Cause and outcome of atypical chest pain in patients admitted to hospital

Abstract

SUMMARYIn patients with acute chest pain the prime need, usually, is to diagnose and treat myocardial infarction or ischaemia. When a cardiac origin for the pain has been excluded, patients are commonly discharged without either a diagnosis or a plan for follow-up. We studied a group of such patients to see how far causation was pursued and how their mortality compared with that of patients with a proven cardiac cause for their symptoms. The study population was 250 patients admitted over five weeks with chest pain suspected of being cardiac in origin. Initial assessment included an electrocardiogram and measurement of troponin T. If neither of these indicated a cardiac event, the patient was deemed to have 'atypical' chest pain and the cause, where defined, was recorded. Outcomes at one year were determined by questionnaire and by assessment of medical notes.Of the 250 patients, 142 had cardiac pain (mean age 79 years, 58% male) and 108 atypical chest pain (mean age 60 years, 55% male). Of those with atypical pain, 40 were discharged without a diagnosis; in the remaining 68 the pain was thought to be musculoskeletal (25), cardiac (21), gastrointestinal (12) or respiratory (10) in origin. 41 patients were given a follow-up appointment on discharge. At one year, data were available on 103 (96%) patients.The mortality rate was 2.9% (3 patients) compared with 18.3% in those with an original cardiac event. Half of the patients with atypical pain had undergone further investigations and 14% had been readmitted. The yield of investigative procedures was generally low (20%) but at the end of the year only 27 patients remained undiagnosed.Patients with atypical chest pain form a substantial proportion of emergency admissions. The symptoms often persist or recur. The commonest causation is musculoskeletal, but a sizeable minority remain undiagnosed even after follow-up.

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

“…One explanation could be that having recurrent and inadequately treated chest pain for a long time, without knowing the cause could lead to worries and depressive symptoms in NCCP and AP patients. 45,47 Regarding depressive symptoms in AMI patients, also previous research have reported high levels of depression the year after an AMI. 48,49 Study participants had a high number of contacts with health-care providers during the two year period, which also Leise and colleagues reported.…”

“…43,44 Out of the 71 patients with depressive symptoms at baseline, more than half were still experiencing depressive symptoms at follow-up. Spalding and colleagues 45 reported that many patients were not diagnosed for more than a year, despite chest pain prevalence. This is probably due to the fact that formal screening for depression is not a part of the routine care for patients with chest pain and therefore depression can go unrecognized by cardiovascular physicians and nurses.…”

Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases

“…Musculoskeletal chest pain accounts for many admissions to hospital, 8 and its natural history is poorly understood. 11 Serious pathologies including coronary artery disease can have similar symptom presentation to musculoskeletal chest pain, making a clear diagnosis challenging.…”

“…Undiagnosed chest pain patients on emergency medical admission are commonly discharged. 8 The absence of a firm diagnosis for chest pain can result in depression, anxiety, and a decrease in daily activity. 40 Such reactions have been ascribed directly to the absence of reassurance that symptoms do not indicate life-threatening disease.…”

“…Another 50% of acute chest pain admissions are for non-cardiac-related reasons 7 ; and in acute chest pain clinics, musculoskeletal chest pain accounts for between 5% and 20% of total visits. [8][9][10] Chest pain of a serious cardiovascular concern, for example, myocardial infarction and acute coronary syndrome, is seen less often in the primary care setting than in the emergency care setting. 11 Chest pain presentations in chiropractic clinics may be of a musculoskeletal origin.…”