![[BHJ LOGO]](../../images/sp_bhjpan.gif) |
       |
|
|
A TYPICAL CHEST PAIN CLINICAL PROFILE OF PATIENTS WITH CHEST PAIN WITH NORMAL AND ABNORMAL ANGIOGRAPHIC FINDINGS
Malay D Dave *, HS Dhavale **
*Resident; **Professor and Head, Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai - 400 008, India.
Chest pain is one of the most common symptoms in psychiatry and in primary care practice and is a frequent reason for extensive diagnostic work-up. Despite extensive investigations no recognizable medical cause to account for the symptoms is detected in many patients with chest pain. Studies of patients with non-cardiogenic chest pain have revealed that many continue to report symptoms and disability despite medical reassurances. These patients did not have progression to coronary artery disease.
The aim of the study was to study the clinical profile of patients who had atypical chest pain and normal angiographic findings (group A; cases) and compare it with those who had chest pain and abnormal angiographic findings (group B; controls). Accordingly 30 consecutive patients were taken in each group from a municipal teaching hospital. Rheumatic heart disease, valvular heart disease, ischaemic cardiomyopathy and congenital heart disease were ruled out in the controls. The patients were given a clinical questionnaire for studying the various clinical aspects of chest pain and type A behaviour patterns.
Patients who had atypical chest pain had more frequent episodes of chest pain, defined their pain more diffusely, had moderate to severe pain, had psychological precipitants, and experienced more autonomic symptoms. These patients also complained of lesser relief with medications. These patients had lesser prevalence of type A behaviour patterns as compared with the controls.
INTRODUCTION
Since Aristotle, pain has been classified not as a perception but as a mood state and so excluded from the five senses. The meaning of the pain is more than the pain itself. The links between the heart and the emotions have been described for thousands of years in ancient medico-religious texts. In modern medicine, psychosomatic physicians have described links between stressful life events, specific personality traits, and the development of coronary artery disease and hypertension. In recent years, literature describing the effects of stress, anxiety and depressive disorders on the development and exacerbation of cardiac disease has appeared and is drawing great interest. Links between panic disorder, mitral valve prolapse and cardiac symptoms have also been described. Psychiatric illness may have indirect effects on health behaviours known to directly affect the pathology of heart disease e.g. smoking, a high fat diet, alcohol and the exacerbation of the pathophysiology of the illness e.g. sudden death associated with stressful life events and severe anxiety and depressive symptoms. [9]
Type A behaviour pattern was originally described by two cardiologists : Meyer Friedman and Ray Rosenman. It can be defined as "a characteristic action-emotion complex which is exhibited by those individuals who are engaged in a relatively chronic struggle to obtain an unlimited number of poorly defined things from their environments in the shortest period of time and if possible, against the opposing efforts of other things or other persons in this same environment".
The association between type A behaviour and coronary artery disease has been investigated for more than three decades. The results are however conflicting. [9]
Chest pain is one of the most common symptoms in primary care practice [10] according to Kroenke et al. An organic aetiology is demonstrable in only about 16% of the patients. Wungling et al [13] estimated that a third of those patients have a current psychiatric disorder and that psychiatric disorders among chest pain patients are associated with high rates of emergency department utilization. Channer et al [4] report that patients with negative stress test had significantly higher scores for anxiety and depression than those with positive tests. More women than men had negative tests. Diagnostic exercise testing in patients with both affective and atypical chest pain symptoms may be misleading. Cormier et al [6] also showed a female preponderance, a younger age group, and higher reporting of autonomic symptoms with atypical chest pain. No prior history of organic heart disease was seen in a majority of these patients. [8] Certain personal and socio-cultural factors also play a significant role in the development of major psychiatric problems in these patients. [2] Many of these patients continue to report symptoms and disability despite medical reassurances. [1]
AIMS AND OBJECTIVES
1.To study the clinical profile of patients who had atypical chest pain and normal angiographic findings (Group A).
2.To compare this group with those who had chest pain and abnormal angiographic findings (Group B).
3.To study the personality pattern (Type A) in both the above mentioned groups.
MATERIAL AND METHODS
Selection criteries
1.Thirty consecutive patients were taken in each group.
2.Patients were not selected on the basis of presence or absence of mental symptoms.
3.Physical illnesses, rheumatic heart disease, valvular heart disease, ischaemic cardiomyopathy and congenital heart disease were ruled out.
4.The patients were interviewed within 48 hours post angiography.
Consent for participation in research was taken from the patients. A detailed history, thorough physical examination and required investigations were performed to rule out any other organic illness. A semistructured questionnaire was devised to study the clinical aspects of chest pain and type A personality behaviour patterns. The visual analogue scale was used to quantify the intensity of the chest pain.
Statistical analysis
Statistical analysis was performed on the data using the chi-square test.
