Cochrane for Clinicians

Putting Evidence into Practice

Psychological Interventions for Noncardiac Chest Pain

Katherine L. Margo, M.D., University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Katherine L. Margo, M.D., presents a clinical scenario and question based on the Cochrane Abstract, followed by an evidence-based answer and a full critique of the review.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been reviewed systematically by an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB004101.htm.

Clinical Scenario

A 35-year-old man comes to you for follow-up after his third emergency department visit for continued intermittent chest pain. He has no cardiac risk factors and his electrocardiography (ECG) and stress test results were normal in the emergency department. You suspect a noncardiac cause for his chest pain.

Clinical Question

What is the best way to treat noncardiac chest pain?

Evidence-Based Answer

Noncardiac chest pain can be caused by gastroesophageal reflux disease (GERD), panic disorder, or a number of other psychological conditions. Psychotherapy, particularly cognitive behavior therapy, has been shown to reduce the number of days with chest pain significantly over a three-month period, whatever the cause.1

Practice Pointers

The cause of chest pain for patients presenting to emergency departments most commonly is noncardiac. Epidemiologic studies have not been conclusive, but noncardiac chest pain is thought to affect about 25 percent of the U.S. population, with equal distribution among men and women. As such, it also is seen commonly in primary care and cardiologists' offices. Reassurance that the pain is not related to cardiac disease does not prevent patients with noncardiac chest pain from experiencing significant functional impairment. This translates into high medical care usage, including hospitalization and inappropriate cardiac medication. The cause of noncardiac chest pain is most commonly GERD or panic disorder, although other gastrointestinal motility diseases and psychiatric diseases also figure prominently.2,3 Even when the cause is gastrointestinal, there often is significant psychiatric comorbidity, as there is with GERD without noncardiac chest pain.4 Chest pain in children rarely is related to the heart and is thought to be most commonly musculoskeletal, although children with chest pain can have increased anxiety-related symptoms.2

Patients who are evaluated in the emergency department and diagnosed with noncardiac chest pain often are not treated for their chest pain in that setting. The assumption is that the anxiety evident in the patient will be eased with the reassurance that they do not have heart disease. This does not seem to be true. Patients with noncardiac chest pain show more cardiac awareness and cardioprotective behavior than those with actual cardiac disease, and noncardiac chest pain may persist for years.5 Noncardiac chest pain can be difficult to treat. Empiric treatment with high-dose omeprazole (Prilosec) can benefit patients in whom GERD is suspected.6 Trazodone (Desyrel) and imipramine (Tofranil) also have been investigated as possible treatments for noncardiac chest pain, although the studies were small.4

The authors of this Cochrane review1 analyzed psychotherapy as treatment for noncardiac chest pain and found a modest benefit. Patients received from one to 12 sessions of therapy. Although the interventions varied, almost all included breathing exercises, and most also included cognitive restructuring and relaxation exercises. In some studies, the intervention also included problem solving, physical exercise, and graded exposure. Cognitive behavior therapy can be carried out in individual or group settings and can be administered by a physician, nurse, psychologist, or other trained professional.

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The Author

Katherine L. Margo, M.D., is predoctoral director and assistant professor in the Department of Family Practice and Community Medicine at the University of Pennsylvania School of Medicine, Philadelphia, where she also is associate residency director. She received her medical degree from the State University of New York Upstate Medical Center, Syracuse, and completed a family medicine residency at St. Joseph's Hospital in Syracuse.

Address correspondence to Katherine Margo, M.D., Department of Family Practice and Community Medicine, University of Pennsylvania School of Medicine, 2 Gates/3400 Spruce St., Philadelphia, PA 19104 (e-mail: margok@uphs.upenn.edu). Reprints are not available from the author.

REFERENCES

1. Kisely S, Campbell LA, Skerritt P. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev 2005;(1):CD004101.

2. Eslick GD. Noncardiac chest pain: epidemiology, natural history, health care seeking, and quality of life. Gastroenterol Clin North Am 2004;33:1-23.

3. Goodacre S, Mason S, Arnold J, Angelini K. Psychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit. Ann Emerg Med 2001;38:369-76.

4. Olden KW. The psychological aspects of noncardiac chest pain. Gastroenterol Clin North Am 2004;33:61-7.

5. Esler JL, Bock BC. Psychological treatments for noncardiac chest pain: recommendations for a new approach. J Psychosom Res 2004;56:263-9.

6. Wang WH, Huang JQ, Zheng GF, Wong WM, Lam SK, Karlberg J, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain? A meta-analysis. Arch Intern Med 2005;165:1222-8.

Cochrane Briefs

MARK H. EBELL, M.D., M.S.

Corticosteroids for Pulmonary Sarcoidosis

Clinical Question

Do inhaled or oral corticosteroids improve outcomes for patients with pulmonary sarcoidosis?

