Q J Med 2014; 107:429–434 doi:10.1093/qjmed/hcu009 Advance Access Publication 20 January 2014
Original papers The rapid access chest pain clinic: unmet distress and disability E.M. MARKS1,2, J.B. CHAMBERS1, V. RUSSELL1, L. BRYAN1 and M.S. HUNTER2 From the 1Cardiothoracic Centre, Guy’s and St Thomas Hospital, London, SE1 9RT and 2Institute of Psychiatry, Department of Psychology King’s College London, London, SE1 9RT, UK Address correspondence to Prof. J Chambers, Cardiothoracic Department, 1st Floor Southwark Wing, Guy’s Hospital, SE1 9RT, UK. email: [email protected] Received 10 December 2013 and in revised form 31 December 2013
Aims: To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital. Methods: A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period. Results: There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60,
OR = 1.05) and reported ‘atypical’ pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower ‘illness coherence’ (a patient’s belief that the illness ‘makes sense’) (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05). Conclusion: Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.
Introduction
NCCP is defined negatively by the absence of coronary disease and is not a unitary diagnosis. Patients with NCCP may have evidence of gastrooesophageal, musculoskeletal, psychiatric or psychological abnormalities. Our ability to provide adequate care is limited by a lack of information on the characteristics of patients with NCCP, particularly the nature of psychological distress. The aim of this study was to compare the use of health-care resources, chest pain characteristics and levels of psychological distress in consecutive patients attending a Rapid Access Chest Pain Clinic, with cardiac (CCP) and non-cardiac pain (NCCP).
Rapid Access Chest Pain Clinics (RACPC) were developed to reduce mortality in new-onset angina.1 However, three-quarters of patients attending these clinics have non-cardiac chest pain (NCCP)2,3 for which there are no current protocols for care.4 This is a serious deficiency because despite a low mortality rate,5 NCCP is associated with high levels of psychological distress, work absenteeism and impaired quality of life.6–8 Relatively little information exists about the use of health-care resources.
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
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Summary
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E.M. Marks et al.
Methods Setting
Measures Chest pain Frequency of chest pain was assessed using a 10-point scale (from 0 = never to 9 = all the time). Chest pain was assessed using a self-report version of the Guy’s Hospital Chest Pain Questionnaire.10,11 This questionnaire assesses for three symptoms
Brief Illness Perception Questionnaire Brief Illness Perception Questionnaire (BIPQ)12 assesses perceptions and beliefs about chest pain. Items are rated on a 0 to 10 scale assessing consequences, timeline, personal and treatment control, identity, coherence (how the patient ‘makes sense’ of or understands their illness), concern and emotional representation of chest pain. Patients also identified the three most important factors in their chest pain. These were clustered into ‘biological’, ‘psychological’ or ‘social’ factors, to show whether a patient had a no model, a biomedical, psychosocial or biopsychosocial model of chest pain.
Table 1 Diagnostic tests completed in the RACPCa Tests
NCCP (n = 234) N (%) doing test
Had any test Exercise tolerance test Myocardial perfusion scan Stress echo Coronary CT Invasive contrast angiogram Perfusion cardiac MRI Previous tests predicted CAD Surgery for coronary disease
222 73 65 34 43 11 4 0 0
(95) (31) (28) (14) (19) (5) (2)
+ ve (n)
1 2 4 0 0 0 0 0
CCP (n = 47) ve (n)
72 63 30 43 11 4 0 0
N (%) doing test 47 5 7 9 8 24 4 2 5
(100) (11) (15) (21) (17) (51) (9) (4) (11)
+ve (n)
5 7 8 7 24 4 2 5
ve (n)
0 0 1 1 0 0 0 0
a Some NCCP cases had positive non-invasive tests leading to normal invasive contrast angiography. There are also a few cases of CCP with initial negative test results, followed by positive invasive contrast angiography
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The RACPC at St Thomas’ Hospital, London sees approximately 500 cases each year. It adheres to 2010 NICE guidelines.9 Initial assessment is with a history and physical examination, a 12 lead ECG and questionnaires. The questionnaires were collected between 1 April and 31 August 2011, with a sub-sample (patients from February 2012 to February 2013) completing additional psychological screening questions. If indicated, further tests were performed including blood analysis, chest X-ray, resting transthoracic echocardiogram, CT scan, functional testing or coronary angiography. The diagnosis of NCCP is based upon on the outcome from all completed investigations and the clinical judgement of the clinical nurse specialist and supervising cardiologist, who were blinded to the results of the questionnaires. The majority had at least one functional or imaging investigation (Table 1). Only patients with a low coronary risk, non-cardiac sounding history and a normal resting 12-lead ECG did not receive a functional test. The study was given approval as a clinical evaluation by Guy’s and St Thomas’ NHS Foundation Trust.
