respectively. The negative predictive value for all 4 algorithms did not significantly differ (99.2% vs. 100% vs. 99.3% vs. 99.6%, respectively).

CONCLUSIONS

The Tehran Herat Center protocol was a relatively safe protocol with high efficacy. Despite the high safety of the other diagnostic pathways, the high volume of patients needing additional evaluation could impose a high burden on the health care system.

Association between sleep duration and chest pain in US adults: A cross-sectional study

Objective

Herein, we purposed to explore the association of sleep duration with chest pain among adults in US.

Methods

This research work enrolled 13,274 subjects in the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2018. The association of sleep duration with chest pain among adults in US was evaluated by Multivariable logistic regression.

Results

To elucidate the association, we made adjustments for gender, BMI, diabetes, smoking status, drinking status, race, marital status, annual family income, hyperlipoidemia, Hypertension. Chest pain incidence decreased by 5% [OR = 0.95 (0.93, 0.98), p = 0.0004] for an increase in sleep duration by 1 h. A generalized additive model (GAM) was used to reseal a U-shaped relationship of sleep duration with incident chest pain. When duration of sleep was <6.5 h, chest pain incidence negatively correlated to sleep duration [OR = 0.77 (0.72, 0.82) P < 0.0001]. However, when sleep duration was ≥6.5 h, chest pain incidence rose with escalating sleep duration [OR = 1.07 (1.03, 1.11) p = 0.0014].

Conclusions

Duration of sleep was established to be independently linked with an increase in the occurrence of chest pain. Excessive sleep, as much as insufficient sleep, increases the risk of chest pain. Both excessive sleep and insufficient sleep are associated with an increased risk of chest pain.

Association of anxiety and depression with chronic liver diseases in patients with noncardiac chest pain: A cross-sectional study

Causes of chest pain can vary from benign to life-threatening conditions, and in many cases not necessary of cardiac origin. A possible reason for noncardiac chest pain could be anxiety or depression caused by chronic liver diseases. The aim of this study was to investigate the association of anxiety and depression with chronic liver disease in patients with noncardiac pain. Patients with chest tightness or pain referred for treadmill exercise testing were recruited from a regional hospital in southern Taiwan. Medical records of the patients were used to define the presence and type of chronic liver disease. Multiple logistic regression analyses were conducted to assess the association of anxiety and depression with chronic liver disease. A total of 2537 patients with liver function test results and abdominal sonography data were analyzed, and 1965 patients showed a negative treadmill exercise testing. The mean age of these 1965 patients was 51.9 years and 54.2% were male. The prevalence of alcoholic liver disease, hepatitis B, hepatitis C, and fatty liver disease was 10.6%, 10.9%, 3.7%, and 27.0%, respectively. Results from multiple logistic regression analyses showed that the risk of anxiety (adjusted odds ratio [aOR] = 1.83, P < .001) and depression (aOR = 1.85, P < .001) was significantly higher in patients with alcoholic liver disease. Anxiety was significantly higher in patients with fatty liver disease (aOR = 1.30, P = .031), and the risk of depression was significantly higher in patients with chronic hepatitis C (aOR = 2.18, P = .005). In conclusion, in patients with noncardiac chest pain, alcoholic liver disease was significantly associated with anxiety and depression, while those with fatty liver and chronic hepatitis C were associated with anxiety and depression, respectively. Clinicians should be vigilant to these correlations in their practice.

Use of POCUS in Chest Pain and Dyspnea in Emergency Department: What Role Could It Have?

Chest pain and dyspnea are common symptoms in patients presenting to the emergency room (ER); oftentimes it is not possible to clearly identify the underlying cause, which may cause the patient to have to return to the ER. In other cases, while it is possible to identify the underlying cause, it is necessary to perform a large number of tests before being able to make a diagnosis. Over the last twenty years, emergency medicine physicians have had the possibility of using ultrasound to help them make and rule out diagnoses. Specific ultrasound tests have been designed to evaluate patients presenting with specific symptoms to ensure a fast, yet complete, evaluation. In this paper, we examine the role of ultrasound in helping physicians understand the etiology behind chest pain and dyspnea. We analyze the different diseases and disorders which may cause chest pain and dyspnea as symptoms and discuss the corresponding ultrasound findings.

Are Patients at Risk for Developing Panic Disorder After an Emergency Department Visit With Noncardiac Chest Pain?

BACKGROUND

Panic disorder (PD) is common in emergency department (ED) patients with noncardiac chest pain (NCCP). The literature suggests that initially PD-free patients may be at increased risk of developing PD in the months or years following an ED visit.

OBJECTIVES

This study aims to determine the incidence of PD in the 2 years following an ED visit with NCCP and to identify predictors of incident PD.

