Abstract
BackgroundMost people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation. Consequently, many patients are not reassured they have the correct diagnosis or treatment. A previous trial reported that, in people with non-cardiac chest pain, a brief discussion with a health psychologist before the tests about the meaning of potential results led to people being significantly more reassured. The aim of this pilot was to test study procedures and inform sample size for a future multi-centre trial and to gain initial estimates of effectiveness of the discussion intervention.MethodsThis was a two-arm pilot randomised controlled trial in outpatient rapid access chest pain clinic in 120 people undergoing investigation for new onset, non-urgent chest pain. Eligible participants were randomised to receive either: a discussion about the meaning and implication of test results, delivered by a nurse before tests in clinic, plus a pre-test pamphlet covering the same information (Discussion arm) or the pre-test pamphlet alone (Pamphlet arm). Main outcome measures were recruitment rate and feasibility for a future multi-centre trial, with an estimate of reassurance in the groups at month 1 and 6 using a 5-item patient-reported scale.ResultsTwo hundred and seventy people attended rapid access chest pain clinic during recruitment and 120/270 participants (44%) were randomised, 60 to each arm. There was no evidence of a difference between the Discussion and Pamphlet arms in the mean reassurance score at month 1 (34.2 vs 33.7) or at month 6 (35.3 vs 35.9). Patient-reported chest pain and use of heart medications were also similar between the two arms.ConclusionsA larger trial of the discussion intervention in the UK would not be warranted. Patients reported high levels of reassurance which were similar in patients receiving the discussion with a nurse and in those receiving a pamphlet alone.Trial registrationCurrent Controlled Trials ISRCTN60618114 (assigned 27.05.2011).Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2261-14-138) contains supplementary material, which is available to authorized users.
Highlights
Most people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation
The pamphlet (A5, 4-page booklet, 664 words; see Additional file 1) outlined: the three possible results from tests in Rapid access chest pain clinic (RACPC) that day (negative/normal (NCCP), positive/abnormal (CHD), or inconclusive i.e. need to return for more tests); the meaning of negative results with a high risk of developing heart disease versus low risk; possible reasons for chest pain in those with a negative result; what to do if results are negative but chest pain continues; and treatment options for those with a positive result
Around 40% of patients attending RACPC were randomised in the study
Summary
Most people referred to rapid access chest pain clinics have non-cardiac chest pain, and in those diagnosed with stable coronary heart disease, guidance recommends that first-line treatment is usually medication rather than revascularisation. A previous trial reported that, in people with non-cardiac chest pain, a brief discussion with a health psychologist before the tests about the meaning of potential results led to people being significantly more reassured. The aim of this pilot was to test study procedures and inform sample size for a future multi-centre trial and to gain initial estimates of effectiveness of the discussion intervention. As studies in people undergoing outpatient tests for heart disease have shown, many with a negative (normal) result are not reassured that their chest pain is noncardiac in origin [6,7], and continue to report chest pain in the following months and use NHS services [3,8]. There are several causes of NCCP, including physical problems (e.g. gastroesophageal disorders, musculoskeletal causes) or psychological disorders (such as anxiety, panic attacks, and depression), and often there is an interaction between psychological and physical causes [9]
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