Non-Cardiac Chest Pain: the Role of Physical, Psychosocial, and Service-Related Factors in the Persistence of Pain and Health Service Use

Chest pain is one of the most frequent complaints in medical settings, yet more than half of cases have no detectable cause. Once a cardiac cause has been excluded, patients are typically discharged with a label of non-cardiac chest pain (NCCP). Patients with NCCP have been shown to have poor outcomes in terms of continued symptoms, distress, and continuing concern about heart disease. In addition, NCCP represents a significant burden to health services. The aetiology and management of NCCP is under-researched and poorly understood. This study sought to examine the predictors of persistent pain and health service use for patients in whom a cardiac diagnosis had been excluded. It also sought to explore how patients interpreted their symptoms in the context of normal test results, and the impact of their experiences with health services on these interpretations. A mixed-methods design was adopted. A prospective cohort study was initially conducted with 145 participants with chest pain who attended exercise stress testing and had normal test results. At one-year follow-up, 69% reported continued pain. In addition, nearly half of participants had returned to their general practitioner and one in ten had attended the emergency department for the investigation of chest pain. In logistic regression analyses, the variables heartburn, pain precipitated by movement, cardiac anxiety, illness perceptions, and lack of communication about test results were predictive of persistent chest pain. When participants with continued chest pain were categorised into persistent healthcare users and non-persistent healthcare users, these variables were predominantly associated with participants with persistent health service use for chest pain. In addition, a number of psychological variables including anxiety and depression distinguished the persistent service users. Employment appeared to be a protective factor against persistent pain and related service use. A small sample of participants from this cohort was interviewed in a qualitative study informed by the principles of Interpretative Phenomenological Analysis (IPA). Analysis revealed three predominant themes: 1) the disempowerment of normal test results; 2) limbo - the inner struggle of negating and relating to potential causes; and 3) the inadequacy of healthcare to validate and care for symptoms. The dynamic, complex process of interpreting symptoms and deciding whether to seek healthcare was illuminated. The results indicate that interventions targeting the assessment of a potential gastro-oesophageal or musculoskeletal cause and the reduction of cardiac anxiety are likely to improve outcomes in these patients. Improved communication with patients is also indicated. Psychological factors appear to drive persistent service use and interventions targeting these are likely to reduce medical costs. Patients with NCCP are not a homogenous patient group and an individualised, stepped-care approach to management appears to be warranted.