found to have discriminatory value expressed in binary fashion (‘typical’ vs. ‘atypical’). Patients report the consistency with which pain is reproduced by exercise (typical score index is 10/10), the usual duration of pain (typical score index is 5 min or less) and the frequency of pain when at rest (typical score index is 10% of all pain episodes). Each ‘typical’ response scores one point, each ‘atypical’ response scores zero points, and the three responses are summed. Scores of 0 or 1 are defined as ‘atypical pain’, and scores of 2 or 3 are defined as ‘typical pain’ of cardiac origin. Chest pain was rated for severity, distress, interference and problematic nature on three 10-point scales (from 1 = not at all to 10 = extremely), with the average of the three scales giving an overall ‘interference’ score. The subset of patients rated, on the same scales, how much they believed that chest pain was a sign that they were about to have a heart attack (panic-type beliefs) and a sign of a serious heart condition (health anxiety-type beliefs).
The rapid access chest pain clinic: distress and disability
Patient Health Questionnaire-15 Patient Health Questionnaire-15 (PHQ-15)13 assesses the severity (0 to 2 scale) of 15 common somatic symptom clusters. The total score reflects the severity of somatic symptoms. Scoring 10 or more predicts a diagnosis of a somatoform disorder.
Client Service Receipt Inventory The Client Service Receipt Inventory (CSRI)14 was used to estimate use of health-services. Patients give information about health-care use in the preceding 6 months: Contacts with health-care professionals for chest pain and other symptoms, hospital admissions and medication profile. The sub-sample completed additional questionnaire measures:
Patient Health Questionnaire-9.
Generalized Anxiety Disorder Assessment7. Generalized Anxiety Disorder Assessment-7 (GAD-7)16 measures anxiety symptoms. Seven items are rated on a 0 to 3 scale. A total score of 8 or more demonstrates clinically significant anxiety symptoms.
Work and Social Adjustment Scale.
Work and Social Adjustment Scale (WSAS)17 measures impairment of quality of life due to chest pain. Five items are rated on a 0 to 8 scale. A total score of 10–20 suggests significant functional impairment. Scores over 20 suggest severe psychopathology.
Behavioural reactions.
Behavioural reactions were measured. Patients reported any avoidance of physical activity because of chest pain (from 0 = never to 3 = often) and their frequency of moderate physical activity (from 0 = never to 5 = every day).18
Analysis SPSS version 21 was used to analyze the data. Groups were compared using t-tests and chi-square tests on the main outcomes. Binary logistic regression analyses were conducted to assess whether beliefs and chest pain characteristics were predictive of membership in either group. All tests were two-tailed and P was considered significant at the < 0.05 level.
Results Demographics Of 294 patients, 13 were excluded from analysis due to lack of test results. Of the remaining 281 patients, 234 (83%) had normal cardiac investigations and were classed as NCCP. Patient characteristics are shown in Table 2. The sub-sample of patients completing the additional measures included 175 patients of whom 150 (86%) had NCCP. The sub-sample did not differ significantly from the total sample on any characteristics. The NCCP group was significantly younger (53, SD 10.8) than the CCP group (60, SD 11.4), t(278) = 3.5, P < 0.001. There were no other significant differences between groups. The sample reflects the ethnic diversity of this population, with 37% of the total sample from an ethnic minority. Overall, 54% were employed with 66% in nonmanual occupations.
Chest pain characteristics A significantly greater proportion of NCCP (82%) than CCP (50%) patients reported atypical pain x2 = 17.3, P < 0.001. There were no significant differences between NCCP and CCP in terms of chronicity, frequency, severity or interference. Chest pain was typically chronic, with a mean duration of 9 (SD 16.6) months, and present for longer than 3
Table 2
Characteristics of NCCP and CCP patients
Patient characteristics
NCCP N = 225
CCP N = 61
Age (years), mean [SD] Gender (% male) Ethnicity (%) White Black Asian Other Socioeconomic status, occupation (%) Non-manual Manual Other Employment status (%) Employed Unemployed Retired due to ill health Retired due to age Other
53 [10.8] 50
60 [11.4]* 55
61 27 6 6
73 16 9 2
67 26 7
62 28 10
56 15 3 14 12
48 16 5 25 6
*P < 0.001
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Patient Health Questionnaire-9 (PHQ-9)15 measures depressive symptoms over the past 2 weeks. Nine items are rated on a 0 to 3 scale. A total score of 10 or more indicates clinically significant depressive symptoms.
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months in 46%. Pain frequency was high in both groups with 51% of the whole sample reporting at least daily chest pain. Both groups reported similar levels of somatic symptoms (PHQ15) (Table 3), and the mean score of the whole sample lay above clinical significance at 10.5 (SD 6.1).
Chest pain beliefs and perceptions
Psychosocial and behavioural factors There were no significant group differences for anxiety (GAD7) or depression (PHQ9). Overall, 34% reported clinically relevant scores on the PHQ9 and 33% on the GAD7.
