Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis

Abstract

BackgroundNon-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.MethodsA systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.ResultsOut of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.ConclusionsIn patients with NCCP, thorough clinical evaluation of the patient’s history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

Prehospital factors associated with an acute life-threatening condition in non-traumatic chest pain patients — A systematic review

“…Some potentially life-threatening disorders are acute myocardial infarction (AMI), pericarditis, myocarditis, pulmonary embolism and aortic dissection [3]. Less severe diseases such as anxiety, gastritis and musculoskeletal injuries can also cause chest pain [4].…”

Complaints of neurotic patients that are of interest for a cardiologist

“…Our findings seem important, as pseudocardiac symptoms are often misdiagnosed [25], and a significant but neglected component of psychogenic complaints may be present even in patients with ischaemic heart disease [9,26].…”

A non-ischaemic cause of elevated troponin

“…The patient had a history significant for anxiety and GERD and was being treated pharmacologically for both. Gastrointestinal diseases and psychological disorders are two of the leading causes of non-cardiovascular chest pain 12. Given the patient's very low pretroponin risk profile, these non-cardiovascular causes of chest pain should have been further investigated and cardiac disease should have been much lower on the differential.…”

“…In a recent meta-analysis, Wertli et al 12 have reported that high-dose proton pump inhibitor treatment is an efficient diagnostic approach for GERD in the context of NCCP. GERD should be considered highly likely if treatment response occurs within 1 week but highly unlikely if there is no response after 4 weeks.…”

“…A large percentage of patients with NCCP have been diagnosed with psychiatric comorbidities, most frequently anxiety, panic disorder or major depression 8. Psychiatric conditions are associated with physiological symptoms (eg, lightheadedness, dizziness, faintness or diaphoresis)12 that may initiate ED presentation for NCCP. In addition, psychological symptoms of anxiety such as worry, tension and feeling frightened are associated with NCCP 11.…”