Evidence-Based Answer

Patients who take oral corticosteroids are more likely to show improvement in their chest radiographs than those taking placebo, although improvements in symptoms and lung function are less certain. The typical dosage used in randomized trials was 20 mg daily or 40 mg every two days tapered over several months.

Practice Pointers

Sarcoidosis is a multisystem disease that often affects the lungs. Pulmonary sarcoidosis is characterized by cough, breathlessness, and progressive respiratory failure. Corticosteroids are the most widely used treatment, but until now, the evidence had not been reviewed systematically. Other treatments, such as methotrexate, antimalarial drugs, cyclosporine (Sandimmune), and the immunomodulator infliximab (Remicade), have been less well studied.1

Paramothayan and associates found 12 randomized controlled trials using different doses and routes of administering corticosteroids. Only two were double-blinded, and only two used adequate concealment of allocation. The 1,051 participants involved in the studies were at various stages of histology-confirmed disease. The studies used a variety of outcomes, primarily symptoms, lung function, and chest radiograph findings. Few data were available for more than two years of follow-up, and none of the studies measured the impact on mortality. In general, studies were small, most with fewer than 50 participants.

Four studies compared oral steroids with placebo, and two compared oral steroids with no treatment. Of the two largest studies, one used a tapering dose of 20 to 10 mg daily and the other a tapering dose of 40 to 20 mg every two days. The researchers found a consistent benefit in terms of improved chest radiograph appearance at the end of follow-up (70 versus 49 percent, P = .04, number needed to treat = 5). However, they found no consistent evidence of symptomatic improvement or improvement in measures of lung function. Comparisons of inhaled steroids with placebo did not show any consistent benefit.

Paramothayan NS, et al. Corticosteroids for pulmonary sarcoidosis. Cochrane Database Syst Rev 2005;(2):CD001114.

REFERENCE

1. Baughman RP, Lower EE, du Bois RM. Sarcoidosis. Lancet 2003;361: 1111-8.

Acute Treatment of Hyperkalemia

Clinical Question

What is the best acute treatment of an elevated serum potassium level?

Evidence-Based Answer

According to disease-oriented evidence, insulin and intravenous glucose, inhaled albuterol (Ventolin), and dialysis are the best treatment options; the first two may be given in combination. Bicarbonate or resins are not recommended for routine use, particularly without one of the more effective agents listed above.

Practice Pointers

Acute treatment of hyperkalemia falls into the still considerable "widely used but little studied" category of medical interventions. No study has reported outcomes that matter to patients, such as the likelihood of death or cardiac arrhythmias. The available literature focuses largely on the ability of interventions to lower serum potassium levels acutely. The Cochrane review by Mahoney and colleagues applies to patients with a significantly elevated potassium level (i.e., greater than 6.5 to 7.0 mEq per L [6.5 to 7.0 mmol per L]).

The researchers identified 12 randomized, quasi-randomized, or crossover studies comparing different approaches to the treatment of hyperkalemia. In a quasi-randomized study, assignment to treatment groups is based on the day of the week or time of day rather than true randomization, making bias more likely. The crossover studies typically involved a series of interventions in the same small group of hemodialysis patients. Each patient acts as his or her own control, so it is possible to have a much smaller sample size and still obtain statistically significant results. Only four studies used blinding, and only four concealed allocation to treatment groups adequately. Most of the patients studied had acute or chronic renal failure and were receiving hemodialysis.

Nebulized or inhaled albuterol proved effective; a dose of 20 mg was more effective than 10 mg in lowering potassium levels, and both doses were better than placebo. Intravenous albuterol and levalbuterol (Xopenex) were no more effective than inhaled albuterol. The combination of insulin with intravenous glucose was effective, as was dialysis. In one study, the combination of insulin, glucose, and inhaled albuterol was more effective than insulin and glucose alone. Although potassium-binding polystyrene resins such as Kayexalate are widely used, only one study evaluated their effectiveness in the acute setting, and they proved ineffective. Adding bicarbonate to insulin and glucose was helpful in one study but not in another.

A review of the National Guideline Clearinghouse Web site (http://www.guidelines.gov) did not identify any practice guidelines for the management of hyperkalemia. Recommendations from textbooks vary considerably. For example, Griffith's 5-Minute Clinical Consult 20051 recommends dextrose and insulin, sodium bicarbonate, and polystyrene resins but does not mention inhaled beta agonists.

Mahoney BA, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev 2005;(2):CD003235.

REFERENCE

1. Dambro MR, ed. Griffith's 5-Minute clinical consult, 2005. CD-ROM ed. Philadelphia: Lippincott Williams & Wilkins, 2004.

The series coordinator for AFP is Clarissa Kripke, M.D., Department of Family and Community Medicine, University of California, San Francisco.

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