Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study

Abstract

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.

Fig 1. Initial ECG and troponin testing in patients non-cardiac chest pain groups.

MSD, musculoskeletal chest pain; non-specific, non-specific chest pain; pulmonary, pulmonary diseases; GI-tract, gastrointestinal tract related chest pain; Psychiatric, chest pain related to psychiatric conditions.

Fig 2. Additional non-invasive and invasive tests for cardiac diseases.

MSD, musculoskeletal chest pain; non-specific, non-specific chest pain; pulmonary, pulmonary diseases; GI-tract, gastrointestinal tract related chest pain; Psychiatric, chest pain related to psychiatric conditions.

Fig 3. Medications at discharge in non-cardiac chest pain groups.

MSD, musculoskeletal chest pain; non-specific, non-specific chest pain; pulmonary, pulmonary diseases; GI-tract, gastrointestinal tract related chest pain; Psychiatric, chest pain related to psychiatric conditions; ASS, acetylsalicylic acid; PPI, proton pump inhibitor.