Medication and health service use The CCP patients were significantly more likely to be taking medication; they took significantly more medications overall (4.0, SD 3.0) than NCCP patients (2.8, SD 2.4): t(198) = 2.5, P < 0.05. Unsurprisingly, more CCP patients (22%) compared with NCCP patients (8%) were taking medication for angina or hypertension (x2 = 6.0, P < 0.05) and secondary prophylaxis (59% vs. 33%), x2 = 7.8, P < 0.01. CCP patients also took more respiratory medication (22% vs. 8%) x2 = 5.2, P < 0.05. In the preceding 6 months the NCCP group sought help from significantly more different types of health-care professional (1.7, SD 1.0) than the CCP group (1.4, SD 0.7): t(258) = 2.0, P < 0.05. There was also a non-significant trend for the NCCP group to attend more health-care
Table 3 Chest pain and somatic symptoms in NCCP and CCP Symptom characteristics
NCCP N = 234
CCP N = 47
Atypical chest pain (%) Months chest pain present, mean [SD] Chronic chest pain (%) (pain present for >3 months) Frequency of pain (%) Daily or more often At least weekly / less than daily less than once a week Severity of chest pain, mean [SD] Interference of chest pain, mean [SD] Somatization - PHQ-15, mean [SD] Score above clinical significance (510)
151 (82) 9 [15.4] 95 (43)
19 (50)* 11 [21.8] 25 (58)
106 65 47 5.3 5.1 10.7 128
27 7 7 4.5 5.1 9.5 20
*P < 0.001
(48) (30) (22) [2.4] [2.4] [6.1] (56)
(66) (17) (17) [2.2] [2.3] [6.4] (43)
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Illness perceptions on the BIQP items were equivalent in both groups on all but item 7, measuring understanding of chest pain chest pain (‘illness coherence’): the NCCP group reported significantly lower illness coherence (3.5, SD 3.0) compared with the CCP group (4.7, SD 3.5): t(240) = 2.2, P < 0.05. There were no differences between the groups’ view of the causes of chest pain. Of the total sample, 64% reported a biomedical model or no model at all, 13% reported a psychosocial model and 24% reported a biopsychosocial model of chest pain. There were significant differences in the beliefs held by each group about chest pain. The NCCP group reported significantly higher scores on panic-type beliefs about having a heart attack (5.8, SD 3.1) compared with the CCP group (4.3, SD 3.1): t(159) = 2.12, P < 0.05. There was also a nonsignificant trend towards the NCCP group reporting stronger health-anxiety beliefs about having a serious heart condition (5.2, 2.8) than the CCP group (4.0, 2.9): t(158) = 21.83, P = 0.07.
The impact of chest pain on work and social adjustment (WSAS) was similar in both groups. The overall mean score of 7.2 (SD 8.8) was sub-clinical although a proportion (23%) of the total sample reported a significant impairment (>10) and 10% scored at the level suggesting psychopathology (>20). Both groups reported similar levels of activity, with 47% of the sample describing low activity levels (exercising once a week or less), and 57% avoiding activity due to concern about their heart. A significantly larger proportion of the CCP reported that they had stopped work because of chest pain (8%) compared to the NCCP group (2%): x2 = 4.8, P < 0.05. There were no other differences between groups on measures of unemployment, benefits or absenteeism. Overall, 27% of the sample reported receiving state benefits for ill health.
The rapid access chest pain clinic: distress and disability
Figure 1. Pattern of health-care use in NCCP and CCP patients over the preceding 6 months.
appointments for chest pain (1.2, SD 1.2) compared with the CCP group (0.7, SD 1.0): t(136) = 1.9, P = 0.055. All patients tended to seek help but the NCCP group showed increased help-seeking behaviours overall, as seen in the pattern of attendance shown in Figure 1.
