Cause and Outcome of Atypical Chest Pain in Patients Admitted to Hospital

Abstract

In 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.

The head says yes but the heart says no: what is non-cardiac chest pain and how is it managed?

“…Between 5% and 30%13 23 49 are thought to have a musculoskeletal origin for chest pain including cervical spondylosis, or fibromyalgia50 A thoracic respiratory pattern sometimes associated with overt hyperpnoea (‘hyperventilation’) is commonly associated with NCCP. This may occur spontaneously or be precipitated by psychophysiological processes such as panic or stress arousal.…”

Living with unexplained chest pain

“…In a study by Spalding et al. (2003) the results show that of 108 individuals with atypical chest pain, nearly half were discharged without a diagnosis and one year later, several of those with persistent symptoms remained undiagnosed.…”

“…In a study by Spalding et al (2003) the results show that of 108 individuals with atypical chest pain, nearly half were discharged without a diagnosis and one year later, several of those with persistent symptoms remained undiagnosed. According to Good (1994), undiagnosed and untreated illness influences a person's view of his or her own health as naming the origin of the pain is a way to seize power to alleviate it and if the intensity demands urgency.…”

Atypical Chest Pain from Myofascial Pain Syndrome of Subscapularis Muscle

“…Atypical chest pain is defined as chest pain associated with nonsignificant serum troponin T level [<0.06 µg] and absence of T segment changes from ECG (7). In a study of 250 patients admitted to the coronary unit, 43.2 percent presented with atypical chest pain to the hospital and 37 percent had no definitive diagnosis at baseline.…”

“…Many patients will need further investigation and treatment. Three-quarters will be diagnosed within a year, but many will continue to have symptoms nevertheless (7). Lack of a firm diagnosis can result in depression, anxiety, and decreased performance in daily activity (3).…”