Abstract
BackgroundNon-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment.ObjectivesTo summarize treatment efficacy for patients presenting with NCCP.MethodsSystematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group).ResultsThirty eligible RCT’s were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI −0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions.LimitationsOnly a small number of studies were available.ConclusionsTimely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered.
Highlights
Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden
In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered
Sixty to ninety percent of the patients that present to emergency departments with chest pain have no underlying cardiovascular disease [3,4,5,6]
Summary
Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Sixty to ninety percent of the patients that present to emergency departments with chest pain have no underlying cardiovascular disease [3,4,5,6]. The proportion of patients with cardiovascular disease is higher in specialized units (cardiology emergency departments, CCU, ICU) [7] and lower in the primary care setting [6,8,9,10]. Patients with NCCP have a high disease burden; many patients that seek care for NCCP complain of persisting symptoms in a 4year follow-up [13]. Patients with non-cardiac chest pain experience an impaired quality of life and greater number of medical visits compared with patients with cardiac pain [14]
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