Regression model
Discussion Rapid Access Chest Pain Clinics (RACPC) were set up to reduce mortality associated with new-onset cardiac pain. However the majority (83%) of our patients had non-cardiac pain (NCCP) present for a mean of 9 months. Patients with NCCP reported levels of pain and distress similar to those with cardiac disease. Some differences between groups were found which may be of potential importance when planning treatment. We confirmed previous work showing similar levels of psychiatric comorbidity19–21 in CCP and NCCP, but showed in addition that both groups had equally high levels of interference from chest pain. Approximately a quarter of both groups reported impaired work, social adjustment, unemployment and absenteeism. Two-thirds avoided activity, an important finding since avoidance has a role in
the maintenance of NCCP.18 NCCP patients tended to hold a biomedical view of pain, or to have no clear causal understanding and this gives a focus for improving treatment. As NCCP is often classed as a ‘Medically Unexplained Symptom’,22 it might be expected to co-occur with other somatic symptom, but previous studies have not explored this. We found somatic symptoms were equivalent between groups, and approximately half of our sample reported symptoms at a level above clinical significance. However NCCP is not properly ‘medically unexplained’, since a proportion of patients have pain of organic origin, principally from the gastrointestinal and musculoskeletal systems or from thoracic respiratory patterns, and they may respond to appropriate medication or physical treatments. Chest discomfort is a common symptom, reported by as many as 25% in population surveys,23 and this normal somatic sensation may only be seen as a ‘symptom’ following complex and varying interpretative processes. Symptoms arising from an organic cause can be sustained or exacerbated by further unhelpful psychological and behavioural processes. These potential interactions underline why an individualised biopsychosocial approach may improve management of NCCP. This approach has been effective in services for chronic pain in other bodily systems.4,24 It should include cardiologists, cardiac nurses and experts in psychosocial assessment and treatment, such as clinical psychologists. This team could offer multidisciplinary assessment, and so account for the various organic, psychiatric and psychological factors that affect chest pain. Interventions could then be targeted to the individual’s needs, with medical and/or psychological treatment provided as appropriate. We believe that this approach may be best offered as part of the RACPC, and NCCP patients attending the RACPC who require further help could have the opportunity to attend a specialist biopsychosocial clinic for NCCP. Without fully exploring interactions between cognition, behaviour, emotion and physical symptoms in the RACPC, it is difficult to differentiate CCP from NCCP. Atypical chest pain as formally defined using a statistically-derived score was found in 50% of those with cardiac pain as well as 82% with NCCP. Although age and pain-typicality independently differentiated patients with CCP and NCCP, these factors only explained 16% of the variance. These similarities may be partly because general practitioners tend to send diagnostically uncertain cases to the RACPC, while sending those with definite cardiac pain to cardiology outpatients or the emergency department. Such similarity in clinical
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A binary logistic regression analysis was performed, using the predictor variables that demonstrated significant differences between the two groups on the whole sample (age, typicality of chest pain, IPQ7 (coherence), number of health-care professionals visited and total number of different medications taken). In the final model only age and typicality remained significant: Age (OR = 1.05, 95% CI 1.01–1.09 P < 0.005) and Typicality (OR=3.72, 95% CI 1.74–8.00 P < 0.001), correctly classified 16% of all cases.
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characteristics underlines the importance of objective investigation in chest pain. There is little recent information about the use of health-care resources for patients with NCCP. Our patients with NCCP saw significantly more different types of health-care professional, and showed a trend to seek more appointments for chest pain than patients with cardiac pain, and overall the NCCP patients showed increased help-seeking (Figure 1). This underlines the economic impact of NCCP. Other reports have found similar changes in health-related quality of life and employment status.8,25,26
Conclusions Despite their good medical prognosis, NCCP patients are as disabled and distressed as patients with CCP. Their needs remain unmet under current protocols. We suggest a biopsychosocial, multidisciplinary approach be explored.
Funding
References 1. Department of Health. Coronary Heart Disease: National Service Framework for Coronary Heart Disease - Modern Standards and Service Models. Chapter 4 - Stable Angina. London, HMSO, 2000. 2. Sekhri N, Feder GS, Junghans C, Hemingway H, Timmis AD. How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients. Heart 2007; 93:458–63. 3. Debney MT, Fox KF. Rapid access cardiology – a nine year review. QJ Med 2011; 105:231–4. 4. Chambers JB, Marks E, Knisley L, Hunter M. Non-cardiac chest pain: time to extend the rapid access chest pain clinic? Int J Clin Pract 2013; 67:303–6. 5. Chambers J, Bass C. Chest Pain with normal coronary anatomy: a review of natural history and possible aetiological factors. Prog Cardiovas Dis 1990; 33:161–84. 6. Parkash O, Almas A, Hameed A, Islam M. Comparison of non cardiac chest pain (NCCP) and acute coronary syndrome (ACS) patients presenting to a tertiary care centre. J Pak Med Ass 2009; 59:667–71. 7. Robertson N, Javed N, Samani NJ, Khunti K. Psychological morbidity and illness appraisals of patients with cardiac and non-cardiac chest pain attending a rapid access chest pain clinic: a longitudinal cohort study. Heart 2008; 94:e12. 8. Fass R, Achem SR. Non-cardiac chest pain: epidemiology, natural course and pathogenesis. J Neurogastroenterol Motil 2011; 17:110–23. 9. National Institute for Health and Care Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest
