Date Published: February 1, 2019
Publisher: Public Library of Science
Author(s): Maria M. Wertli, Tenzin D. Dangma, Sarah E. Müller, Laura M. Gort, Benjamin S. Klauser, Lina Melzer, Ulrike Held, Johann Steurer, Susann Hasler, Jakob M. Burgstaller, Raffaele Serra.
Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out.
To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED).
Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing.
In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation.
In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.
The top priority in patients presenting with chest pain to the emergency department (ED) is to rule out a potentially life-threatening disease such as an acute coronary syndrome (ACS), pulmonary embolism, aortic dissection, or pneumonia. After a thorough diagnostic work-up, an acute myocardial ischemia can be ruled out for 60% to 90% of patients presenting with chest pain [1–4]. While in specialized units, including cardiac care units and intensive care units, the proportion of patients with ACS may be higher , the percentage of patients in the ED with ACS decreased in the US from 23.6% in 1999–2000 to 13.0% in 2007–2008 . When no specific disease causing the chest pain can be identified, patients are usually discharged with the diagnosis of non-cardiac chest pain (NCCP).
Single-center, retrospective medical chart review of patients presenting to one of the ten largest hospitals in Switzerland, the Cantonal Hospital Winterthur, between January 1, 2009 and December 31, 2011. The study period was chosen because an outpatient clinic opened in 2012 and therefore, many patients eligible for this study were potentially treated elsewhere. The hospital is affiliated to the University of Zurich and covers the medical services for approximately 200’000 persons (15 percent of the inhabitants of the canton Zürich).
Out of 31,902 visits to the ED, 2,438 records with the ICD-10 codes R07.1–4 were screened and 1,341 ED admissions for non-cardiac chest pain (4.2%, Table 1) were finally analyzed. The main discharge diagnoses were musculoskeletal chest pain (n = 602, 45%) and non-specific chest pain (n = 599, 45%). Musculoskeletal diagnosis were mainly non-specific related to the chest wall (90%) or to the spine (3%). Specific musculoskeletal diagnosis were found in a few patients (fractured rip n = 5, late onset rheumatoid arthritis n = 1, and contusion n = 3). In a small proportion of patients the diagnostic work-up resulted in a pulmonary (n = 30, 2%), GI-tract (n = 35, 2%), or psychiatric diseases (n = 75, 6%).
The major finding of this study is that chest pain of non-cardiac origin accounted for 4.2% of all ED visits and the diagnostic evaluation included in a minority of patients a formal cardiologic work-up with sequential cardiac troponin testing. In the majority of patients musculoskeletal chest pain or a non-specific chest pain was the discharge diagnosis and psychiatric diseases were rarely considered. Over 72 different recommendations at discharge were given, ranging from no further measures to extensive cardiac evaluation. Despite the recommendation for cardiologic follow-up evaluation in one fifth of the patients, ASS treatment was initiated in only a small proportion of those patients. The most frequently initiated treatment was analgesics where mainly paracetamol was prescribed. A diagnostic test with proton pump inhibitor was prescribed in 20% of patients without specific recommendations about the follow-up assessment.