METHODS

This study was conducted using a longitudinal, observational design. Five hundred and eighty-five patients with NCCP (without PD) were recruited in two EDs. They underwent an interview and completed a series of questionnaires assessing anxiety disorders, perceived social support, psychological distress, anxiety sensitivity, comorbidities, and stressful life events. PD was assessed 6 months, 1 year, and 2 years after the initial interview.

RESULTS

PD incidence was 11.1% (95% confidence interval: 8.7-13.9) in the two years following the baseline assessment. Anxiety sensitivity (odds ratio = 1.08; 95% confidence interval: 1.04-1.11; P < .001) and stress related to life events (odds ratio = 1.14; 95% confidence interval: 1.06-1.24; P = .001) significantly predicted incident PD.

CONCLUSIONS

Patients with NCCP are at high risk for developing PD in the 2 years following an ED visit with NCCP. Anxiety sensitivity and stress related to life events may be promising clinical targets for preventive interventions.

The associations between psychological distress and health-related quality of life in patients with non-cardiac chest pain

Background

Recurrent chest pain episodes with no clear explanation may affect patients’ psychological wellbeing and health-related quality of life (HRQoL) negatively. Despite the fact that a significant amount of patients with non-cardiac chest pain (NCCP) might have a history of Cardiac Disease (CD), there is today a lack of knowledge on how CD influences the association between psychological wellbeing and HRQoL in patients with NCCP. Therefore, the aim of this study is to describe HRQoL in patients with NCCP, with or without history of CD, and to explore the association between HRQoL and cardiac anxiety, depressive symptoms, fear of body sensations and somatization.

Methods

Five hundred fifty-two patients discharged with NCCP from four hospitals in Southeast Sweden completed the EQ-5D, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9, Body Sensations Questionnaire, and Patient Health Questionnaire-15.

Results

Fifty precent reported at least moderate problems regarding pain/discomfort and 25% reported at least moderate problems in the HRQoL dimensions mobility, usual activities, and anxiety/depression. Patients with NCCP and history of CD reported significantly lower HRQoL (p ≤ 0.05) compared to patients with NCCP without CD. In the total study population, cardiac anxiety, depressive symptoms, and somatization had weak significant negative associations (beta = 0.187–0.284, p < 0.001) with HRQoL. In patients with history of CD, the association between depressive symptoms and HRQoL was moderate (beta = − 0.339, p < 0.001), compared to weak association in patients without CD (beta = − 0.193, p < 0.001). On the other hand, the association between cardiac anxiety and HRQoL was weak in both patients with history of CD (beta = − 0.156, p = 0.05), and in those without (beta = − 0.229, p < 0.001).

Conclusions

Patients with NCCP, in particular those with history of CD, reported low levels of HRQoL, which was associated with psychological distress. This should be considered when developing psychological interventions aiming to improve HRQoL in patients with NCCP.

RNA-sequencing reveals that STRN, ZNF484 and WNK1 add to the value of mitochondrial MT-COI and COX10 as markers of unstable coronary artery disease

Markers in monocytes, precursors of macrophages, which are related to CAD, are largely unknown. Therefore, we aimed to identify genes in monocytes predictive of a new ischemic event in patients with CAD and/or discriminate between stable CAD and acute coronary syndrome. We included 66 patients with stable CAD, of which 24 developed a new ischemic event, and 19 patients with ACS. Circulating CD14+ monocytes were isolated with magnetic beads. RNA sequencing analysis in monocytes of patients with (n = 13) versus without (n = 11) ischemic event at follow-up and in patients with ACS (n = 12) was validated with qPCR (n = 85). MT-COI, STRN and COX10 predicted new ischemic events in CAD patients (power for separation at 1% error rate of 0.97, 0.90 and 0.77 respectively). Low MT-COI and high STRN were also related to shorter time between blood sampling and event. COX10 and ZNF484 together with MT-COI, STRN and WNK1 separated ACS completely from stable CAD patients. RNA expressions in monocytes of MT-COI, COX10, STRN, WNK1 and ZNF484 were independent of cholesterol lowering and antiplatelet treatment. They were independent of troponin T, a marker of myocardial injury. But, COX10 and ZNF484 in human plaques correlated to plaque markers of M1 macrophage polarization, reflecting vascular injury. Expression of MT-COI, COX10, STRN and WNK1, but not that of ZNF484, PBMCs paired with that in monocytes. The prospective study of relation of MT-COI, COX10, STRN, WNK1 and ZNF484 with unstable CAD is warranted.

Hospitalised patients with unexplained chest pain: incidence and prognosis

BACKGROUND

The prognosis of unexplained chest pain patients provides valuable information for evaluation of health services.

OBJECTIVE

To examine prognosis of unexplained chest pain.

