Glombiewski Julia Anna, Rief Winfried, Bösner Stefan, Keller Heidemarie, Martin Alexandra, Donner-Banzhoff Norbert
Department of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Germany.
Arch Intern Med. 2010 Feb 8;170(3):251-5. doi: 10.1001/archinternmed.2009.474.
Nonspecific chest pain is common in primary care, yet knowledge is sparse about its course and outcome and how they relate to optimum health care usage. We investigated the following observations: (1) many patients who present with nonspecific chest pain in primary care show symptom persistence for 6 months, (2) many patients with nonspecific chest pain showed signs of overinvestigation, and (3) many patients with chronic chest pain were referred to mental health specialists.
We conducted a prospective, general physician-based cohort study with 6-week and 6-month follow-ups in 74 primary care offices in Hessen, Germany. Of approximately 190 000 consecutive patients who visited their general physicians from October 1, 2005, to July 31, 2006, 807 patients with nonspecific chest pain were identified by an expert committee (delayed-type reference standard). The dropout rate was 2.7%. Main outcome measures were persistent chest pain at a 6-month follow-up visit and health care usage at 6 months.
The rate of persistent chest pain was 55.5%. A total of 10.7% of patients had inappropriate health care usage, defined as 2 or more visits to a cardiologist or 3 or more cardiac diagnostic investigations. Most patients with persistent nonspecific chest pain were referred to a cardiologist, and less than 2% were referred to mental health specialists.
For most patients with nonspecific chest pain, standard medical care does not offer sufficient help for symptom relief. One-tenth of patients with persistent chest pain underwent additional diagnostic testing of no known clinical benefit. Psychological referrals were rarely given.
非特异性胸痛在初级保健中很常见，但关于其病程、结局以及它们与最佳医疗保健使用之间的关系，人们了解甚少。我们调查了以下情况：（1）许多在初级保健中出现非特异性胸痛的患者症状持续6个月，（2）许多非特异性胸痛患者存在过度检查的迹象，（3）许多慢性胸痛患者被转诊至心理健康专家处。
我们在德国黑森州的74个初级保健诊所进行了一项基于全科医生的前瞻性队列研究，并进行了6周和6个月的随访。在2005年10月1日至2006年7月31日期间连续就诊于全科医生的约190000名患者中，由一个专家委员会（延迟型参考标准）确定了807例非特异性胸痛患者。失访率为2.7%。主要结局指标为6个月随访时的持续性胸痛以及6个月时的医疗保健使用情况。
持续性胸痛的发生率为55.5%。共有10.7%的患者医疗保健使用不当，定义为就诊心脏病专家2次或以上或进行3次或以上心脏诊断检查。大多数持续性非特异性胸痛患者被转诊至心脏病专家处，不到2%的患者被转诊至心理健康专家处。
对于大多数非特异性胸痛患者，标准医疗护理在缓解症状方面帮助不足。十分之一的持续性胸痛患者接受了无已知临床益处的额外诊断检查。很少进行心理转诊。
