Intended for healthcare professionals


Underlying psychological distress must be addressed in chest pain

BMJ 2000; 321 doi: (Published 12 August 2000) Cite this as: BMJ 2000;321:452
  1. Catherine Kinane, senior registrar in psychiatry
  1. Shaftesbury Clinic, Springfield University Hospital, London SW17 7DJ

    EDITOR—The editorial by Capewell and McMurray states that a rapid cardiological assessment service may reduce admissions of patients with chest pain.1 Such clinics apparently offer risk stratification, an exercise electrocardiogram, and review by a skilled hospital cardiologist. This approach also reduces worry about missed cases of coronary heart disease.

    Capewell and Murray quote Davie et al who described the 49% of their series of 317 patients with non-cardiac chest pain as being immediately reassured by a rapid assessment chest pain clinic and to have a high degree of satisfaction at six month follow up. These results, described as crucial by the authors, surprise me. With a consultant cardiologist and psychiatrist, I reviewed a series of 195 first time attenders at a secondary referral centre in a hospital in inner London.2 Psychological questionnaires were returned by 113 (58%) patients. Measures used included the hospital anxiety and depression questionnaire, the symptom checklist 90 revised (SCL-90), and the illness behaviour questionnaire. Fifty-two (46%) of the responders presented with chest pain, and of these 23 (20%) had typical anginal pain whereas 29 (26%) had atypical chest pain. After review by the consultant cardiologist and investigation as clinically indicated, 56 (50%) of the patients had a cardiac diagnosis and 57 (50%) had non-cardiac symptoms. Forty (35.4%) of the population had serious psychological distress. Logistic regression exploring the absence of a cardiac diagnosis yielded only two weak predictors, young age and a clinically significant score on the somatisation subscale of the SCL-90.

    The degree of psychological distress among those presenting with cardiac symptoms is high, and I am surprised that users of chest pain assessment services are reassured and hold on to such reassurance over time without the underlying psychological distress being addressed. Somatisers attending cardiology centres may continue to present at some level of care provision, particularly primary care. An outcome measure that included repeat presentations with non-coronary chest pain would answer this important resource question. Somatisation can be explained as a response to transient stress, but it can also herald persistent distress, care seeking, and disability. When unnecessary admissions are avoided illness behaviour may well be reduced, as there is no reinforcement of hypochondriasis through hospital admission. Non-coronary chest pain is a challenge as there is so much potential to reduce costs, minimise distress, and identify somatisation.


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