10. Wu EB, Smeeton N, Chambers JB. A chest pain score for stratifying the risk of coronary artery disease in patients having day case coronary angiography. Int J Cardiol 2001; 78:257–64. 11. Cooke RA, Smeeton N, Chambers JB. Comparative study of chest pain characteristics in patients with normal and abnormal coronary angiograms. Heart 1997; 78:142–6. 12. Broadbent E, Petrie KJ, Maina J, Weinman J. The brief illness perception questionnaire. J Psychosom Res 2006; 60:631–7. 13. Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002; 64:258–66. 14. Beecham JK, Knapp MRJ. Costing psychiatric interventions. In: G, Thornicroft G, Brewin C, Wing JK, eds. Measuring Mental Health Needs. London, Gaskell, 1992, 163–83. 15. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606–13. 16. Spitzer RL, Kooenke K, Williams JBW, Lowe B. A brief measure for assessing Generalized Anxiety Disorder: the GAD-7. Arch Intern Med 2006; 166:1092–7. 17. Mundt JC, Marks IM, Shear K, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry 2002; 180:461–4. 18. Jonsbu E, Dammen T, Morken G, Moum T, Martinse EW. Short-term cognitive behavioural therapy for non-cardiac chest pain and benign palpitations: a randomized controlled trial. J Psychosom Res 2011; 70:117–23. 19. Bass C, Wade C. Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity. Psychol Med 1984; 14:51–61. 20. Eifert GH, Hodson SE, Tracey DR, Seville JL, Gunawardane K. Heart focused anxiety, illness beliefs, and behavioral impairment: comparing heart-anxious patients with cardiac and surgical inpatients. J Behav Med 1996; 19:385–99. 21. Hocaoglu C, Gulec MY, Durmus I. Psychiatric comorbidity in patients with chest pain without a cardiac etiology. Isr J Psychiatry Relat Sci 2008; 45:49–53. 22. Department of Health. IAPT: Medically Unexplained Symptoms Positive Practice Guide. 2008. www.iapt.nhs.uk/ wp-content/uploads/2008/11/medically-unexplained-symp toms-positive-practiceguidetxt.pdf (3 October 2012, date last accessed). 23. Eslick GD, Coulshed DS, Talley N. Review article: the burden of illness of non-cardiac chest pain. Ali- ment Pharmacol Ther 2002; 16:1217–23. 24. Morley S, Eccleston C, William A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behavioural therapy for chronic pain in adults, excluding headache. Pain 1999; 80:1–13. 25. Eslick GD, Jones MP, Talley NJ. Non-cardiac chest pain: prevalence, risk factors, impact and consulting. Aliment Pharmacol Ther 2003; 17:1115–24. 26. Tew R, Guthrie EA, Creed FH, Cotter L, Kisley S, Tomenson B. A long-term follow-up study of patients with ischaemic heart disease versus patients with non-specific chest pain. J Psychosom Res 1995; 39:977–8.
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This study was conducted as part of a routine clinical evaluation, funded by the Guy’s and St Thomas’ Charity (G100710).
pain or discomfort of suspected cardiac origin. 2010. National Institute for Health and Care Excellence Site. www.nice.org. uk/guidance/CG95 (29 May 2013, date last accessed).
Original papers The rapid access chest pain clinic: unmet distress and disability E.M. MARKS1,2, J.B. CHAMBERS1, V. RUSSELL1, L. BRYAN1 and M.S. HUNTER2 From the 1Cardiothoracic Centre, Guy’s and St Thomas Hospital, London, SE1 9RT and 2Institute of Psychiatry, Department of Psychology King’s College London, London, SE1 9RT, UK Address correspondence to Prof. J Chambers, Cardiothoracic Department, 1st Floor Southwark Wing, Guy’s Hospital, SE1 9RT, UK. email: [email protected] Received 10 December 2013 and in revised form 31 December 2013
Aims: To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital. Methods: A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period. Results: There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60,
OR = 1.05) and reported ‘atypical’ pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower ‘illness coherence’ (a patient’s belief that the illness ‘makes sense’) (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05). Conclusion: Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.
Introduction
NCCP is defined negatively by the absence of coronary disease and is not a unitary diagnosis. Patients with NCCP may have evidence of gastrooesophageal, musculoskeletal, psychiatric or psychological abnormalities. Our ability to provide adequate care is limited by a lack of information on the characteristics of patients with NCCP, particularly the nature of psychological distress. The aim of this study was to compare the use of health-care resources, chest pain characteristics and levels of psychological distress in consecutive patients attending a Rapid Access Chest Pain Clinic, with cardiac (CCP) and non-cardiac pain (NCCP).
Rapid Access Chest Pain Clinics (RACPC) were developed to reduce mortality in new-onset angina.1 However, three-quarters of patients attending these clinics have non-cardiac chest pain (NCCP)2,3 for which there are no current protocols for care.4 This is a serious deficiency because despite a low mortality rate,5 NCCP is associated with high levels of psychological distress, work absenteeism and impaired quality of life.6–8 Relatively little information exists about the use of health-care resources.
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
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Summary
430
E.M. Marks et al.
Methods Setting
Measures Chest pain Frequency of chest pain was assessed using a 10-point scale (from 0 = never to 9 = all the time). Chest pain was assessed using a self-report version of the Guy’s Hospital Chest Pain Questionnaire.10,11 This questionnaire assesses for three symptoms
Brief Illness Perception Questionnaire Brief Illness Perception Questionnaire (BIPQ)12 assesses perceptions and beliefs about chest pain. Items are rated on a 0 to 10 scale assessing consequences, timeline, personal and treatment control, identity, coherence (how the patient ‘makes sense’ of or understands their illness), concern and emotional representation of chest pain. Patients also identified the three most important factors in their chest pain. These were clustered into ‘biological’, ‘psychological’ or ‘social’ factors, to show whether a patient had a no model, a biomedical, psychosocial or biopsychosocial model of chest pain.
