Over 40% of patients admitted to emergency departments (ED) with chest pain receive a non-cardiac diagnosis. Patients with non-cardiac chest pain (NCCP) have a good prognosis in terms of cardiac adverse events and mortality; however, they tend to have poor outcomes in terms of psychological morbidity, quality of life (QoL), further chest pain and the use of health services. In recent years there has been an increase in the use of ED-based ‘rapid rule-out’ protocols and the provision of dedicated chest pain units. This review sought to chart the psychological outcomes of NCCP patients who access ED-based care, and identify the correlates of poorer psychological outcomes. Twelve papers were identified reporting 10 studies. NCCP patients had similar levels of anxiety, depression, and QoL to patients who received a cardiac diagnosis for their pain, but worse levels than healthy controls. Factors associated with poorer psychological outcomes included gender, age, previous psychiatric history and certain symptoms such as fear of dying and light headedness. However, the studies were heterogeneous, with a variety of outcome measures, designs and settings. In summary, the review identifies poor psychological outcomes in NCCP patients accessing ED-based care; however, there is a need for longitudinal studies using reliable and valid measures to define further the predictors of these poor outcomes.
- chest pain
- cost effectiveness
- emergency medicine
- quality of life
- thromboembolic disease
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- chest pain
- cost effectiveness
- emergency medicine
- quality of life
- thromboembolic disease
Acute chest pain accounts for approximately 700 000 emergency department (ED) attendances each year in England and Wales and approximately a quarter of all medical admissions to ED.1 Over 40% of ED patients with acute chest pain receive a diagnosis of non-cardiac chest pain (NCCP).1 2 Patients shown to be free from coronary heart disease through coronary angiography survive significantly longer without experiencing a myocardial infarction than those diagnosed with coronary heart disease.3 NCCP patients therefore have a good prognosis regarding cardiac problems; however, evidence has shown that they experience poor outcomes in terms of psychological wellbeing and quality of life (QoL). NCCP patients have been found to report higher levels of depression and anxiety, poorer QoL, more mental stress and strain, less physical activity and more sleep problems than healthy controls.4 5 Importantly, these patients are likely to experience further chest pain, and thus re-attend ED,4 5 which has important implications for healthcare costs.6
Previous research on psychological distress in NCCP patients has primarily focused on patients who have been referred for coronary angiography for example,7 8 or to cardiology outpatient departments,9 10 and has reported that that NCCP patients have similar10 11 or worse psychological outcomes than cardiac chest pain (CCP) patients.12 13 However, over recent years there has been an increase in the use of ED-based ‘rapid-rule-out’ protocols and the provision of dedicated chest pain units (CPU) either in, or adjacent to, the ED.14 15 These units allow all emergency chest pain patients to undergo a period of testing and observation as soon as they present at the ED with chest pain, whereas previously they were either discharged without thorough testing or were admitted to hospital for further testing. After a period of 2–6 h, patients can be either admitted (upon positive results), or discharged (upon negative results).16 With the advent of CPU, NCCP patients are now likely to be investigated and discharged within the ED, and thus may never access cardiology outpatient care or undergo coronary angiography. NCCP patients only seen in ED settings might be susceptible to poor psychological outcomes, as they spend less time engaged in the healthcare system at diagnosis, and therefore may have less opportunity to be reassured.
The present review had two main aims: to chart levels of psychological distress and QoL in NCCP patients attending acute care for their chest pain, which, when possible, will be compared with patients who receive a cardiac diagnosis for their chest pain or healthy controls, and to assess the correlates of poor psychological outcomes in NCCP patients in ED-based settings.
This review was conducted and reported in line with preferred reporting items for systematic reviews and meta-analyses PRISMA guidelines.17 A protocol was developed for the purposes of this review and is available from the first author upon request.
Articles published in English reporting quantitative, questionnaire-based studies, including cohort, case–control, cross-sectional and longitudinal studies, on adult patients with acute (rather than chronic) chest pain presenting to acute care (eg, ED, CPU) were included. To be included, the patients must have received a diagnosis of non-cardiac or non-specific chest pain, or chest pain of uncertain aetiology. Studies including a comparison group (eg, patients who received a cardiac diagnosis for their chest pain, healthy controls) were included, but the review was not restricted to this type of study. The patient outcomes that were considered were anxiety, depression and QoL.