METHODS

Using data from in- and outpatient hospital visits in Norway of patients discharged with a main diagnosis of unexplained chest pain (ICD-10: R072-R074) in 2010-2012, the 1-year incidence of coronary heart disease (CHD), any cardio-vascular disease (CVD) and mortality was evaluated. Cases with prior 2-year history of CVD or chest pain were excluded. Cox proportional hazards evaluated outcomes by patient characteristics and standardized mortality ratios evaluated observed versus expected mortality.

RESULTS

Of 59 569 patients identified (20-89 years of age), the majority (86%) were referred to hospital by out-of-hours emergency care centres. Subsequent CHD was noted for 12.5%, 19.5% and 25.0% of men and 7.2%, 11.0%, 14.0% of women aged 45-64, 65-74 and 75-89 years, respectively. The per cent of deaths attributed to CVD were greatest within the first 2 months of postdischarge. Total mortality rates (per 1000 person-years) were 6.6 in men and 4.7 in women aged 45-64 and 69.2 in men and 39.5 in women aged 75-89 years. Relative to the general population, mortality was 53% and 45% higher for men and women under 65 years of age, respectively, attributed primarily to non-CVD causes.

CONCLUSION

Patients in Norway discharged with unexplained chest pain are an at-risk group in terms of incident CHD, any CVD and mortality, including non-CVD mortality during the first-year postdischarge. The results suggest that unexplained chest pain patients may benefit from greater healthcare coordination between medical disciplines.

History of gastroesophageal reflux disease in patients with suspected coronary artery disease

It is well known that patients with gastroesophageal reflux disease (GERD) experience GERD-related chest pain, but little is known about the relationship between GERD and coronary artery disease (CAD). We evaluated medical history of GERD in patients with suspected CAD and its association with types of CAD. We enrolled 236 patients who underwent coronary angiography (CAG). We assessed past medical history of each patient, making note of esophageal or stomach diseases such as GERD including reflux esophagitis and non-erosive reflux disease. The patients were divided into the following three subgroups based on the CAG results. Group I, patients with o-CAD (> 50% stenosis with ischemic findings, n = 141); Group II, patients with vasospastic angina (VSA, with positive spasm provocation test without organic coronary stenosis, n = 52); and Group III, patients without organic coronary stenosis or VSA (n = 43). Group I included more men than women (p < 0.001) and the frequencies of smoking, lipid disorders, and diabetes mellitus in this group were higher than those in the other groups (p < 0.01). The frequency of medical history of GERD was significantly higher in Group II (21%) than in Group I (3%) or Group III (7%, p < 0.0001). Logistic regression analysis showed that a medical history of GERD (OR 7.8; p < 0.01) was one of the factors associated with the presence of VSA. Our findings showed that a medical history of GERD was frequently observed in approximately one-fifth of patients with VSA, indicating that VSA may be present in patients with chest pain and a medical history of GERD.

Symptoms are not the solution but the problem: Why psychiatric research should focus on processes rather than symptoms

Progress in psychiatric research has been hindered by the use of artificial disease categories to map distinct biological substrates. Efforts to overcome this obstacle have led to the misconception that relevant psychiatric dimensions are not biologically reducible. Consequently, the return to phenomenology is once again advocated. We propose a process-centered paradigm of biological reduction compatible with non-reductive materialism.

Association of 25-hydroxyvitamin D with HDL-cholesterol and other cardiovascular risk biomarkers in subjects with non-cardiac chest pain

BACKGROUND

Chest pain is a serious symptom that is routinely investigated as a sign of coronary artery disease. Non-cardiac chest pain (NCCP) is indistinguishable from ischemic chest pain and both are considered serious and receive similar medical investigations. Although NCCP is not associated with cardiovascular diseases (CVDs), patients with NCCP may become anxious and frightened from developing coronary events. So, it will be valuable to improve modifiable cardiovascular risk factors in such subjects to reduce fear from CVDs. Because vitamin D deficiency was considered as a possible modifiable cardiovascular risk factor, our aim was to investigate association between serum vitamin D and cardiovascular risk variables in subjects with NCCP.

METHODS

A cross-sectional study involved 104 subjects who underwent cardiac catheterization that did not reveal any cardiac origin for their chest pain. 25-hydroxyvitamin D was measured by electrochemiluminescence immunoassay, glucose was measured by hexokinase method, hemoglobin A1c (HbA1c) was measured by turbidimetric inhibition immunoassay and lipid profile was measured by enzymatic colorimetric assays.

RESULTS

High density lipoprotein cholesterol (HDL-C) was significantly higher in subjects with sufficient vitamin D compared to those with insufficient or deficient vitamin D (p-value< 0.01). 25-hydroxyvitamin D was positively associated with HDL-C (p-value< 0.01) and inversely associated with HbA1c (p-value = 0.02). 25-hydroxyvitamin D was not significantly correlated with other cardiovascular biomarkers including blood pressure, glucose, and other components of lipid profile (p-values> 0.05).

