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.
Highlights
Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation
Results in light of existing literature To the best of our knowledge, this is the first systematic review summarizing the current evidence on the accuracy of diagnostic tests in patients with NCCP
We found no additional value of provocation testing for diagnosing underlying gastroesophageal conditions, as provocation tests failed to identify many patients that would have reflux during a 24-h pH measurement period
Summary
Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. In the USA, 6 million patients present to emergency departments with chest pain each year, at an annual cost of $8 billion [1,2]. Roughly 60% to 90% of the patients presenting with chest pain have no underlying cardiovascular disease [3,4,5,6]. In patients with chest pain, the diagnostic investigation focuses primarily on cardiovascular disease diagnosis and is often performed by cardiologists. Upon ruling out cardiovascular disease, only vague recommendations exist for further diagnostic investigation, often delaying diagnosis and appropriate treatment and causing uncertainty for patients [13]. Information is scarce regarding the appropriate diagnostic tests, and their sensitivity and specificity to discriminate different non-cardiac diseases
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