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Non-Cardiac Chest Pain and Benign Palpitations in the Cardiac Clinic Br Heart J: First Published As 10.1136/Hrt.72.6.548 on 1 December 1994

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Non-Cardiac Chest Pain and Benign Palpitations in the Cardiac Clinic Br Heart J: First Published As 10.1136/Hrt.72.6.548 on 1 December 1994 548 Br HeartJ 1994;72:548-553 Non-cardiac chest pain and benign palpitations in the cardiac clinic Br Heart J: first published as 10.1136/hrt.72.6.548 on 1 December 1994. Downloaded from Richard Mayou, Bridget Bryant, Colin Forfar, David Clark Abstract Reports of chest pain and palpitations are the Objectives-To assess the characteristics most common reasons for referral from a gen- of consecutive patients referred from eral practice to cardiac clinics. Patients not general practice with the presenting dis- given a cardiac diagnosis are known by clini- order ofchest pain or palpitations, and to cians to be difficult to manage. In particular, determine the outcome at six months and there is consistent evidence that patients with three years. chest pain who are found to have normal Setting-A single consultant teaching coronary angiograms have a poor outcome hospital cardiac clinic receiving new and continue to report persistent symptoms, referrals from a health district. disability, and continuing concern about heart Design-94 consecutive referrals by gen- disease.' Less is known about the much larger eral practitioners to a cardiac clinic with number of patients with non-cardiac chest the presenting disorder of chest pain or pain who are seen in cardiac clinics but do not palpitations were assessed at first atten- undergo angiography,2" and especially about dance (research interview, cardiologists' patients who are reassured that their palpita- ratings, systematic medical case note tions are not medically significant.4 There is information), home interview six months therefore a need for further research directed later, and by a postal questionnaire at to improving the differential diagnosis of non- three years. cardiac disorders, the recognition of those Outcome measures-Physical and who might benefit from extra treatment, and psychological symptoms, limitation of to the development and evaluation of treat- activities, satisfaction with care, and use ments suitable for use with large numbers of ofhealth care resources. patients in routine clinical settings. Results-39 patients were given a cardiac This paper describes the assessment and diagnosis and 51 patients were not given management of a cohort of new patients http://heart.bmj.com/ a cardiac or other major physical diag- referred to a district hospital cardiac clinic nosis. The non-cardiac group was more and reports their symptomatic and functional likely to be young women, and to report outcome at six months and three years. other physical symptoms and previous Findings for those with and without cardiac psychiatric problems. The cardiac and disorders are compared, and issues relating to non-cardiac groups reported progressive patients thought not to have heart disease are improvement in presenting symptoms discussed: and disability at the six months and three (a) What is the size of the clinical problem? on October 2, 2021 by guest. Protected copyright. year follow up, but little change in mental What proportion of the patients is reassured state. Even so, three quarters of the non- by clinic assessment that their chest pain or cardiac subjects described continuing palpitations are not medically serious? How limitation of activities, concern about the many continue to suffer physical symptoms, cause oftheir symptoms, and dissatisfac- disability, and distress? tion with medical care. (b) What are the clinical or other characteristics University Conclusions-A substantial proportion of of non-cardiac patients compared with those Department of the consecutive referrals continued to diagnosed as having definite or probable heart Psychiatry, describe symptoms and disability disease? Warneford Hospital, Can we either at initial clinic Oxford throughout the three years after clinic (c) identify R Mayou attendance. Outcome was poor for those attendance, or at follow up, a subgroup of B Bryant who had negative investigations and were patients with poor prognosis who might bene- D Clark reassured that they had no cardiac dis- fit from extra intervention? Department of order or other serious physical finding. (d) What are the clinical implications of the Cardiovascular Medicine, John These results have implications for defin- provision of improved, but cost-effective, care Radcliffe Hospital, ing the role of psychological assessment for large numbers of patients? Oxford and for the formulation of cost effective C Forfar clinical measures to (a) minimise dis- Correspondence to: Dr Richard Mayou, ability associated with cardiac disorder; Methods University Department of and (b) prevent and treat handicaps in Consecutive patients referred by general prac- Psychiatry, Wameford Hospital, Oxford OX3 7JX. those without major physical diagnoses. titioners to a consultant cardiologist with pre- Accepted for publication senting disorders of chest pain or palpitations 1 June 1994 (Br Heart J 1994;72:548-553) were identified at their outpatient