CONCLUSIONS

low serum vitamin D could be involved in reducing HDL-C and increasing HbA1c and thus it may increase cardiovascular risk in subjects with NCCP.

Chest Pain: If It Is Not the Heart, What Is It?

Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.

The associations between psychological distress and healthcare use in patients with non-cardiac chest pain: does a history of cardiac disease matter?

BACKGROUND

Psychological distress such as somatization, fear of body sensations, cardiac anxiety and depressive symptoms is common among patients with non-cardiac chest pain, and this may lead to increased healthcare use. However, the relationships between the psychological distress variables and healthcare use, and the differences in relation to history of cardiac disease in these patients has not been studied earlier. Therefore, our aim was to explore and model the associations between different variables of psychological distress (i.e. somatization, fear of body sensations, cardiac anxiety, and depressive symptoms) and healthcare use in patients with non-cardiac chest pain in relation to history of cardiac disease.

METHODS

In total, 552 patients with non-cardiac chest pain (mean age 64 years, 51% women) responded to the Patient Health Questionnaire-15, Body Sensations Questionnaire, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9 and one question regarding number of healthcare visits. The relationships between the psychological distress variables and healthcare visits were analysed using Structural Equation Modeling in two models representing patients with or without history of cardiac disease.

RESULTS

A total of 34% of the patients had previous cardiac disease. These patients were older, more males, and reported more comorbidities, psychological distress and healthcare visits. In both models, no direct association between depressive symptoms and healthcare use was found. However, depressive symptoms had an indirect effect on healthcare use, which was mediated by somatization, fear of body sensations, and cardiac anxiety, and this effect was significantly stronger in patients with history of cardiac disease. Additionally, all the direct and indirect effects between depressive symptoms, somatization, fear of body sensations, cardiac anxiety, and healthcare use were significantly stronger in patients with history of cardiac disease.

CONCLUSIONS

In patients with non-cardiac chest pain, in particular those with history of cardiac disease, psychological mechanisms play an important role for seeking healthcare. Development of interventions targeting psychological distress in these patients is warranted. Furthermore, there is also a need of more research to clarify as to whether such interventions should be tailored with regard to history of cardiac disease or not.

Non-Cardiac Chest Pain

Background

Non-cardiac chest pain (NCCP) is recurrent angina pectoris-like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected (in this order) at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life due to NCCP is comparable, and partially even higher, to that caused by cardiac chest pain. Reasons for psychological strain are symptom recurrence in approximately 50%, nonspecific diagnosis with resulting uncertainty, and insufficient integration of other medical disciplines in the diagnostic workup.

Methods and Results

The management of patients with chest pain has to be multidisciplinary because non-cardiac causes may be frequently encountered. Especially gastroenterological expertise is required since the cause of chest pain is gastroesophageal reflux disease (GERD) in 50-60%, hypercontractile esophageal motility disorders with nutcracker/jackhammer esophagus or diffuse esophageal spasm or achalasia in 15-18%, and other esophageal alterations (e.g., infectious esophageal inflammation, drug-induced ulcers, rings, webs, eosinophilic esophagitis) in 32-35%.

Conclusion

This review highlights the importance of regular interdisciplinary ward rounds and management of chest pain units.

Chest pain and shortness of breath in cardiovascular disease: a prospective cohort study in UK primary care

OBJECTIVE

To determine characteristics associated with monthly chest pain and shortness of breath (SoB) during activity in cardiovascular disease (CVD) and trajectories of these symptoms over 10 months.

STUDY DESIGN AND SETTING

Baseline questionnaire was sent to patients aged ≥40 years from 10 UK general practices. Responders were sent monthly questionnaires for 10 months. For patients with CVD (ischaemic heart disease and heart failure), the association of sociodemographic characteristics, pain elsewhere and anxiety and depression with monthly reports of chest pain and SoB during activity were determined using multilevel, multinomial logistic regression. Common symptom trajectories were determined using dual trajectory latent class growth analysis.

RESULTS

661 patients with CVD completed at least 5 monthly questionnaires. Multiple other pain sites (relative risk ratio: 4.03; 95% CI 1.64 to 9.91) and anxiety or depression (relative risk ratio: 3.31; 95% CI 1.89 to 5.79) were associated with reporting weekly chest pain. Anxiety or depression (relative risk ratio: 4.10; 95% CI 2.72 to 6.17), obesity (relative risk ratio: 2.53; 95% CI 1.49 to 4.30), older age (80+: relative risk ratio: 2.51; 95% CI 1.19 to 5.26), increasing number of pain sites (4+: relative risk ratio: 4.64; 95% CI 2.35 to 9.18) and female gender (relative risk ratio: 1.81; 95% CI 1.20 to 2.75) were associated with reporting weekly SoB. Eight symptom trajectories were identified, with SoB symptoms more common than chest pain.