TABLE 1
Nature of painType Group A Group B Gripping 3 10% 10 33.30% Pricking 3 10% 10 33.30% Heaviness 18 60% 6 20% Throbbing 5 70% 4 13.30% Burning 1 3.33% 0 SIG; P < = 0.05
TABLE 2
Intensity of pain (VAS score)Score Group A Group B 0 0 — 0 — 1 0 — 0 — 2 0 — 0 — 3 2 6.66% 0 — 4 5 16.66% 1 3.33% 5 8 26.66% 14 46.66% 6 8 26.66% 7 23.33% 7 5 1.66% 4 13.33% 8 0 — 4 13.33% 9 1 3.33% 0 — 10 1 3.33% 0 — NSIG
TABLE 3
Autonomic SymptomsNo. Group A Group B 0 10 33.33% 19 63.33% 1 13 43.33% 7 23.33% 2 3 10% 3 10% 3 3 10% 1 3.33% 4 1 3.33% 0 — NSIG
TABLE 4
Nature of painType Group A Group B Gripping 3 10% 10 33.30% Pricking 3 10% 10 33.30% Heaviness 18 60% 6 20% Throbbing 5 70% 4 13.30% Burning 1 3.33% 0 SIG; P < = 0.05
TABLE 4
Precipitating (A) and relieving (B) factor; response to medication (C) and type "A" behaviour (D)Group A Group B
A : Physical 7 23.33% 24 80% Psychological 23 76.66% 6 20% SIG; P < = 0.001 B : 19 63.33% 4 13.33% Rest 11 36.66% 26 86.66% Medication SIG; P < = 0.001 C : Improved 0 — 24 80% Not improved 28 98.33% 6 20% Worsening 2 6.66% 0 — SIG; P < = 0.05 D : Yes 9 30% 17 57% No 21 70% 13 43% SIG; P < = 0.05
RESULTS
In group A, 93% of the patients were in the 30-60 years age group whereas in group B 74% patients were in this age group. 26% of patients in group B were in the greater than 60 years age group. Equal sex distribution was present in group A whereas in group B there was a male preponderance (84%). This was a statistically significant findings. 50% of group A patients were unemployed (more housewives) compared to 34% of group B patients who were retired. No significant differences were found in the educational status, family structure, marital status, socioeconomic class, number of children, place of residence, religion and nativity.
No differences were found in the pattern of onset of symptoms, the duration of symptoms and the radiation of chest pain. 57% of group A patients reported no change compared to 67% of group B patients who reported worsening of symptoms over time. Group A patients had double the frequency of episodes of chest pain compared with the controls.
Most of the patients in group A (77%) described their chest pain as heaviness in the chest or as throbbing sensation. In the control group, 20 patients (67%) described their chest pain as either griping or pricking in nature. This was statistically significant. On the visual analogue scale (VAS), 70% of cases described their pain to be moderately severe whereas 70% of group B patients reported moderate pain. Two patients in group A reported very severe pain. 63% of group B patients reported no autonomic symptoms with the others reporting one or two autonomic symptoms. Most of the group A patients (67%) experienced 1, 2 or 3 autonomic symptoms. One patient experienced four autonomic symptoms in this group. Statistically significant difference (p < 0.001) was seen between the groups with 70% of group A patients giving psychological precipitators for chest pain and 80% of group B patients reporting physical or exertional precipitators for chest pain. Similarly 64% of patients in the study group reported rest as a relieving factor and 87% of patient in the control group described medications to be effective in the relief of chest pain (p < 0.001); 93% of patients in group A reported no improvement in chest pain with medication whereas 80% of group B patients reported improvement in chest pain with drugs. This was a statistically significant finding (p < 0.05).
There was a statistically significant difference between the groups (p < 0.05) with group B having 57% patients exhibiting type A behaviour pattern as compared to 30% patients in group A. No significant differences were found as regards previous hospitalizations or family history of chest pain and other physical co-morbidity. Group A and 17% patients with a past history of psychiatric disturbance and 20% having a family history of psychiatric illness with none whatsoever in group B patients.
DISCUSSION
The findings of the study compare well with previous research findings. We found that a younger age group was seen in those with atypical chest pain. Katon et al [5] , Cormier et al [6] , Channer et al [4] report similar findings. They have found out that there was a female predominance in patients of atypical chest pain. This was not found in our study.
