EHJ: Non-cardiac chest pain can hint at risk for CVD death
While most consider non-cardiac chest pain (NCCP) a benign condition that infrequently leads to death, a study published Dec. 1 in the European Heart Journal found that this may not be the case. Patients discharged from a Scottish hospital with NCCP were at a measurable risk of death within a year of initial presentation. And patients who had a previous psychiatric hospitalization also had higher rates of short-term all-cause cardiovascular disease-related mortality.

“Although the incidence of acute MI (AMI) has fallen in recent years, there has been a substantial rise in hospitalizations for NCCP, a diagnosis of exclusion,” Michelle Gillies, MBChB, of the University of Glasgow in Glasgow, Scotland, and colleagues wrote. “Despite reassurance from clinicians, patients with NCCP often experience persistent symptoms, impaired psychosocial functioning, and present repeatedly to the acute medical services. Non-cardiac chest pain is a significant, and increasing, burden on healthcare systems.”

While commonly non-cardiac chest pain is considered a benign condition, the outcomes of NCCP remain unstudied. To help bolster these data, Gillies et al evaluated case-fatality following an incident hospitalization for NCCP to determine whether or not a previous psychiatric hospitalization was associated with short-term mortality.

The researchers conducted a population-based retrospective cohort study of 159,888 patients who were discharged from a hospital in Scotland between 1991 and 2006 following a first NCCP hospitalization. The study’s primary endpoint was all-cause and cardiovascular disease mortality at one year following hospitalization.

A total of 3,514 men and 3,136 women with a first NCCP hospitalization had a psychiatric hospitalization within 10 years preceding a NCCP hospitalization.

Over the study period, the researchers reported overall crude case fatality at one year to be 4.4 percent in men and 3.7 percent in women. Death was higher in men and women with a previous psychiatric hospitalization than those without, 6.3 percent vs. 4.3 percent in men and 5.4 percent vs. 3.6 percent in women. This was the same over all age groups of patients. The proximity of psychiatric hospitalization to incident NCCP hospitalization was linked to greater mortality in both men and women, the authors reported.

All-cause mortality rates in men with a previous psychiatric hospitalization were 9.6 percent, 5.8 percent and 3.8 percent, in the time periods of zero to one years, one to five years and five to 10 years from psychiatric hospitalization to NCCP hospitalization. These same values for women were 8.7 percent, 4.9 percent and 3.6 percent, respectively.

For those who underwent a previous psychiatric hospitalization, cardiovascular disease seemed to be the most common culprit of death, accounting for 22.2 percent of all deaths in men and 44.1 percent of all deaths in women. For those without a previous history of psychiatric hospitalization, the most common cause of death was cancer.

“In our study, NCCP was not a benign diagnosis; short-term case fatality following a first hospitalization for NCCP in individuals otherwise free from IHD [ischemic heart disease] was high,” the authors wrote. “Previous psychiatric hospitalization was associated with all-cause and CVD-specific mortality in patients hospitalized for NCCP.”

The study results suggest that previous psychiatric hospitalization should be considered in the risk stratification of patients presenting with NCCP, as patients with severe mental illness have been shown to have greater incidence of cardiac death compared with age-matched population controls.

“[H]aving identified and engaged with a group of patients at excess risk, a window of opportunity exists to deliver appropriately tailored risk reduction interventions,” the authors wrote. Patients with psychiatric issues could be at excess risk for CVD due to multiple reasons including that these patients have less than favorable lifestyles (poor diet, smoking, etc.).

“Early identification and intervention to modify cardiovascular risk factors in this population may reduce subsequent events and should be aggressively pursued, a view supported by a recent joint position statement issued by the European Psychiatric Association and European Society of Cardiology.”

The researchers concluded that factors that contribute to excess risk in this population and the development of risk scores to assess risk and help predict outcomes should be considered.