Management Of Noncardiac Chest Pain Research Articles

Beyond the heart: Noncardiac chest pain.

Noncardiac chest pain (NCCP) is a diagnosis usually made after cardiac investigations have failed to demonstrate a specific diagnosis to explain either a single episode or recurrent episodes of chest pain. The aim of this article is to describe themajor causes and management of NCCP, with a focus on gastrointestinal conditions. Despite its generally benign prognosis, NCCP is a cause of significant morbidity and can be responsible for a high personal cost and healthcare burden. NCCP is commonly associated with gastrointestinal conditions, including gastro-oesophageal reflux disease and oesophageal spasm. However, the differential diagnosis extends to musculoskeletal, neurological and psychiatric conditions, and the broad range of causes of the syndrome, which are not mutually exclusive, means that clinicians need to remain vigilant for changes in clinical pattern.

Emergency Department Clinician Experiences and Perceptions Regarding Noncardiac Chest Pain: A Cross-Sectional Survey

ObjectivesThe objectives of this study are to report the responses of emergency department (ED) clinicians regarding the characteristics and management of patients with noncardiac chest pain (NCCP) and to explore clinician experiences with the current standard of care and whether nonpharmacologic or nonsurgical referral options would be considered. MethodsA cross-sectional survey was delivered to 40 ED clinicians from hospitals in Winnipeg, Manitoba from 2012 to 2013. Data were reduced descriptively and thematically summarized to assess the characteristics of patients with NCCP along with the responses of ED clinicians regarding the management of NCCP. ResultsThe survey response was 27 (67.5% response rate). They reported that patients with NCCP comprised a considerable amount of ED care and are a variable and heterogeneous population. Respondents agreed (63.0%) that onsite and on-call providers for NCCP referral would assist in patient management. Further, ED clinicians (66.7%) would consider referring patients with NCCP to a nonpharmacologic, nonsurgical clinical research study. ConclusionClinicians in this study wanted better access to on-site referrals and outpatient clinics for patients experiencing NCCP after discharge and would consider nonpharmacologic or nonsurgical referral.

Management of Noncardiac Chest Pain in Women

Noncardiac chest pain (NCCP) is very prevalent in the community. Although mortality remains low, morbidity and the financial implications are high. Women, especially those of middle age, should be thoroughly investigated as per current guidelines for coronary artery disease before labeling their chest pain as NCCP. Gastroesophageal reflux disease is the most common cause of NCCP; however other esophageal pathology including esophageal hypersensitivity, neuromuscular disease and eosinophilic esophagitis may also cause NCCP. Proton pump inhibitors are commonly used initially to manage NCCP, although patients who do not respond to this therapy require further investigation and differing treatment regimes. This article will focus on current knowledge regarding GI tract-related NCCP management strategies.

Effects of coping skills training and sertraline in patients with non-cardiac chest pain: A randomized controlled study

Non-cardiac chest pain (NCCP) is a common and distressing condition. Prior studies suggest that psychotropic medication or pain coping skills training (CST) may benefit NCCP patients. To our knowledge, no clinical trials have examined the separate and combined effects of CST and psychotropic medication in the management of NCCP. This randomized clinical trial examined the separate and combined effects of CST and antidepressant medication (sertraline) in participants with non-cardiac chest pain. A sample of individuals diagnosed with NCCP was randomly assigned to one of four treatments: (1) CST plus sertraline (CST+sertraline), (2) CST plus placebo (CST+placebo), (3) sertraline alone, or (4) placebo alone. Assessments of pain intensity, pain unpleasantness, anxiety, pain catastrophizing, depression, and physical disability were collected prior to treatment, and at 10- and 34-weeks following randomization. Data analyses revealed that CST and sertraline either alone or in combination significantly reduced pain intensity and pain unpleasantness. The combination of CST plus sertraline may have the greatest promise in that, when compared to placebo alone, it not only significantly reduced pain but also pain catastrophizing and anxiety. Overall, these findings support the importance of further research on the effects of CST and sertraline for non-cardiac chest pain.

The view of gastroenterologists on non‐cardiac chest pain in Asia

Non-cardiac chest pain is an important disorder in Asia. The practice and views of gastroenterologists on non-cardiac chest pain in this region are not known. To determine the current understanding, diagnostic practice and treatment strategies among gastroenterologists on the management of non-cardiac chest pain in Asia. A 24-item questionnaire was sent to gastroenterologists in Mainland China, Hong Kong, Malaysia, Indonesia, Philippines, Singapore, Taiwan and Thailand. 186 gastroenterologists participated with a response rate of 74%. 98% of gastroenterologists managed patients with non-cardiac chest pain over the last 6 months. 64% felt that the number of non-cardiac chest pain patients was increasing and 85% believed that the most common cause of non-cardiac chest pain was GERD. 94% of the gastroenterologists believed that they should manage non-cardiac chest pain patients, but only 41% were comfortable in diagnosing non-cardiac chest pain. The average number of investigations performed was four in non-cardiac chest pain patients, and oesophago-gastro-duodenoscopy was the most commonly used initial test. A proton pump inhibitor was considered the first-line treatment in non-cardiac chest pain and was reported as the most effective treatment by the gastroenterologists. Most gastroenterologists were practicing evidence-based medicine, but frequent use of investigations and a lack of awareness of the role of visceral hypersensitivity in non-cardiac chest pain patients were noted.

