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Atypical chest pain: looking beyond the heart
1Department of Cardiology, Guy's Hospital, London, UK.
Insights
Chest pain is often overinvestigated. Early diagnosis of non-cardiac causes and appropriate referrals can improve management for patients with normal coronary anatomy.
Area of Science:
- Cardiology
- Psychiatry
- Gastroenterology
Background:
- Chest pain is a common symptom often leading to extensive investigations.
- Patients with normal coronary anatomy experience significant incapacitation despite low mortality.
- Current management strategies for these patients require improvement.
Purpose of the Study:
- To discuss improved management strategies for patients presenting with chest pain.
- To emphasize early diagnosis of non-cardiac causes by general practitioners.
- To guide appropriate referrals and treatment options for chest pain patients.
Main Methods:
- Review of diagnostic considerations including risk factors, pain characteristics, and psychological elements.
- Emphasis on performing a minimum number of investigations.
- Consideration of referral pathways to cardiology, gastroenterology, psychiatry, or clinical psychology.
Main Results:
- Normal coronary anatomy in chest pain patients indicates low mortality but significant disability.
- Early identification of non-cardiac pain origins is crucial.
- Multidisciplinary approach may enhance patient care.
Conclusions:
- Appropriate risk stratification guides cardiological referral for suspected ischemic heart disease.
- Non-cardiac chest pain management involves targeted treatments like medications, reassurance, cognitive therapy, and psychiatric drugs.
- A multidisciplinary chest pain clinic is proposed to optimize patient care and outcomes.
Abstract:
Chest pain is common, and tends to be overinvestigated. Patients with normal coronary anatomy have a low mortality, but remain significantly incapacitated. We discuss ways of improving the management of such patients. An early diagnosis of a non-cardiac cause of pain should be made, ideally by the general practitioner, taking account of risk factors for cardiac as well as psychological disorders, the quality of the pain, the patient's concerns and worries and the presence of stressful life events. The minimum of investigation should be performed. Cardiological referral should be considered for patients with a high a priori risk of ischaemic heart disease. Otherwise referral, if necessary, should be to a gastroenterologist, psychiatrist or clinical psychologist, as appropriate. Treatment options are medications with musculoskeletal or oesophageal activity, simple or repeated reassurance, cognitive therapy, psychiatric drugs, and respiratory retraining. We suggest that a multidisciplinary chest-pain clinic may improve the care of such patients.