Table 1 Diagnostic tests completed in the RACPCa Tests
NCCP (n = 234) N (%) doing test
Had any test Exercise tolerance test Myocardial perfusion scan Stress echo Coronary CT Invasive contrast angiogram Perfusion cardiac MRI Previous tests predicted CAD Surgery for coronary disease
222 73 65 34 43 11 4 0 0
(95) (31) (28) (14) (19) (5) (2)
+ ve (n)
1 2 4 0 0 0 0 0
CCP (n = 47) ve (n)
72 63 30 43 11 4 0 0
N (%) doing test 47 5 7 9 8 24 4 2 5
(100) (11) (15) (21) (17) (51) (9) (4) (11)
+ve (n)
5 7 8 7 24 4 2 5
ve (n)
0 0 1 1 0 0 0 0
a Some NCCP cases had positive non-invasive tests leading to normal invasive contrast angiography. There are also a few cases of CCP with initial negative test results, followed by positive invasive contrast angiography
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The RACPC at St Thomas’ Hospital, London sees approximately 500 cases each year. It adheres to 2010 NICE guidelines.9 Initial assessment is with a history and physical examination, a 12 lead ECG and questionnaires. The questionnaires were collected between 1 April and 31 August 2011, with a sub-sample (patients from February 2012 to February 2013) completing additional psychological screening questions. If indicated, further tests were performed including blood analysis, chest X-ray, resting transthoracic echocardiogram, CT scan, functional testing or coronary angiography. The diagnosis of NCCP is based upon on the outcome from all completed investigations and the clinical judgement of the clinical nurse specialist and supervising cardiologist, who were blinded to the results of the questionnaires. The majority had at least one functional or imaging investigation (Table 1). Only patients with a low coronary risk, non-cardiac sounding history and a normal resting 12-lead ECG did not receive a functional test. The study was given approval as a clinical evaluation by Guy’s and St Thomas’ NHS Foundation Trust.
found to have discriminatory value expressed in binary fashion (‘typical’ vs. ‘atypical’). Patients report the consistency with which pain is reproduced by exercise (typical score index is 10/10), the usual duration of pain (typical score index is 5 min or less) and the frequency of pain when at rest (typical score index is 10% of all pain episodes). Each ‘typical’ response scores one point, each ‘atypical’ response scores zero points, and the three responses are summed. Scores of 0 or 1 are defined as ‘atypical pain’, and scores of 2 or 3 are defined as ‘typical pain’ of cardiac origin. Chest pain was rated for severity, distress, interference and problematic nature on three 10-point scales (from 1 = not at all to 10 = extremely), with the average of the three scales giving an overall ‘interference’ score. The subset of patients rated, on the same scales, how much they believed that chest pain was a sign that they were about to have a heart attack (panic-type beliefs) and a sign of a serious heart condition (health anxiety-type beliefs).
The rapid access chest pain clinic: distress and disability
Patient Health Questionnaire-15 Patient Health Questionnaire-15 (PHQ-15)13 assesses the severity (0 to 2 scale) of 15 common somatic symptom clusters. The total score reflects the severity of somatic symptoms. Scoring 10 or more predicts a diagnosis of a somatoform disorder.
Client Service Receipt Inventory The Client Service Receipt Inventory (CSRI)14 was used to estimate use of health-services. Patients give information about health-care use in the preceding 6 months: Contacts with health-care professionals for chest pain and other symptoms, hospital admissions and medication profile. The sub-sample completed additional questionnaire measures:
Patient Health Questionnaire-9.
Generalized Anxiety Disorder Assessment7. Generalized Anxiety Disorder Assessment-7 (GAD-7)16 measures anxiety symptoms. Seven items are rated on a 0 to 3 scale. A total score of 8 or more demonstrates clinically significant anxiety symptoms.
Work and Social Adjustment Scale.
Work and Social Adjustment Scale (WSAS)17 measures impairment of quality of life due to chest pain. Five items are rated on a 0 to 8 scale. A total score of 10–20 suggests significant functional impairment. Scores over 20 suggest severe psychopathology.
Behavioural reactions.
Behavioural reactions were measured. Patients reported any avoidance of physical activity because of chest pain (from 0 = never to 3 = often) and their frequency of moderate physical activity (from 0 = never to 5 = every day).18
Analysis SPSS version 21 was used to analyze the data. Groups were compared using t-tests and chi-square tests on the main outcomes. Binary logistic regression analyses were conducted to assess whether beliefs and chest pain characteristics were predictive of membership in either group. All tests were two-tailed and P was considered significant at the < 0.05 level.