Noncardiac Chest Pain

The current assumption is that noncardiac chest pain (NCCP) patients diagnosed by a cardiologist are commonly referred to a gastroenterologist for further evaluation. Thus far, there are no studies that assess the clinical approach and referral patterns of cardiologists when evaluating subjects with NCCP. To determine the extent of involvement of cardiologists in the management of NCCP patients. Cardiologists were randomly selected from the American College of Cardiology national membership list and sent a 20-item questionnaire that included demographic information, characteristics of practice, preferences of diagnostic tests, referral patterns, and treatment plans. A total of 246 (33%) cardiologists returned the questionnaire. A mean of 12.6% of patients were diagnosed with NCCP and 45.5% were treated by a cardiologist in the past 6 months. Of the NCCP patients that were referred, most ended up in the primary care physician clinic (45.9%) followed by gastroenterologist clinic (29.3%). Most cardiologists are either comfortable (35%) or very comfortable (43.1%) in diagnosing NCCP. Proton pump inhibitors (44.9%), lifestyle modifications (28.7%), and H2 blockers (11.8%) are the three most commonly used therapeutic modalities for NCCP. Cardiologists manage about half of the diagnosed NCCP patients by themselves. Of those NCCP patients that are referred, cardiologists prefer to send them to a primary care physician rather than a gastroenterologist.

Randomized trial of sertraline in patients with unexplained chest pain of noncardiac origin

Background Between 10% and 30% of patients with symptoms similar to angina and sufficient to justify cardiac catheterization are found to have normal coronary angiograms. Treatment of patients with chest pain with no apparent cardiac cause is a major clinical problem. Our hypothesis was that sertraline would reduce the severity of pain in patients with chest pain of noncardiac origin. Methods and Results This was a single-site, double-blind, placebo-controlled study of the efficacy, tolerability, and safety of sertraline in the treatment of noncardiac chest pain in outpatients. Thirty patients were enrolled in the study. After 1 week of single-blind placebo washout, patients were randomly assigned in a double-blind fashion either to drug or placebo. The Beck Depression Inventory was administered at baseline and at completion of study. Daily pain diaries (visual analogue scale, rating pain on a scale of 1 to 10) were selfadministered and evaluated at baseline and at follow-up visits. Statistical measures were performed with an intention-to-treat approach. Patients who received sertraline over the course of the study showed a statistically significant reduction in pain compared with those who were receiving placebo. Conclusions The use of sertraline in patients with noncardiac chest pain produced clinically significant reduction of daily pain. These results suggest the need for further studies of the efficacy and tolerability of sertraline and other selective serotonin reuptake inhibitors in the long-term management of noncardiac chest pain. (Am Heart J 2000;140:367-72.)

Management of non-cardiac chest pain: from research to clinical practice

BACKGROUNDNon-cardiac chest pain assessed by cardiologists in their outpatient clinics or by coronary angiography usually has a poor symptomatic functional and psychological outcome. Randomised trials have shown the effectiveness of...

Investigation and management of non-cardiac chest pain

Recurring substernal chest pain is an important clinical problem, causing anxiety for patients and their physicians because of the fear of possible cardiac disease. The differential diagnosis includes coronary artery disease, oesophageal disorders such as acid reflux disease and motility disturbances, musculoskeletal problems, psychological disorders including panic attacks and a new ‘fly in the ointment’—microvascular angina. History alone usually cannot distinguish cardiac from non-cardiac chest pain. After exclusion of significant coronary artery disease, attention must be turned to oesophageal disorders, which may be seen in as many as 50% of these patients. Oesophageal motility disorders, particularly the nutcracker oesophagus, are common, but the relationship between pain and abnormal contraction pressures is not well established. Provocative tests such as edrophonium (Tensilon) and balloon distension help to identify the oesophagus as the source of chest pain but do not direct therapy. Recent studies with ambulatory oesophageal monitoring suggest that gastro-oesophageal reflux may be a more common cause of chest pain than motility disorders. This is an important finding as acid reflux is a treatable problem, while therapies for motility disorders may only worsen reflux disease. The recent observation that oesophageal disorders are frequently associated and interact with psychological disorders such as anxiety, depression, somatization and panic attacks complicates the evaluation and understanding of chest pain. How these various abnormalities may be linked is an unresolved issue. Increased central nervous system stimulation and altered visceral and/or central pain sensitivity could be the common factors. It is hoped that further research into these areas will lead to new understandings of and possible solutions to the complex problem of non-cardiac chest pain.

Noncardiac chest pain. There's often an esophageal cause.

Noncardiac chest pain remains an enigma that often defies precise diagnosis. Overlap of symptoms between esophageal and cardiac disorders may make differentiation extremely difficult. Exclusion of coronary artery disease is a key element of the management of noncardiac chest pain. Once this is accomplished, the physician can address the fears and concerns of the patient with confidence and often avoid any diagnostic studies of the esophagus. When diagnostic studies are performed, the physician should be mindful of their limitations. Since gastroesophageal reflux disease is probably the most common cause of esophageal chest pain, prompt recognition and treatment of this disorder may provide relief for many patients. Future studies should address the relationship between physiologic events in the esophagus and chest pain.