According to Katon et al, [9] the majority of patients with normal findings on coronary arteriography have persistent complaints of chest pain on follow-up and continued socio-occupational disabilities. In this study, 57% of group A patients had no change in the course of the illness and 93% of them showed no response to medication. Lantinga et al11 also showed that these patients have a non-progressive disorder on a longer follow-up and on follow-up there were continued high neuroticism scores among these patients. Isner et al7 followed a group of 121 patients for upto 11 years and noted that there was only a 2.5% incidence of sudden death and a 3.4% incidence of acute myocardial infarction, thus showing that majority of such patients had a chronic, non-progressive type of an illness. Bass et al [3] suggest that many of these patients continue to report symptoms and disability despite medical reassurances. In our study, no significant difference was found in the duration of illness between the two groups but majority of patients in group A did not respond to medication and had more symptoms and more frequent episodes compared with group B patients. These findings were also seen in studies conducted by Kroenke et al [10] and Katon et al. [8] The pain described by these patients tend to be more diffuse than that experienced by patients of ischaemic heart disease. A study by Bass et al [2] yielded similar results. Plenty of psychosocial stressors are associated with atypical chest pain and may be chief precipitating factors. This was shown by Vasquez et al. [12] Atypical chest pain is also associated with a number of autonomic symptoms which is in keeping with results obtained from studies by Katon et al. [6,8] In this study, 77% of group A patients defined their chest pain as heaviness or throbbing sensation (i.e. : more diffuse) as compared with 67% of group B patients who had a griping or a pricking type of pain. Most of the cases reported moderately severe pain and most of the controls, moderate pain. 77% of cases had psychological precipitator as compared with 80% of controls who reported physical-exertional precipitator. Most of the patients in group A (67%) reported autonomic symptoms whereas 37% patients in group B had them.
The relationship of type A behaviour pattern with coronary artery disease is known (Katon et al [9] ). A predominance of type A behaviour pattern was seen in group B patients (57%) in this study.
CONCLUSIONS
As a distinct group, patients with atypical chest pain reported more frequent episodes of chest pain. They described their chest pain to be moderately severe in intensity and to be more diffuse. They reported psychological precipitants mainly, for the frequent episodes of chest pain. In addition, these patients reported a number of autonomic symptoms along with chest pain. These patients obtain minimal relief with drugs. Most of these patients did not exhibit type A behaviour patterns. A detailed clinical history will avoid unnecessary investigations and wastage of resources for these patients.
ACKNOWLEDGEMENT
Dr. Leelam Shah, Professor and Head and Residents of Department of Cardiology for their kind assistance in this study.
REFERENCES :
1. Bass C. Chest pain and breathlessness - Relationship to psychiatric illness. American Journal of Medicine 1992; 92 (Supplement IA) : 12s-17s.
2. Bass C. Non-cardiogenic chest pain. Practitioner 1989; 233 : 352, 355-7.
3. Bass C, Wade C. Chest pain with normal coronary arteries - A comparative study of psychiatric and social morbidity. Psychological Medicine 1984; 14 : 51-61.
4. Channer, KS, Papouchado M, James MA, Rees JA. Anxiety and depression in-patients with chest pain referred for exercise testing. Lancet 1985; 820-2.
5. Colgan SM, Schofield PM, Whorwell PJ, Benneth DH, Brooks NH, Jones PE. Angina like chest pain - A joint medical and psychiatric investigation. Postgraduate Medical Journal 1988; 64 : 743-6.
6. Cormier LE, Katon W, Russo J, Hollifield M, Hall ML, Vitaliano PP. Chest pain with negative cardiac studies - relationship to psychiatric illness. Journal of Nervous and Mental Disorders 1988; 6 : 351-8.
7. Isner JM, Salem DN, Banas JS, Levine HJ. Long term clinical course of patients with normal coronary arteriography - follow up of 121 patients with normal or nearly normal coronary arteriograms. American Heart Journal 1981; 4 : 645-53.
8. Katon W, Hall ML, Russo J, Cormier L, Hollifield M, Vitaliano PP, Beitman BD. Chest pain : relationship of psychiatric illness to coronary arteriographic results. American Journal of Medicine 1988; 84 : 1-9.
9. Katon W, Sullivan M, Clark M. Cardiovascular disorders. In : Comprehensive text book of psychiatry, (Eds.) Kaplan HI, Sadoc BJ, Baltimore : Williams and Wilkins. Vol. 2 (6) : 1491-1501.
10. Kroenke K, Mangelsdorf D. Common symptoms in ambulatory care - Incidence, evaluation, therapy and outcome. American Journal of Medicine 1989; 86 : 262-6.
11. Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA, Hill NE. One year psychological follow-up of patients with chest pain and angiographically normal coronary arteries. American Journal of Cardiology 1988; 62 : 209-13.
12. Vasquez Barquero JI, Padierna Acero JA, Ochoteco A, Diez Manrique JF. Mental illness and ischemic heart disease - Analysis of psychiatric morbidity. General Hospital Psychiatry 1985; 1 : 15-20.
13. Wulsin ZR, Yingling R. Psychiatric aspects of chest pain in the emergency department. Medical Clinics of North America 1991; 5 : 1175-88.
 |