Results Demographics Of 294 patients, 13 were excluded from analysis due to lack of test results. Of the remaining 281 patients, 234 (83%) had normal cardiac investigations and were classed as NCCP. Patient characteristics are shown in Table 2. The sub-sample of patients completing the additional measures included 175 patients of whom 150 (86%) had NCCP. The sub-sample did not differ significantly from the total sample on any characteristics. The NCCP group was significantly younger (53, SD 10.8) than the CCP group (60, SD 11.4), t(278) = 3.5, P < 0.001. There were no other significant differences between groups. The sample reflects the ethnic diversity of this population, with 37% of the total sample from an ethnic minority. Overall, 54% were employed with 66% in nonmanual occupations.
Chest pain characteristics A significantly greater proportion of NCCP (82%) than CCP (50%) patients reported atypical pain x2 = 17.3, P < 0.001. There were no significant differences between NCCP and CCP in terms of chronicity, frequency, severity or interference. Chest pain was typically chronic, with a mean duration of 9 (SD 16.6) months, and present for longer than 3
Table 2
Characteristics of NCCP and CCP patients
Patient characteristics
NCCP N = 225
CCP N = 61
Age (years), mean [SD] Gender (% male) Ethnicity (%) White Black Asian Other Socioeconomic status, occupation (%) Non-manual Manual Other Employment status (%) Employed Unemployed Retired due to ill health Retired due to age Other
53 [10.8] 50
60 [11.4]* 55
61 27 6 6
73 16 9 2
67 26 7
62 28 10
56 15 3 14 12
48 16 5 25 6
*P < 0.001
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Patient Health Questionnaire-9 (PHQ-9)15 measures depressive symptoms over the past 2 weeks. Nine items are rated on a 0 to 3 scale. A total score of 10 or more indicates clinically significant depressive symptoms.
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months in 46%. Pain frequency was high in both groups with 51% of the whole sample reporting at least daily chest pain. Both groups reported similar levels of somatic symptoms (PHQ15) (Table 3), and the mean score of the whole sample lay above clinical significance at 10.5 (SD 6.1).
Chest pain beliefs and perceptions
Psychosocial and behavioural factors There were no significant group differences for anxiety (GAD7) or depression (PHQ9). Overall, 34% reported clinically relevant scores on the PHQ9 and 33% on the GAD7.
Medication and health service use The CCP patients were significantly more likely to be taking medication; they took significantly more medications overall (4.0, SD 3.0) than NCCP patients (2.8, SD 2.4): t(198) = 2.5, P < 0.05. Unsurprisingly, more CCP patients (22%) compared with NCCP patients (8%) were taking medication for angina or hypertension (x2 = 6.0, P < 0.05) and secondary prophylaxis (59% vs. 33%), x2 = 7.8, P < 0.01. CCP patients also took more respiratory medication (22% vs. 8%) x2 = 5.2, P < 0.05. In the preceding 6 months the NCCP group sought help from significantly more different types of health-care professional (1.7, SD 1.0) than the CCP group (1.4, SD 0.7): t(258) = 2.0, P < 0.05. There was also a non-significant trend for the NCCP group to attend more health-care
Table 3 Chest pain and somatic symptoms in NCCP and CCP Symptom characteristics
NCCP N = 234
CCP N = 47
Atypical chest pain (%) Months chest pain present, mean [SD] Chronic chest pain (%) (pain present for >3 months) Frequency of pain (%) Daily or more often At least weekly / less than daily less than once a week Severity of chest pain, mean [SD] Interference of chest pain, mean [SD] Somatization - PHQ-15, mean [SD] Score above clinical significance (510)
151 (82) 9 [15.4] 95 (43)
19 (50)* 11 [21.8] 25 (58)
106 65 47 5.3 5.1 10.7 128
27 7 7 4.5 5.1 9.5 20
*P < 0.001
(48) (30) (22) [2.4] [2.4] [6.1] (56)
(66) (17) (17) [2.2] [2.3] [6.4] (43)
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Illness perceptions on the BIQP items were equivalent in both groups on all but item 7, measuring understanding of chest pain chest pain (‘illness coherence’): the NCCP group reported significantly lower illness coherence (3.5, SD 3.0) compared with the CCP group (4.7, SD 3.5): t(240) = 2.2, P < 0.05. There were no differences between the groups’ view of the causes of chest pain. Of the total sample, 64% reported a biomedical model or no model at all, 13% reported a psychosocial model and 24% reported a biopsychosocial model of chest pain. There were significant differences in the beliefs held by each group about chest pain. The NCCP group reported significantly higher scores on panic-type beliefs about having a heart attack (5.8, SD 3.1) compared with the CCP group (4.3, SD 3.1): t(159) = 2.12, P < 0.05. There was also a nonsignificant trend towards the NCCP group reporting stronger health-anxiety beliefs about having a serious heart condition (5.2, 2.8) than the CCP group (4.0, 2.9): t(158) = 21.83, P = 0.07.