attendance. Non-cardiac chest pain and benign palpitations 549 Table I Characteristics ofpatients with cardiac diagnoses (definite or probable) and those with no cardiac or other major physical diagnosis. Values are No (%) unless stated othenvise Non-cardiac patients (n = 51) Cardiac patients (n = 39) Mean (range) age (years) 43-5 (21-65) 53-4 (39-69) Br Heart J: first published as 10.1136/hrt.72.6.548 on 1 December 1994. Downloaded from Male 22 (43) 23 (59) Previous hospital care for current episode Outpatient 10 (20) 2 (5) Inpatient 2 (4) 4 (10) Emergency 3 (6) 3 (8) General practice care Cardiac drugs 20 (39) 22 (56) Psychotropic drugs 4 (8) - (-) Diagnosis of heart disease 6 (12) 11 (28) Time before referral (months) <6 24 (47) 17 (44) 6-12 8 (16) 7 (20) >12 19 (37) 15 (40) Symptoms Mean (SD) Beck depression inventory 4-96 (4 33) 4.59 (4 08) Mean (SD) Spielberger trait anxiety 3900 (11-16) 37-10 (10-74) Mean (SD) hyperventilation score 12-24 (10-56) 9-72 (7-26) DSMIIIR psychiatric diagnosis 22 (42) 9 (24) Cardiologists' assessment and notes Mental state (moderate/severe) 20 (39) 7 (18) Hyperventilation (possible/probable) 13 (26) 4 (10) Psychiatric contribution to symptoms (probable/definite) 17 (33) 5 (13) Current psychiatric problem 22 (42) 6 (16) Social problem 11 (21) 4 (11) Investigations Exercise test 25 (49) 26 (67) 24 hour tape 8 (16) 5 (13) Angiography 1 (2) 10 (25) Subjects were interviewed using a brief semi- Fifty one (54%) were given no physical diag- structured interview derived from previous nosis (non-cardiac group). Most of those with work with angina5 and non-cardiac chest pain6 cardiac diagnoses, but few of the non-cardiac and completed three standard self report patients, were offered continuing clinic follow questionnaires: the Beck depression inven- up. tory,7 the Spielberger trait anxiety,8 and a hyperventilation check list.9 The cardiac CARDIAC GROUP assessment by a single consultant (CF) fol- The cardiologist diagnosed heart disease in 39 lowed normal clinical practice but, in addi- patients, 31 (79%) with angina (24 definite tion, the cardiologist completed a single page and seven probable) and eight (21%) with standard assessment sheet at the end of the paroxysmal arrhythmias (six definite and two consultation covering the physical diagnosis, probable). Table 1 gives their characteristics. aetiology ofthe present symptoms, hyperventi- Physical symptoms were usually marked (fig- lation, and role of psychological factors. ure): 17 (43%) rated their symptoms as sub- http://heart.bmj.com/ Further information was abstracted from jectively "severe", 11 (28%) as "very medical case notes. RM subsequently made distressing", and 8 (21%) as "very limiting". Severity stan- 100 psychiatric diagnoses according to the The means of the self report anxiety and 90 U diagnostic and statistical man- 80 Non cardiac dard American depression scores were within the upper nor- 70 IiCardi cdaual IIIR diagnostic criteria'° for psychiatric mal range for the general population,78 and 50 disorders. we made a research diagnosis of psychiatric 40 at disorder major depression and five anxi- 30 Six months later subjects were reassessed (four on October 2, 2021 by guest. Protected copyright. 20 10 home. The self report questionnaires were ety disorders) in a quarter of patients. 0 repeated and a semistructured interview cov- Reactions to the diagnosis of heart disease 100 Distress ered symptoms, beliefs, consultation, and dis- varied. Five patients found the definite diag- 90 80 ability. At three years subjects were sent nosis of heart disease a relief after months of 70 m postal questionnaires covering the same areas uncertainty. Ten patients described consider- o 60 .1 50 as assessments, with the able, but transient, distress. Two, both of 40 the previous together 30 Beck and Spielberger scales. Non-responders whom had long histories of chronic psycho- 20 10 were contacted by telephone. logical problems, reported continuing severe Statistical analysis was by the x2 test and by worry. Limitation generalised linear interactive modelling. 90 80 Outcome 70 Patients with cardiac disorders continued to Results use cardiological and general practice Most patients had been managed in general resources throughout the three year follow up 230 practice for several months before referral period. Outcome was generally encouraging, 0 6/12 3 years (table 1) and were eventually referred to but a small minority had disproportionate dis- Proportions ofsubjects establish a definite diagnosis for persistent ability and appeared to pose management reporting symptoms as symptoms. Clinical diagnosis was usually problems for other than strictly physical being subjectively severe, established within two clinic visits. Thirty reasons. distressing, and limiting at one had been clinic attendance, three nine of the 94 (41%) consecutive referrals At six months patient rediag- months, and three yearsfor were given either a definite or a probable car- nosed as "non-cardiac" having had a normal cardiac (n = 39, 29, 31 diac diagnosis (cardiac group). Four further coronary angiogram. Twenty nine patients non- respectively), and were other (74%) were still attending the clinic and 31 cardiac (n = 51, 46, 40 patients given specific physical respectively) subjects.
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