CONCLUSIONS

Potentially modifiable characteristics are associated with the experience of chest pain and SoB. Identified symptom trajectories may facilitate tailored care to improve outcomes in patients with CVD.

Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety

BACKGROUND

Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders.

OBJECTIVE

Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes.

METHODS

Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism.

RESULTS

Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to "stress" or "anxiety"; their mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety.

CONCLUSIONS

Without prompting, 8% of patients self-identified "stress" or "anxiety" as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes.

Guided Internet-delivered cognitive behavioural therapy in patients with non-cardiac chest pain - a pilot randomized controlled study

BACKGROUND

Patients with recurrent episodes of non-cardiac chest pain may experience cardiac anxiety and avoidance behavior, leading to increased healthcare utilization. These patients might benefit from help and support to evaluate the perception and management of their chest pain. The purpose of this study was to test the feasibility of a short guided Internet-delivered cognitive behavioural therapy (CBT) program and explore the effects on cardiac anxiety, fear of body sensations, depressive symptoms, and chest pain in patients with non-cardiac chest pain, compared with usual care.

METHODS

A pilot randomized controlled study was conducted. Fifteen patients with non-cardiac chest pain with cardiac anxiety or fear of body sensations, aged 22-76 years, were randomized to intervention (n = 7) or control (n = 8) groups. The four-session CBT program contained psychoeducation, physical activity, and relaxation. The control group received usual care. Data were collected before and after intervention.

RESULTS

Five of seven patients in the intervention group completed the program, which was perceived as user-friendly with comprehensible language, adequate and varied content, and manageable homework assignments. Being guided and supported, patients were empowered and motivated to be active and complete the program. Patients in both intervention and control groups improved with regard to cardiac anxiety, fear of body sensations, and depressive symptoms, but no significant differences were found between the groups.

CONCLUSIONS

The Internet-delivered CBT program seems feasible for patients with non-cardiac chest pain, but needs to be evaluated in larger groups and with a longer follow-up period.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02336880 . Registered on 8 January 2015.

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

Background

Depression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.

Objectives

Our aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.

Design

The UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.

Setting

Thirty-three GP surgeries in south London.

Participants

Adult patients on GP CHD registers.

Interventions

From the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.

Main outcome measures

The main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.

Results

Personalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.

Conclusions

Chest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.

Trial registration

Current Controlled Trials ISRCTN21615909.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

MicroRNAs as circulating biomarkers in acute coronary syndromes: A review

Coronary artery disease (CAD) and its complications remain the most common cause of death worldwide. Cardiac troponins (cTn) are standard biomarkers used today for diagnosis and risk stratification of myocardial infarction (MI). Increasing efforts are made to develop additional, new biomarkers for more effective and safe rule-in and rule-out of MI patients at the emergency department. During the past decade, microRNAs (miRNAs) have emerged as new, potential diagnostic biomarkers in several diseases, including MI. In this review, we aimed to summarize some of the prominent studies in the field, and discuss the potential value of miRNAs in the diagnosis of MI.

An intervention to reassure patients about test results in rapid access chest pain clinic: a pilot randomised controlled trial

Background

Most people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation. Consequently, many patients are not reassured they have the correct diagnosis or treatment. A previous trial reported that, in people with non-cardiac chest pain, a brief discussion with a health psychologist before the tests about the meaning of potential results led to people being significantly more reassured. The aim of this pilot was to test study procedures and inform sample size for a future multi-centre trial and to gain initial estimates of effectiveness of the discussion intervention.

Methods

This was a two-arm pilot randomised controlled trial in outpatient rapid access chest pain clinic in 120 people undergoing investigation for new onset, non-urgent chest pain. Eligible participants were randomised to receive either: a discussion about the meaning and implication of test results, delivered by a nurse before tests in clinic, plus a pre-test pamphlet covering the same information (Discussion arm) or the pre-test pamphlet alone (Pamphlet arm). Main outcome measures were recruitment rate and feasibility for a future multi-centre trial, with an estimate of reassurance in the groups at month 1 and 6 using a 5-item patient-reported scale.

Results

Two hundred and seventy people attended rapid access chest pain clinic during recruitment and 120/270 participants (44%) were randomised, 60 to each arm. There was no evidence of a difference between the Discussion and Pamphlet arms in the mean reassurance score at month 1 (34.2 vs 33.7) or at month 6 (35.3 vs 35.9). Patient-reported chest pain and use of heart medications were also similar between the two arms.

