Management of non-cardiac chest pain: from research to clinical practice

Background-Non-cardiac chest pain assessed by cardiologists in their outpat ient clinics or by coronary angiography usually has a poor symptomatic func tional and psychological outcome. Randomised trials have shown the effectiv eness of specialist psychological treatment with those who have persistent symptoms, but such treatment is not always acceptable to patients and may n ot be feasible in routine clinical settings. Objectives-To describe a sample of patients referred to cardiac outpatient clinics from primary care in a single health district who were consecutivel y reassured by cardiologists that there was not a cardiac cause for their p resenting symptom of chest pain. Design-Systematic recording of referral and medical information of patients consecutively reassured by cardiologists. Reassessment in research clinic six weeks later (with a view to inclusion in a randomised trial of psycholo gical treatment, which has been separately reported) and followed up at six months. Setting-A cardiac clinic in a teaching hospital providing a district servic e to patients referred from primary care. Patients-133 patients from the Oxfordshire district presenting with chest p ain and consecutively reassured that there was no cardiac cause during the recruitment period; 69 had normal coronary angiograms and 64 were reassured without angiography. Intervention-A subgroup (n = 56) with persistent disabling chest pain at si x weeks were invited to take part in a randomised controlled trial of cogni tive behavioural treatment. Main outcome measures-Standardised interview and self report measures of ch est pain, other physical symptoms, mood and anxiety, everyday activities, a cid beliefs about the cause of symptoms at six week assessment; repeat of s elf report measures at six months. Results-Patients had a good outcome at six weeks, but most had persistent, clinically significant symptoms and distress. Some found the six week asses sment and discussion useful. The psychological treatment was helpful to mos t of those recruited to the treatment trial, but a minority (15%) of those treated appeared to need more intensive and individual collaborative manage ment. Patients reassured following angiography were compared with those rea ssured without invasive investigation. They had longer histories of chest p ain, more often reported breathlessness on exertion, and were more likely t o have previously been diagnosed as having angina, treated with antianginal medication, and admitted to hospital as emergencies. Conclusion-These findings suggest a need for ((stepped)) aftercare, with ma nagement tailored according to clinical need. This may range from simple re assurance and explanation in the cardiac clinic to more intensive individua l psychological treatment of associated underlying and often enduring psych ological problems. Simple ways in which the cardiologist might improve care to patients with non-cardiac chest pain are suggested, and the need for ac cess to specialist psychological treatment discussed.