The impact of chest pain on work and social adjustment (WSAS) was similar in both groups. The overall mean score of 7.2 (SD 8.8) was sub-clinical although a proportion (23%) of the total sample reported a significant impairment (>10) and 10% scored at the level suggesting psychopathology (>20). Both groups reported similar levels of activity, with 47% of the sample describing low activity levels (exercising once a week or less), and 57% avoiding activity due to concern about their heart. A significantly larger proportion of the CCP reported that they had stopped work because of chest pain (8%) compared to the NCCP group (2%): x2 = 4.8, P < 0.05. There were no other differences between groups on measures of unemployment, benefits or absenteeism. Overall, 27% of the sample reported receiving state benefits for ill health.
The rapid access chest pain clinic: distress and disability
Figure 1. Pattern of health-care use in NCCP and CCP patients over the preceding 6 months.
appointments for chest pain (1.2, SD 1.2) compared with the CCP group (0.7, SD 1.0): t(136) = 1.9, P = 0.055. All patients tended to seek help but the NCCP group showed increased help-seeking behaviours overall, as seen in the pattern of attendance shown in Figure 1.
Regression model
Discussion Rapid Access Chest Pain Clinics (RACPC) were set up to reduce mortality associated with new-onset cardiac pain. However the majority (83%) of our patients had non-cardiac pain (NCCP) present for a mean of 9 months. Patients with NCCP reported levels of pain and distress similar to those with cardiac disease. Some differences between groups were found which may be of potential importance when planning treatment. We confirmed previous work showing similar levels of psychiatric comorbidity19–21 in CCP and NCCP, but showed in addition that both groups had equally high levels of interference from chest pain. Approximately a quarter of both groups reported impaired work, social adjustment, unemployment and absenteeism. Two-thirds avoided activity, an important finding since avoidance has a role in
the maintenance of NCCP.18 NCCP patients tended to hold a biomedical view of pain, or to have no clear causal understanding and this gives a focus for improving treatment. As NCCP is often classed as a ‘Medically Unexplained Symptom’,22 it might be expected to co-occur with other somatic symptom, but previous studies have not explored this. We found somatic symptoms were equivalent between groups, and approximately half of our sample reported symptoms at a level above clinical significance. However NCCP is not properly ‘medically unexplained’, since a proportion of patients have pain of organic origin, principally from the gastrointestinal and musculoskeletal systems or from thoracic respiratory patterns, and they may respond to appropriate medication or physical treatments. Chest discomfort is a common symptom, reported by as many as 25% in population surveys,23 and this normal somatic sensation may only be seen as a ‘symptom’ following complex and varying interpretative processes. Symptoms arising from an organic cause can be sustained or exacerbated by further unhelpful psychological and behavioural processes. These potential interactions underline why an individualised biopsychosocial approach may improve management of NCCP. This approach has been effective in services for chronic pain in other bodily systems.4,24 It should include cardiologists, cardiac nurses and experts in psychosocial assessment and treatment, such as clinical psychologists. This team could offer multidisciplinary assessment, and so account for the various organic, psychiatric and psychological factors that affect chest pain. Interventions could then be targeted to the individual’s needs, with medical and/or psychological treatment provided as appropriate. We believe that this approach may be best offered as part of the RACPC, and NCCP patients attending the RACPC who require further help could have the opportunity to attend a specialist biopsychosocial clinic for NCCP. Without fully exploring interactions between cognition, behaviour, emotion and physical symptoms in the RACPC, it is difficult to differentiate CCP from NCCP. Atypical chest pain as formally defined using a statistically-derived score was found in 50% of those with cardiac pain as well as 82% with NCCP. Although age and pain-typicality independently differentiated patients with CCP and NCCP, these factors only explained 16% of the variance. These similarities may be partly because general practitioners tend to send diagnostically uncertain cases to the RACPC, while sending those with definite cardiac pain to cardiology outpatients or the emergency department. Such similarity in clinical
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A binary logistic regression analysis was performed, using the predictor variables that demonstrated significant differences between the two groups on the whole sample (age, typicality of chest pain, IPQ7 (coherence), number of health-care professionals visited and total number of different medications taken). In the final model only age and typicality remained significant: Age (OR = 1.05, 95% CI 1.01–1.09 P < 0.005) and Typicality (OR=3.72, 95% CI 1.74–8.00 P < 0.001), correctly classified 16% of all cases.
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characteristics underlines the importance of objective investigation in chest pain. There is little recent information about the use of health-care resources for patients with NCCP. Our patients with NCCP saw significantly more different types of health-care professional, and showed a trend to seek more appointments for chest pain than patients with cardiac pain, and overall the NCCP patients showed increased help-seeking (Figure 1). This underlines the economic impact of NCCP. Other reports have found similar changes in health-related quality of life and employment status.8,25,26
Conclusions Despite their good medical prognosis, NCCP patients are as disabled and distressed as patients with CCP. Their needs remain unmet under current protocols. We suggest a biopsychosocial, multidisciplinary approach be explored.
Funding
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This study was conducted as part of a routine clinical evaluation, funded by the Guy’s and St Thomas’ Charity (G100710).
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