Conclusions

A larger trial of the discussion intervention in the UK would not be warranted. Patients reported high levels of reassurance which were similar in patients receiving the discussion with a nurse and in those receiving a pamphlet alone.

Trial registration

Current Controlled Trials ISRCTN60618114 (assigned 27.05.2011).

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2261-14-138) contains supplementary material, which is available to authorized users.

The UPBEAT nurse-delivered personalized care intervention for people with coronary heart disease who report current chest pain and depression: a randomised controlled pilot study

BACKGROUND

Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression.

METHODS

Multi-centre, outcome assessor-blinded, randomized parallel group study. CHD patients reporting chest pain and scoring 8 or more on the HADS were randomized to personalized care (PC) or treatment as usual (TAU) for 6 months and followed for 1 year. Primary outcome was acceptability and feasibility of procedures; secondary outcomes included mood, chest pain, functional status, well being and psychological process variables.

RESULT

1001 people from 17 General Practice CHD registers in South London consented to be contacted; out of 126 who were potentially eligible, 81 (35% female, mean age = 65 SD11 years) were randomized. PC participants (n = 41) identified wide ranging problems to work on with nurse-case managers. Good acceptability and feasibility was indicated by low attrition (9%), high engagement and minimal nurse time used (mean/SD = 78/19 mins assessment, 125/91 mins telephone follow up). Both groups improved on all outcomes. The largest between group difference was in the proportion no longer reporting chest pain (PC 37% vs TAU 18%; mixed effects model OR 2.21 95% CI 0.69, 7.03). Some evidence was seen that self efficacy (mean scale increase of 2.5 vs 0.9) and illness perceptions (mean scale increase of 7.8 vs 2.5) had improved in PC vs TAU participants at 1 year. PC appeared to be more cost effective up to a QALY threshold of approximately £3,000.

CONCLUSIONS

Trial and intervention procedures appeared to be feasible and acceptable. PC allowed patients to work on unaddressed problems and appears cheaper than TAU.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN21615909.

A non-ischaemic cause of elevated troponin

A 27-year-old woman with chest pain was admitted for elevated troponin levels. Troponin remained mildly elevated upon repeat testing, and a review of the medical record revealed that she had had an elevated troponin level in the past. She had a cardiac catheterisation that revealed angiographically normal coronary arteries. Repeat troponin testing with and without ethylene glycol revealed a negative troponin level after addition of ethylene glycol, suggesting antibodies were interfering with the assay.

Diagnostic potential of plasmatic MicroRNA signatures in stable and unstable angina

Purpose

We examined circulating miRNA expression profiles in plasma of patients with coronary artery disease (CAD) vs. matched controls, with the aim of identifying novel discriminating biomarkers of Stable (SA) and Unstable (UA) angina.

Methods

An exploratory analysis of plasmatic expression profile of 367 miRNAs was conducted in a group of SA and UA patients and control donors, using TaqMan microRNA Arrays. Screening confirmation and expression analysis were performed by qRT-PCR: all miRNAs found dysregulated were examined in the plasma of troponin-negative UA (n=19) and SA (n=34) patients and control subjects (n=20), matched for sex, age, and cardiovascular risk factors. In addition, the expression of 14 known CAD-associated miRNAs was also investigated.

Results

Out of 178 miRNAs consistently detected in plasma samples, 3 showed positive modulation by CAD when compared to controls: miR-337-5p, miR-433, and miR-485-3p. Further, miR-1, -122, -126, -133a, -133b, and miR-199a were positively modulated in both UA and SA patients, while miR-337-5p and miR-145 showed a positive modulation only in SA or UA patients, respectively. ROC curve analyses showed a good diagnostic potential (AUC ≥ 0.85) for miR-1, -126, and -483-5p in SA and for miR-1, -126, and -133a in UA patients vs. controls, respectively. No discriminating AUC values were observed comparing SA vs. UA patients. Hierarchical cluster analysis showed that the combination of miR-1, -133a, and -126 in UA and of miR-1, -126, and -485-3p in SA correctly classified patients vs. controls with an efficiency ≥ 87%. No combination of miRNAs was able to reliably discriminate patients with UA from patients with SA.

Conclusions

This work showed that specific plasmatic miRNA signatures have the potential to accurately discriminate patients with angiographically documented CAD from matched controls. We failed to identify a plasmatic miRNA expression pattern capable to differentiate SA from UA patients.

Societal costs of non-cardiac chest pain compared with ischemic heart disease--a longitudinal study

BACKGROUND

Non-cardiac chest pain (NCCP) is a common complaint. Our aim was to present a detailed description of the costs of patients with NCCP compared to patients with acute myocardial infarction (AMI) and Angina Pectoris (AP) from a societal perspective.

