Mayou R A, Bass C M, Bryant B M
University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK.
Heart. 1999 Apr;81(4):387-92. doi: 10.1136/hrt.81.4.387.
Non-cardiac chest pain assessed by cardiologists in their outpatient clinics or by coronary angiography usually has a poor symptomatic functional and psychological outcome. Randomised trials have shown the effectiveness of specialist psychological treatment with those who have persistent symptoms, but such treatment is not always acceptable to patients and may not be feasible in routine clinical settings.
To describe a sample of patients referred to cardiac outpatient clinics from primary care in a single health district who were consecutively reassured by cardiologists that there was not a cardiac cause for their presenting symptom of chest pain.
Systematic recording of referral and medical information of patients consecutively reassured by cardiologists. Reassessment in research clinic six weeks later (with a view to inclusion in a randomised trial of psychological treatment, which has been separately reported) and followed up at six months.
A cardiac clinic in a teaching hospital providing a district service to patients referred from primary care.
133 patients from the Oxfordshire district presenting with chest pain and consecutively reassured that there was no cardiac cause during the recruitment period; 69 had normal coronary angiograms and 64 were reassured without angiography.
A subgroup (n = 56) with persistent disabling chest pain at six weeks were invited to take part in a randomised controlled trial of cognitive behavioural treatment.
Standardised interview and self report measures of chest pain, other physical symptoms, mood and anxiety, everyday activities, and beliefs about the cause of symptoms at six week assessment; repeat of self report measures at six months.
Patients had a good outcome at six weeks, but most had persistent, clinically significant symptoms and distress. Some found the six week assessment and discussion useful. The psychological treatment was helpful to most of those recruited to the treatment trial, but a minority (15%) of those treated appeared to need more intensive and individual collaborative management. Patients reassured following angiography were compared with those reassured without invasive investigation. They had longer histories of chest pain, more often reported breathlessness on exertion, and were more likely to have previously been diagnosed as having angina, treated with antianginal medication, and admitted to hospital as emergencies.
These findings suggest a need for "stepped" aftercare, with management tailored according to clinical need. This may range from simple reassurance and explanation in the cardiac clinic to more intensive individual psychological treatment of associated underlying and often enduring psychological problems. Simple ways in which the cardiologist might improve care to patients with non-cardiac chest pain are suggested, and the need for access to specialist psychological treatment discussed.
心脏病专家在门诊或通过冠状动脉造影评估的非心源性胸痛，通常在症状功能和心理方面预后较差。随机试验表明，对有持续症状的患者进行专科心理治疗是有效的，但这种治疗并非总是为患者所接受，在常规临床环境中也可能不可行。
描述在一个单一健康区从初级保健转诊至心脏门诊的患者样本，这些患者被心脏病专家连续告知其胸痛症状不存在心脏病因。
系统记录心脏病专家连续给予安心诊断的患者的转诊和医疗信息。六周后在研究诊所进行重新评估（目的是纳入一项心理治疗随机试验，该试验已另行报告），并在六个月时进行随访。
一家教学医院的心脏诊所，为从初级保健转诊来的患者提供区域服务。
牛津郡地区133例出现胸痛的患者，在招募期间被连续告知不存在心脏病因；69例冠状动脉造影正常，64例未经造影即得到安心诊断。
六周时有持续性致残性胸痛的一个亚组（n = 56）被邀请参加认知行为治疗的随机对照试验。
六周评估时胸痛、其他身体症状、情绪和焦虑、日常活动以及对症状原因的信念的标准化访谈和自我报告测量；六个月时重复自我报告测量。
患者在六周时预后良好，但大多数仍有持续的、临床上显著的症状和痛苦。一些人认为六周的评估和讨论有用。心理治疗对大多数纳入治疗试验的患者有帮助，但少数接受治疗的患者（15%）似乎需要更强化的个体化协作管理。对造影后得到安心诊断的患者与未经侵入性检查即得到安心诊断的患者进行了比较。前者胸痛病史更长，更常报告运动时气短，并且更有可能此前被诊断为心绞痛、接受过抗心绞痛药物治疗并曾作为急症入院。
这些发现表明需要“分级”后续护理，根据临床需求进行管理。这可能从心脏诊所的简单安心诊断和解释到对相关潜在且往往持久的心理问题进行更强化的个体化心理治疗。提出了心脏病专家改善对非心源性胸痛患者护理的简单方法，并讨论了获得专科心理治疗的必要性。
