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Prognosis of undiagnosed chest pain: linked electronic health record cohort study
Kelvin P Jordan1, Adam Timmis2, Peter Croft3
1Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele ST5 5BG, UK k.p.jordan@keele.ac.uk.
Insights
Patients with undiagnosed chest pain face a higher risk of cardiovascular events for at least five years. Early diagnosis and risk assessment are crucial for better patient outcomes.
Area of Science:
- Cardiology
- Public Health
- Health Informatics
Background:
- Chest pain is a common presenting complaint in primary care.
- A significant proportion of patients presenting with chest pain do not receive a definitive diagnosis within six months.
- Long-term cardiovascular outcomes for patients with undiagnosed chest pain are not well-established.
Purpose of the Study:
- To investigate the long-term cardiovascular outcomes of patients whose chest pain remained undiagnosed six months after initial presentation.
- To compare cardiovascular event rates between patients with diagnosed (non-coronary, angina) and undiagnosed chest pain.
- To assess the impact of cardiac diagnostic investigations on long-term cardiovascular risk.
Main Methods:
- A retrospective cohort study using the UK CALIBER electronic health record database.
- Inclusion of 172,180 adults presenting with a first episode of chest pain between 2002 and 2009.
- Follow-up for fatal or non-fatal cardiovascular events over 5.5 years, with adjustments for multiple covariates.
Main Results:
- Over 72% of patients had no attributed cause for chest pain at presentation, and 95% of these received no cardiovascular diagnosis within six months.
- Patients with unattributed chest pain had a significantly higher long-term incidence of cardiovascular events (4.7%) compared to those with non-coronary diagnoses (3.0%).
- Cardiac diagnostic investigations within six months were associated with a higher long-term risk of cardiovascular events, irrespective of the initial chest pain classification.
Conclusions:
- The majority of first-onset chest pain patients lack a diagnosis within six months, even if investigated.
- These patients exhibit an elevated risk of cardiovascular events persisting for at least five years.
- Enhanced strategies for cardiovascular risk assessment and management in patients with undiagnosed chest pain are urgently needed.
Abstract:
Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation.Design Cohort study.Setting UK electronic health record database (CALIBER) linking primary care, secondary care, coronary registry, and death registry information.Participants 172 180 adults aged ≥18 from 223 general practices presenting with a first episode of recorded chest pain, classified from medical records as diagnosed (non-coronary condition or angina) or undiagnosed (cause unattributed) at first consultation between 2002 and 2009 and with no previous record of cardiovascular disease.Main outcome measures Fatal or non-fatal cardiovascular events over 5.5 years' follow-up. Adjustments were made for age, sex, deprivation, body mass index, smoking status, year of index presentation, and previous records of diabetes or hypertension or previous prescriptions for lipid lowering drugs.Results At the index presentation, 72.4% of patients (124 688) did not have a cause attributed for their chest pain; 118 687 (95.2%) of these did not receive any type of cardiovascular diagnosis over the next six months. Only a minority of patients in all three groups (non-coronary 2.0% (769 of 39 232); unattributed 11.7% (14 582 of 124 688); angina 31.5% (2606 of 8260)) had a recorded cardiac diagnostic investigation in the first six months after presentation. The long term incidence of cardiovascular events was higher in those whose chest pain remained unattributed after six months (5126 of 109 628; 4.7%) compared with patients with an initial diagnosis of non-coronary pain (1073 of 36 097; 3.0%) (adjusted hazard ratios for 0.5-1 year after presentation: 1.95, 95% confidence interval 1.66 to 2.31; for 1-3 years: 1.35, 1.23 to 1.48); for 3-5.5 years: 1.21, 1.08 to 1.37). Owing to the larger number of patients in the unattributed group, there were more excess myocardial infarctions in the long term in this group (214 more than expected based on the rate in the non-coronary group) than in the angina group (132 more than expected). Patients who had cardiac diagnostic investigations in the first six months had a higher long term risk of cardiovascular events, regardless of the initial chest pain label. Incidence of unattributed chest pain and angina decreased between 2002 (124 per 10 000 person years and 13 per 10 000 person years, respectively) and 2009 (107 per 10 000 person years and 5 per 10 000 person years, respectively), but the incidence of chest pain attributed to a non-coronary cause remained stable (37-40 per 10 000 person years). Risk of cardiovascular events did not change over time.Conclusions Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. Efforts to better assess and reduce the cardiovascular risk of such patients are warranted.