METHODS

Data on healthcare utilization and annual societal costs, including direct healthcare costs and indirect costs due to productivity loss, were collected from different databases. The participants consisted of 199 patients from a general hospital in Sweden (99 with NCCP, 51 with AMI, 49 with AP), mean age of 67 years, 59% men.

RESULTS

NCCP, AMI, and AP patients had on average 54, 50 and 65 primary care contacts and 3, 4, and 4 hospital admissions during a period of 2 years. Length of hospital stay was 6, 11 and 11 days. On average, 14%, 18%, and 25% of NCCP, AMI and AP patients were on sick-leave annually, and about 12% in each group received a disability pension. The mean annual societal costs of NCCP, AMI and AP patients were €10,068, €15,989 and €14,737.

CONCLUSIONS

Although the annual societal cost of NCCP patients was lower than in AMI and AP patients, the cost was still considerable (€10,068). Taken into account the high prevalence of NCCP, the cumulative annual national cost of these patients could be more than the double of AMI and AP if all patients incurred the same costs as in this study. Targeted interventions are important in order to support patients with NCCP and minimize healthcare utilization and costs.

Pharmacokinetic comparison of the vasorelaxant compound ferulic acid following the administration of Guanxin II to healthy volunteers and patients with angina pectoris

Coronary heart disease (CHD) is the leading cause of mortality worldwide. The Chinese medicinal formula Guanxin II has been shown to have a favorable effect in the attenuation of angina. The aim of this study was to compare the pharmacokinetics of ferulic acid (FA), which is a vasorelaxant compound present in Guanxin II, in healthy volunteers and patients with angina pectoris following the administration of Guanxin II. Ex vivo experiments were performed in order to investigate the vasorelaxant effect of FA on the human internal mammary artery (IMA) to provide evidence that it is a bioactive component of Guanxin II. Following the oral administration of Guanxin II, the FA levels in the serum were quantified by a simple and rapid high-performance liquid chromatography (HPLC) method. Treatment with FA (10⁻⁸−10⁻³ M) caused a concentration-dependent relaxation of endothelial IMA rings following precontraction with KCl. Statistically significant differences were identified between the pharmaco-kinetic parameters C_max, t_1/2α, t_1/2β and t_1/2Ka of the healthy volunteers and the patients with angina pectoris following the oral administration of Guanxin II. FA is a bioactive compound absorbed from Guanxin II that attenuates angina pectoris, a condition that may modify the pharmacokinetics of FA. Not only do the pharmacokinetic parameters direct the clinical use of Guanxin II, but they may also be useful for exploring the pathology of angina pectoris.

Ischaemic heart disease: accuracy of the prehospital diagnosis-a retrospective study

Purpose. Correct prehospital diagnosis of ischaemic heart disease (IHD) may accelerate and improve the treatment. We sought to evaluate the accuracy of prehospital diagnoses of ischemic heart diseases assigned by physicians. Methods. The Mobile Emergency Care Unit (MECU) in Odense, Denmark, services a population of 260.000. All admissions in 2009 concerning patients diagnosed in the IHD category were assessed. Outcome and diagnosis of each patient were manually validated in accordance to the final diagnosis established following admission to hospital, using the discharge summary from the relevant department as reference. Results. 428 MECU runs with a prehospital diagnosis of IHD were registered. 422 of these were included in the study and 354 of those patients were suitable for this analysis. 73,4% of the patients hospitalized with a prehospital diagnosis of IHD were initially admitted to the relevant ward. Of these patients, 40,0% had their preliminary diagnosis of IHD confirmed. 14,1% of all patients admitted to the hospital were diagnosed with nonheart conditions. Preliminary diagnoses of STEMI had an accuracy of 87,5%. Conclusions. The preliminary IHD diagnoses assigned by the MECU physicians were acceptable. In case of STEMI patients the diagnostic accuracy was excellent. In this study there was an apparent overtriage.

Characteristics of esophageal proper muscle in patients with non-cardiac chest pain using high-frequency intraluminal ultrasound

BACKGROUND AND AIM

It is unclear which mechanisms play a predominant role in the pathogenesis of esophageal non-cardiac chest pain (NCCP). We aimed to examine the features of esophageal proper muscle and esophageal contractility using a high-frequency intraluminal ultrasound (HFIUS) in patients with NCCP.

METHODS

A total of 68 patients with NCCP were classified into two groups according to the results of typical reflux symptoms and/or esophagogastroduodenoscopy and/or 24-h esophageal pH monitoring: gastroesophageal reflux disease (GERD)-positive NCCP (n = 34) and GERD-negative NCCP groups (n = 34). Additionally 16 asymptomatic healthy subjects were included as controls. Using HFIUS, we analyzed the esophageal proper muscle thickness and cross-sectional area (CSA) at 3 cm above lower esophageal sphincter (LES) and 9 cm above LES during baseline rest and peak contraction periods among the control, GERD-positive NCCP and GERD-negative NCCP groups, and examined the completeness of three phases of esophageal action during five wet swallows in the three groups.