An online database search was carried out in November 2010, searching PsychInfo (via Ovid, 1806 to present), Medline (via Ovid, 1950 to present) and CINAHL (via EBSCO, 1982 to present), using the search terms ‘chest pain’, ‘anxiety’, ‘depression’, ‘quality of life’, mapped onto MeSH subject terms when possible and combined using Boolean operators. The conference proceedings citation index was also searched, via Web of Knowledge, using the free text terms ‘non-cardiac chest pain’, ‘non-specific chest pain’, ‘benign chest pain’, ‘chest pain of uncertain etiology’, ‘quality of life’, ‘psych*’, ‘anx*’ and ‘depress*’, combined using Boolean operators. Reference lists of articles that were included were searched for any further references, as were the citations of included articles via Web of Knowledge.
Data extraction and synthesis
The quality of each of the studies was assessed using the appropriate critical appraisal skills programme (CASP) checklist to the study design.18 19 Data extracted included the population studied, any comparison groups, inclusion and exclusion criteria, recruitment procedures (and rates), baseline demographics, sample size, procedures used to diagnose/define NCCP, outcomes assessed, measurement tools used, follow-up assessments taken, statistical analysis techniques, attrition rates, results for each outcome and any correlates of poor outcomes. All studies were reviewed independently by the first and second authors to ensure accuracy of extraction, and any disagreements were resolved through discussion. Due to the variation in study type (eg, longitudinal vs cross-sectional), outcomes assessed and outcome measures, a narrative comparison and synthesis of the results was conducted.
In total, 815 articles were identified (see figure 1). After screening at title and abstract level, 62 articles remained. After screening the full text, 12 articles reporting 10 studies remained. Jerlock et al5 and Fagring et al20 reported data from the same sample, so findings were drawn from a combination of the two papers. The samples reported by Kuijpers et al21 and Kuijpers et al22 overlapped; only data from Kuijpers et al22 were included as the sample size was larger. Two studies20 23 reported data split by demographic or diagnostic group (eg, by gender, or by diagnosis of panic disorder); when possible, overall means were calculated for NCCP patients and comparison groups. A summary of the included studies can be found in tables 1–3.5 20 22–30
Quality of studies
The overall quality of studies was acceptable to high. However, only four studies reported sufficient information to make a judgement on the quality of recruitment, reporting the number of participants excluded and the reasons.22 23 25 28 There was some variety in the procedures for excluding cardiac causes of chest pain. Most studies reported procedures similar to CPU care (ie, blood tests for cardiac enzymes, ECG, chest x-ray, exercise tolerance test) or equally thorough processes,22–27 30 whereas one study only reported using physical examination and ECG to rule out cardiac causes.29 Two studies did not provide sufficient information on the testing procedures.20 28 The majority of studies used well-established and standardised measures for assessing outcomes, with the hospital anxiety and depression scale (HADS)31 and the short form 3632 being the most widely used measures. One study used the Aga Kahn University anxiety and depression Scale,29 but gave no references of previous use or validation of this measure. Only some of the studies controlled for confounding factors, such as age, gender, diabetes and smoking status, in their analyses.20 23 26–28
Prevalence of psychological outcomes
Nine studies assessed anxiety,20 22 23 25–30 of which seven used the HADS.31 NCCP patients were found to have similar anxiety scores to CCP patients,26–28 but higher levels of anxiety than patients with a determined cause (be it cardiac or another disease such as pneumonia)30 and healthy controls.20 30 Likewise, the percentage of respondents scoring above predefined cut-off scores for probable anxiety was similar for NCCP and CCP patients,26 27 but higher among NCCP patients than those with a determined cause for their chest pain30 and healthy controls.20 The mean baseline anxiety scores for NCCP patients tended to be just below the cut-off for mild anxiety; nonetheless, between 21% and 53.5% of NCCP patients were categorised as probably having anxiety, although it should be noted that different cut-off scores were used across studies. Two studies also reported that 58% and 53.9% of NCCP patients scored above threshold on the HADS for either anxiety or depression.22 29 The one study that charted changes in anxiety in NCCP patients over time reported that the percentage of those with probable anxiety decreased from 21% to 12% from baseline to the 2-year follow-up, but increased to 19% at the 4-year follow-up.27
