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Psychological interventions for symptomatic management of non‐specific chest pain in patients with normal coronary anatomy

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Abstract

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Background

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

Objectives

To update the previously published systematic review.

Search methods

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

Selection criteria

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non‐specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

Data collection and analysis

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

Main results

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed‐effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random‐effects mean difference = ‐2.26 95% CI ‐4.41 to ‐0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random‐effects mean difference ‐0.81 95% CI ‐2.35, 0.74). There was no effect on severity (random‐effects mean difference = ‐4.64 (95% CI ‐12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

Authors' conclusions

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive‐behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow‐up periods of at least 12 months are needed.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Cognitive‐behavioural treatments for non‐cardiac chest pain

Recurrent chest pain in the absence of coronary artery disease is a common, difficult to treat problem that sometimes leads to excess use of medical care. A substantial number of patients are not reassured by negative medical assessment, reporting persistent pain and limitations. Psychological factors appear to be of importance for treatment. This review included all studies of psychotherapy for non‐cardiac chest pain. Due to the small number of studies, the reviewers were able to draw conclusions about cognitive‐behavioural therapy only. The findings were based on 15 trials that were included in this review with a total of 803 participants. The review found that cognitive‐behavioural treatments are probably effective, (in terms of reduced chest pain frequency) in the short term, for the treatment of non‐cardiac related chest pain. No adverse effects of the psychotherapy were found. Hypnotherapy is also a possible alternative. A limitation of this review is the high variability of the studies included, reflected in a wide range of outcome measures, although there was an overall fairly low risk of bias.