Chest pain in people with normal coronary anatomy

Coronary angiography is often necessary for patients with chest pain, but 20% to 30% of examinations show normal anatomy.¹ The use of angiography itself can contribute to symptoms in these patients, and non-organic factors are often overlooked. Providing a diagnosis may be less important than addressing a patient's concerns and fears.

Potentially irrevocable changes in social circumstances may occur while a patient is on a long waiting list. The mean waiting time from the general practitioner's referral to angiography was 261 days in the United Kingdom in 1994 and about 60 days in Canada in 1993.²,³ These delays provide ample time for adverse changes in lifestyle, work patterns or even losing a job, restriction in social and leisure activity, and disruption of family life. Such changes are directly related to time on the waiting list for coronary bypass grafting, and the same is probably true for angiography.⁴ This means that patients can be told, after angiography, that there is no evidence of heart disease and be sent home to a lifestyle geared to the original diagnosis. It may be difficult or impossible for the patient to reconcile this discrepancy.

Angiography itself may provoke anxiety.⁵ It involves a hospital visit, signing a consent form for a procedure with a small but definite morbidity, and the knowledge of possible progression to surgery if serious coronary disease is detected. Similar concerns among patients have been reported after echocardiography: patients were left with anxiety about the heart despite a normal test result and reassurance by the cardiologist.⁶

Patients are justifiably concerned if chest pain recurs and there has been no adequate explanation or treatment. Clinicians may spend less time counselling patients with normal anatomy than those with coronary disease, perhaps in the belief that the patients with disease require greater attention.⁷ The patient's anxiety may be increased by a spurious diagnosis such as coronary artery spasm or syndrome X, the continued prescription of antianginal drugs, or more tests.⁸ All these may contribute to chronic pain.⁹

An alternative non-cardiac diagnosis can be difficult to make, but addressing the patient's concerns may be more important than providing a medical diagnosis.¹⁰ Recent work has confirmed the contribution of patients' perception of their illness to seeking help and to their recovery after acute myocardial infarction.¹¹ Moreover, if these concerns can be elicited in a structured way, it is possible to modify them favourably with a brief psychological interaction.¹² Patients with a high level of anxiety about their health have a lower perception of reassurance than patients with low or medium anxiety and may require additional help.¹³ Patients with more troubling symptoms, would benefit from a follow up visit for more discussion four to six weeks after the visit to the cardiac clinic.⁵ This could take place either with a cardiac nurse or doctor in the cardiac clinic or with their general practitioner. In this session the nurse or doctor should elicit the patient's perceptions of illness in an objective way, exploring their origins and attempting to modify them by offering an acceptable alternative way of viewing the symptoms.¹⁴ Collaboration between specialists and general practitioners is essential to ensure consistency of advice and management, including the withdrawal of antianginal medication. Other drugs or psychological treatments may have a role for patients with continuing symptoms and disability, which often coexist with psychological problems, such as anxiety and depressed mood.¹⁵

The impact in the United Kingdom of rapid access clinics and one stop chest pain clinics is uncertain. These clinics could worsen the situation if staff members do not take the time to prepare patients psychologically for their angiography. On the other hand, shorter waiting times before invasive investigation may allow less time for psychosocial problems to develop. It seems reasonable that we develop better, non-invasive algorithms for use by general practitioners to avoid unnecessary referrals to hospital. Cardiologists need to use coronary angiography with care, prepare patients for the possibility of normal findings, and identify patients at high risk (with normal anatomy or coronary disease). Otherwise, the advantages of an early diagnosis of angina will be offset by an increasing number of chronically disabled patients with non-cardiac pain.