Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study.
Journal
PloS one
ISSN: 1932-6203
Titre abrégé: PLoS One
Pays: United States
ID NLM: 101285081
Informations de publication
Date de publication:
2019
2019
Historique:
received:
25
01
2018
accepted:
17
01
2019
entrez:
2
2
2019
pubmed:
2
2
2019
medline:
23
11
2019
Statut:
epublish
Résumé
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.
Sections du résumé
BACKGROUND
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.
OBJECTIVE
To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED).
METHODS
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.
RESULTS
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.
CONCLUSION
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.
Identifiants
pubmed: 30707725
doi: 10.1371/journal.pone.0211615
pii: PONE-D-18-02644
pmc: PMC6358153
doi:
Substances chimiques
Troponin
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
e0211615Déclaration de conflit d'intérêts
The authors have declared that no competing interests exist.
Références
J Clin Gastroenterol. 2008 May-Jun;42(5):636-46
pubmed: 18364579
BMC Med. 2013 Nov 08;11:239
pubmed: 24207111
J Fam Pract. 1997 Jul;45(1):54-63
pubmed: 9228915
Aliment Pharmacol Ther. 2005 Sep 15;22(6):547-55
pubmed: 16167971
N Engl J Med. 2000 Apr 20;342(16):1163-70
pubmed: 10770981
Gastroenterology. 1998 Jul;115(1):42-9
pubmed: 9649457
Aliment Pharmacol Ther. 2004 Oct 15;20(8):909-15
pubmed: 15479363
J R Soc Med. 2003 Mar;96(3):122-5
pubmed: 12612112
Am J Med. 2017 Oct;130(10):1205-1210
pubmed: 28396229
Med J Aust. 2000 Sep;173(5):233-4
pubmed: 11130345
Pain Physician. 2002 Oct;5(4):354-9
pubmed: 16886012
J Psychosom Res. 2000 Apr-May;48(4-5):347-56
pubmed: 10880657
Cochrane Database Syst Rev. 2012 Jun 13;(6):CD004101
pubmed: 22696339
PLoS One. 2014 Aug 11;9(8):e104722
pubmed: 25111147
Fam Pract. 2010 Aug;27(4):363-9
pubmed: 20406787
Fam Pract. 2001 Dec;18(6):586-9
pubmed: 11739341
JAMA. 1991 Mar 27;265(12):1545-9
pubmed: 1825675
Aliment Pharmacol Ther. 2002 Jul;16(7):1217-23
pubmed: 12144570
BMC Med. 2012 Jun 12;10:58
pubmed: 22691301
Gastroenterology. 1997 May;112(5):1448-56
pubmed: 9136821
Gastroenterol Clin North Am. 2004 Mar;33(1):1-23
pubmed: 15062433
Br J Gen Pract. 1999 Jul;49(444):551-4
pubmed: 10621990
Ann Emerg Med. 2004 Jan;43(1):59-67
pubmed: 14707942
Dis Mon. 2008 Sep;54(9):593-603
pubmed: 18725001
NCHS Data Brief. 2010 Sep;(43):1-8
pubmed: 20854746
Am Fam Physician. 2005 Nov 15;72(10):2012-21
pubmed: 16342831
Circulation. 2014 Dec 23;130(25):e344-426
pubmed: 25249585
J Manipulative Physiol Ther. 2012 Mar-Apr;35(3):184-95
pubmed: 22377444
J Manipulative Physiol Ther. 2012 Jan;35(1):7-17
pubmed: 22185955
Aliment Pharmacol Ther. 2004 May 15;19(10):1123-30
pubmed: 15142202
J Manipulative Physiol Ther. 2012 May;35(4):254-62
pubmed: 22632585
N Engl J Med. 1980 Nov 27;303(22):1249-52
pubmed: 7421961
Emerg Med J. 2015 Aug;32(8):595-600
pubmed: 25217099
J Neurogastroenterol Motil. 2011 Apr;17(2):110-23
pubmed: 21602987