RESULTS

The muscle thickness and CSA tended to be larger in GERD-negative NCCP than in GERD-positive NCCP and in control groups at esophageal body during both periods. All of the controls and patients with GERD-positive NCCP presented the complete peristaltic type. Whereas, 11 of 34 patients with GERD-negative NCCP presented the incomplete peristaltic type.

CONCLUSIONS

Using HFIUS, patients with GERD-negative NCCP had increased muscle thickness and CSA. Some GERD-negative NCCP had the incomplete peristaltic type.

Clinically distinct characteristics in patients younger than 40 years old with non-cardiac chest pain

BACKGROUND AND AIM

Little is known about non-cardiac chest pain (NCCP) in young patients. We aimed to examine the proportion of gastroesophageal reflux disease (GERD) in young patients with NCCP compared to the average-aged NCCP patients and to evaluate their symptomatic characteristics and the clinical efficacy of a 2-week proton pump inhibitor (PPI) trial.

METHODS

Ninety-six patients with NCCP≥1/week were classified into the young-aged (≤ 40 years, n =38) and the average-aged groups (>40 years, n=58). Typical reflux symptoms were assessed. The patients were defined into a GERD group and non-GERD group according to reflux esophagitis on esophagogastroduodenoscopy and/or pathologic acid exposure on 24-h esophageal pH monitoring. Then the patients were treated with 30mg of lansoprazole bid for 14 days.

RESULTS

Nine patients (23%) in the young-aged group and 22 patients (38%) in average-aged group were diagnosed with GERD-related NCCP (P=0.144). The proportion of typical reflux symptoms was higher in the GERD group compared with the non-GERD group in both age groups. A PPI test improved symptoms in the GERD group irrespective of age, but this improvement was not observed in non-GERD group.

CONCLUSIONS

In young NCCP patients, the prevalence of GERD was relatively low compared to average-aged NCCP, but the difference was insignificant. The PPI test was very effective in diagnosing GERD in the NCCP patients in both age groups. Therefore, in young NCCP patients, if there is a negative response to a 2-week PPI trial, the possibility of extra-esophageal disease origin needs to be considered.

A enfermeira no cuidado aos pacientes submetidos ao eco-stress farmacológico: implicações para a prática clínica

Estudo que teve por objetivos identificar os sinais e sintomas prévios e os ocorridos durante o exame de eco-stress farmacológico, descrever a atuação da enfermeira e os pressupostos para o cuidado de enfermagem na realização desse exame. Trata-se de pesquisa exploratório-descritiva, em uma unidade diagnóstica cardiológica de um hospital universitário de Porto Alegre. Foram estudadas, retrospectivamente, 246 fichas de registros de pacientes submetidos ao eco-stress, com quatro diferentes protocolos farmacológicos. A análise estatística apontou que os sinais e sintomas associados ao tipo de fármaco utilizado durante o exame foram, prevalentemente: angina típica, dor precordial, cansaço, cefaleia e extrassístoles. Esses resultados propiciaram conhecer melhor o eco-stress farmacológico, de forma a instrumentalizar a enfermeira para a prática clínica, tanto na organização da unidade para a realização do exame quanto no cuidado ao paciente submetido ao mesmo.

Depressive symptoms and healthcare utilization in patients with noncardiac chest pain compared to patients with ischemic heart disease

OBJECTIVES

We compared depressive symptoms and healthcare utilization in patients admitted for noncardiac chest pain, acute myocardial infarction, and angina pectoris after hospitalization and at 1-year follow-up.

METHODS

One hundred and thirty-one patients with noncardiac chest pain, 66 with acute myocardial infarction, and 70 with angina pectoris completed a depression screening questionnaire and the Montgomery Åsberg Depression Rating Scale. Healthcare utilization data were collected from a population-based, diagnosis-related database.

RESULTS

More than 25% of respondents reported depressive symptoms, regardless of diagnosis. At follow-up, 9% had recovered, 19% were still experiencing depressive symptoms, and 13% had developed depressive symptoms. Noncardiac patients with chest pain had similar primary care contacts, but fewer hospital admissions, than patients with an acute myocardial infarction. Patients with angina pectoris and depressive symptoms used the most healthcare services.

CONCLUSIONS

Depressive symptoms were common. Patients with noncardiac chest pain used as much primary care as did patients with an acute myocardial infarction. Interventions should focus on identifying and treating depressive symptoms.