Kisely Steve R, Campbell Leslie A, Yelland Michael J, Paydar Anita
School of Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia, QLD 4102.
Cochrane Database Syst Rev. 2015 Jun 30;2015(6):CD004101. doi: 10.1002/14651858.CD004101.pub5.
Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.
To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.
We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.
Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).
Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.
We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.
AUTHORS' CONCLUSIONS: This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.
在无冠状动脉疾病的情况下反复出现胸痛是一个常见问题，有时会导致医疗资源的过度使用。尽管许多研究已探讨了这些患者疼痛的原因，但很少有临床试验评估治疗方法。这是对一篇Cochrane综述的更新，该综述最初发表于2005年，上次更新于2010年。本文所综述的研究深入探讨了心理干预对这类患者的有效性。
评估心理干预对非特异性胸痛患者胸痛、生活质量和心理参数的影响。
我们检索了Cochrane图书馆（CENTRAL，2014年第12期第4卷和DARE，2014年第4期第2卷）、MEDLINE（OVID，1966年至2014年4月第4周）、EMBASE（OVID，1980年至2014年第18周）、CINAHL（EBSCO，1982年至2014年4月）、PsycINFO（OVID，1887年至2014年4月第5周）和BIOSIS Previews（Web of Knowledge，1969年至2014年5月2日）。我们还检索了参考文献列表并联系了研究作者。
采用标准化结局方法的随机对照试验（RCT），测试任何形式的针对解剖结构正常的胸痛的心理治疗。诊断包括非特异性胸痛（NSCP）、非典型胸痛、X综合征或冠状动脉解剖结构正常的胸痛（住院患者或门诊患者）。
两位综述作者独立选择纳入研究、提取数据并评估研究质量。我们联系了试验作者以获取有关纳入的RCT的更多信息。
我们纳入了两篇新论文，其中一篇是之前纳入研究的更新。因此，共有17项RCT，1006名随机参与者符合纳入标准，一项新研究又增加了113名参与者。干预后前三个月胸痛报告显著减少：随机效应相对风险 = 0.70（95%可信区间0.53至0.92）。此后三至九个月维持该效果：相对风险0.59（95%可信区间0.45至0.76）。干预后至三个月无胸痛天数也显著增加：平均差（MD）3.00（95%可信区间0.23至5.77）。这与胸痛频率降低相关（随机效应MD -2.26，95%可信区间 -4.41至 -0.12），但三至十二个月期间无证据表明治疗对胸痛频率有影响（随机效应MD -0.81，95%可信区间 -2.35至0.74）。干预后三个月内对严重程度无影响（随机效应MD -4.64（95%可信区间 -12.18至2.89））。由于主要感兴趣干预措施的性质，治疗师无法对参与者是在干预组还是对照组不知情。此外，在三项研究中，当地伦理委员会因获取完全知情同意方面的问题明确禁止对参与者进行盲法。因此，所有研究存在较高的实施偏倚风险。此外，三项研究被认为存在较高的结局偏倚风险。总体而言，其他领域的偏倚风险较低。然而，存在高度异质性，解释这些结果时需谨慎。次要结局指标的广泛变异性使得整合研究结果困难。
本Cochrane综述表明心理干预有适度至中度益处，特别是那些采用认知行为框架的干预，这主要限于干预后的前三个月。催眠疗法也是一种可能的选择。然而，这些结论受到许多结果的高度异质性以及个别研究参与者数量较少的限制。其他简短干预的证据不太明确。需要对NSCP进行心理干预的进一步RCT，随访期至少为12个月。