Nine studies assessed depression,20 22–24 26–30 of which six used the HADS. NCCP patients were found to have similar26 or lower28 depression scores than CCP patients, and similar depression scores to patients with a determined cause for their chest pain.30 Likewise, the percentage of NCCP patients scoring above predefined cut-off scores for probable depression was similar to CCP patients26 27 and those with a determined cause for their chest pain,30 although more NCCP patients were categorised as having probable depression than healthy controls.20 The mean depression scores for NCCP patients were typically below the cut-off for mild depression; nonetheless, between 9% and 40% of NCCP patients were categorised as probably having depression, although it should be noted that different cut-off scores were used across studies. One study charted changes in depression in NCCP patients over time, reporting that the percentage of those with probable depression decreased from 9% to 7% to 2% from baseline to the 2 and 4-year follow-up.27
Quality of life
Only three studies assessed QoL.20 27 28 NCCP patients were found to have better QoL than CCP patients in various domains,28 but worse QoL than healthy controls.20 There was some evidence to suggest that QoL improves 2 years after diagnosis, but then remains stable over the longer term (up to 4 years).27
Correlates of poor psychological outcomes
Only three studies reported variables that may be associated with poor psychological outcomes in NCCP patients alone.22 23 25 Demiryoguran et al25 reported that gender (female), the presence of associated symptoms, previous referral with the same disease, family history of psychiatric illness, and certain symptoms (such as fear of dying, light headedness and chills or hot flushes) were associated with elevated levels of anxiety. Srinivasan and Joseph23 found that NCCP patients were more likely to experience anxiety and depression if they also had co-morbid panic disorder. Kuijpers et al22 found that younger patients were more likely to score above the HADS cut-off for anxiety or depression. In addition, severe chest pain, diabetes and gender (female) have been found to be associated with poorer psychological outcomes in studies that have combined NCCP and CCP samples.26 27
This review sought to quantify the levels, and correlates, of anxiety, depression and QoL in NCCP patients. In general, psychological outcomes in this patient group were worse than in healthy controls and comparable to or, in the case of anxiety, slightly worse than CCP patients. A range of variables was found to correlate with poor psychological outcomes including younger age, female gender, previous psychiatric history and panic disorder. However, it should be noted that the literature on psychological outcomes, particularly the correlates of poor outcomes, in NCCP patients attending emergency care is somewhat sparse in comparison to the literature on psychological outcomes in NCCP patients attending outpatient or non-acute care, which is evident from the large number of papers excluded due to a non-acute setting (n=24). This reflects the relatively recent development of rapid rule-out protocols in acute care.14
The strongest evidence regarding the psychological effects of NCCP was for anxiety, which reflects the number of studies assessing anxiety, the use of reliable and valid measures such as the HADS and consistency of the results. Anxiety levels were thus high in NCCP patients, showing similar or higher levels than CCP patients and higher levels than healthy controls. Between 21% and 53.5% of NCCP patients were categorised as having probable anxiety. A number of authors have suggested that NCCP may actually be caused by anxiety for example,33 34 or anxiety disorders such as panic disorder,35 and one study in the review found evidence linking panic disorder with poorer psychological outcomes in NCCP.23 While this review considered anxiety as an outcome of NCCP, it is possible that anxiety may also cause NCCP. However, Soares-Filho et al30 found that NCCP patients experience higher levels of anxiety than chest pain patients with a determined cause (including those with anxiety-related causes), suggesting high levels of anxiety might be a reaction to the lack of a clear diagnosis for one's chest pain. Moreover, the high levels of psychological morbidity that are observed in both NCCP and CCP patients suggest that such outcomes are related to illness or chest pain in general, and are not the cause of NCCP.11 Nonetheless, anxiety may serve to worsen the patient's chest pain, creating a ‘vicious cycle’, in which neither the anxiety nor the pain diminishes. However, it is difficult to test these relationships, as one cannot feasibly determine anxiety levels before the patient accesses emergency healthcare. One study reported that anxiety decreased in the 2 years following diagnosis, but increased again over the next 2 years.27 It is therefore important to target such anxiety with psychological interventions, to break this cycle and improve patient outcomes. Encouragingly, techniques such as cognitive behavioural therapy have been found to reduce further chest pain, anxiety and depression.36
Evidence for the effects of NCCP on depression was more mixed. Levels of depression in NCCP patients were similar to, or lower than, CCP patients.26 28 30 The mean levels of depression suggest that depression is not a major consequence of NCCP. Although up to 40% of NCCP patients were categorised as having probable depression,20 this may be due to the use of variable cut-off scores across studies.
