Clinical Scenario A 35-year-old m...

Clinical Scenario

A 35-year-old man flows to you for follow-up after his third sudden [i]or[/i] unexpected occurrence department visit for continued intermittent chest pain. He has no cardiac risk factors and his electrocardiography (ECG) and stres example results were normal in the urgency department. You suspect a noncardiac cause for his chest pain.

Clinical Question

What is the best way to treat noncardiac chest pain?

Evidence-Based Answer

Noncardiac chest pain can be caused by way of gastroesophageal reflux disease (GERD), panic disorder, or a number of other psychological conditions. Psychotherapy, particularly cognitive behavior therapy, has been shown to make less the number of days with chest pain significantly above a three-month period, whatever the cause. (1)

Practice Pointers

The cause of chest pain for patients presenting to extremity departments most commonly is noncardiac. Epidemiologic studies have not been conclusive, however noncardiac chest pain is speculation to affect about 25 percent of the U population, with equal distribution among men and women As so it also is seen commonly in primary care and pain is not related to cardiac disease does not interrupt patients with noncardiac chest pain from experiencing significant functional impairment. This translates into high medical care usage, including hospitalization and inappropriate cardiac medication. The cause of noncardiac chest pain is most numerous commonly GERD or panic disorder, although other gastrointestinal motility diseases and psychiatric diseases also figure prominently. (23) level when the cause is gastrointestinal, there frequently is significant psychiatric comorbidity, as there is with GERD without noncardiac chest pain. (4) Chest pain in children rarely is related to the heart and is conception to be most commonly musculoskeletal, although children with chest pain can have increased anxiety-related symptoms. (2)

Patients who are evaluated in the pass department and diagnosed with non-cardiac chest pain repeatedly are not treated for their chest pain in that setting. The assumption is that the anxiety evident in the patient will be eased with the reassurance that they do not have heart disease. This does not strike one as being to be true. Patients with noncardiac chest pain exhibit to more cardiac awareness and cardioprotective behavior than those with actual cardiac disease, and noncardiac chest pain may persist for years. (5) Noncardiac chest pain can be difficult to treat. Empiric treatment with high-dose omeprazole (Prilosec) can benefit patients in whom GERD is suspected. (6) Trazodone (Desyrel) and imipramine (Tofranil) also have been investigated as possible treatments for non-cardiac chest pain, although the studies were small. (4)

The authors of this Cochrane review (1) analyzed psychotherapy as treatment for noncardiac chest pain and ground a modest benefit. Patients received from the same to 12 sessions of therapy. Although the interventions varied, almost all included breathing exercises, and in the greatest degree also included cognitive restructuring and relaxation exercises. In about studies, the intervention also included question solving, physical exercise, and graded exposing Cognitive behavior therapy can be carried disclosed in individual or group settings and can be administered by dint of a physician, nurse, psychologist, or other trained professional.

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied through an interpretation that will help clinicians impose evidence into practice. Katherine L Margo, MD not absents a clinical scenario and question based forward the Cochrane Abstract, followed by dint of an evidence-based answer and a filled critique of the review.

This clinical contentment conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical contented presented with practice recommendations supported through evidence that has been reviewed systematically according to an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane. org/cochrane/revabstr/ AB004101.htm.

REFERENCES

(1) Kisely s Campbell LA, Skerritt P. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev 2005;(1):CD004101

(2) Eslick GD Noncardiac chest pain: epidemiology, natural history, health care seeking, and quality of life. Gastroenterol Clin North Am 2004;33:1-23

(3) Goodacre s Mason S, Arnold J, Angelini K Psychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit. Ann Emerg M 2001;38:369-76

(4) ancient KW. The psychological aspects of noncardiac chest pain. Gastroenterol Clin North Am 2004;33:61-7

(5) Esler JL Bock BC Psychological treatments for noncardiac chest pain: recommendations for a fresh approach. J Psychosom Res 2004;56:263-9

(6) Wang WH Huang JQ Zheng GF Wong WM Lam SK Karlberg J et al. Is proton cross-examine inhibitor testing an effective approach to diagnose gastroesophageal ebb disease in patients with noncardiac chest pain? A meta-analysis. Arch Intern M 2005;165:1222-8