Data on QoL were especially limited, with only three studies reporting QoL outcomes in NCCP patients. Overall, NCCP patients appear to have similar, or slightly better, QoL than CCP patients, but worse QoL than healthy controls. NCCP patients do not have any serious physical problem, so their QoL should be comparable to the general population, unlike CCP patients who have been diagnosed with a cardiac problem that may have a large impact on physical health and warrant significant lifestyle changes. QoL has been found to be worse in NCCP and CCP patients (combined sample) with more severe or frequent pain.27 It is likely that it is the pain itself that impacts negatively on QoL through disturbing general day-to-day activities. It may therefore be difficult to intervene to improve QoL while the patient is still experiencing pain.
To date, only three studies have focused on the correlates (ie, risk factors) of poorer psychological outcomes in ED NCCP patients. A number of variables has been found to be associated with negative psychological outcomes including age (younger patients), gender (female), the presence of associated symptoms, previous referral with the same disease, certain symptoms (eg, fear of dying, light headedness), family history of psychiatric illness and panic disorder.22 23 25 However, the range of variables assessed has been quite narrow focusing almost exclusively on demographic, medical and psychiatric variables. Moreover, research in this area has failed to draw upon theory when selecting potential risk factors. Research in behavioural medicine and health psychology indicates that patients' perceptions and interpretations of health threats are important determinants of psychological outcomes.37 Theories such as the common sense model of illness representations38 could be usefully employed to examine the relationship between NCCP patients' perceptions of the chest pain and psychological outcomes. For example, Robertson et al39 found that NCCP patients had more negative illness representations than CCP patients, which may help to explain the higher levels of anxiety experienced by NCCP patients. Finally, research on the correlates of poorer psychological outcomes in NCCP patients has used cross-sectional designs.
The distinction between patients with pain of undetermined cause and patients with pain of determined cause may also be important within NCCP. The study that made this comparison was the only one to find a significant difference in anxiety between NCCP and a chest pain comparison group.30 Therefore, patients who receive no explanation for their chest pain may experience poorer psychological outcomes than those patients who receive an alternative non-cardiac explanation (eg, anxiety, gastrointestinal, or musculoskeletal). Patients who receive no explanation may think their pain is caused by a cardiac problem that may cause them to experience high levels of worry and thus anxiety. Alternatively, being given a clear explanation, or label, may increase patients' understanding of their chest pain, thereby reducing anxiety.40 This distinction should be explored further in future studies.
The review has a number of limitations that should be noted. First, the heterogeneity between the studies makes it difficult to draw firm conclusions from the review. For example, studies used a range of cut-offs when categorising NCCP patients for possible anxiety and depression. Second, the 10 studies included in the review were conducted in nine different countries, therefore precluding comparisons between countries with different healthcare systems. However, the results of the review indicate that the negative impact of NCCP on psychological outcomes (especially anxiety) may be persistent across different settings and cultures. Third, relatively few studies assessed the potential correlates of poor psychological outcomes in NCCP patients. As a result, it is difficult to draw any strong conclusions regarding the potential risk factors for psychological morbidity. Finally, publication bias may be an issue as no unpublished studies were included in the review. Despite attempts to include such studies, none were identified.
The findings of the review suggest that, clinically, more attention should be paid to the needs of NCCP patients, whether it be through reassurance or further follow-up assessment following discharge. There may be a need for brief interventions at discharge to reduce the feelings of anxiety experienced by many NCCP patients accessing care in CPU and ED settings as this may lead to further chest pain and re-attendance at ED.4 5 The content of such interventions would need to be confirmed through further research into the risk factors for psychological morbidity.
NCCP patients accessing acute medical care have higher levels of psychological morbidity than healthy controls and similar or higher levels of psychological morbidity (especially anxiety) than CCP patients. To date, few consistent correlates of poor psychological outcomes have been identified. Further research is needed that: (1) employs longitudinal designs to chart the natural course of psychological outcomes in NCCP patients; (2) uses reliable and valid measures of psychological outcomes, such as the HADS, with recommended cut-offs (ideally confirmed with clinical diagnostic interviews); (3) considers the distinction between NCCP patients who are given an alternative (non-cardiac) explanation for their chest pain and those who are not; and (4) focuses on a broader array of potential risk factors including patients' illness perceptions that are (5) assessed at baseline and related to subsequent psychological outcomes (6) using multivariate analyses.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.