Functional Cardiac Presentations: Clinical Management Considerations

Experiencing a symptom that suggests heart disease or being investigated or diagnosed with any type of heart problem is terrifying. While this may seem like an obvious statement, it is a fact that is sometimes forgotten in clinical practice. Almost a century ago, Auerback, quoting Conor, noted: “The psychic reaction to doubt about the integrity of the heart... appears to be much more violent and profound than in the case of any of the other internal organs . ”

The particularly emotive nature of cardiac symptoms may be one of several factors contributing to both the presumed high rates of cardiac symptoms in somatoform disorders and the high levels of psychiatric comorbidity (such as depression and anxiety) associated with cardiac symptoms of organic origin. or not organic.

Diagnosis and management of functional cardiac symptoms is challenging. Requires articulation between multiple potential physical conditions (including cardiac, gastrointestinal, musculoskeletal, respiratory, neurological, vascular and hematological disorders), somatic symptoms of a psychiatric disorder (such as anxiety, depression, panic attack or post-traumatic stress disorder) or a combination of these problems.

Knowledge, sensitivity, and curiosity about the health beliefs and attributions that patients have regarding the meaning of their symptoms is the first principle of assessment and management. These must be obtained and addressed directly during investigation, diagnosis and treatment. The language, clinical approach and information provided in consultations can have an impact on both the patient experience and the course of the disease, including the persistence of symptoms and the use of health services.

It is vitally important that doctors recognize the reality and impact of these symptoms on patients.

Clinical presentation and classification

Common symptoms include noncardiac precordial pain (NCCP), palpitations, dyspnea, and syncope. There is substantial variation in presentation and severity. Some patients have a single symptom (such as NCCP) while others have multiple symptoms (such as fatigue, chest pain, shortness of breath, and palpitations).

Severity ranges from mild distress or concern about resolution of symptoms to persistent symptoms, severe distress, associated disability, and extremely high healthcare utilization.

There is an ongoing debate about the best way to classify these presentations and the terminology used to describe them. Approaches have included the description of syndromes involving one symptom (e.g., NCCP), multiple symptoms (“body distress syndrome”) consistent with the cardiopulmonary system, and symptoms involving multiple body systems. Classification systems based on prognostic factors (e.g., self-limiting symptoms versus recurrent and persistent symptoms) have been suggested to have practical benefits.

Noncardiac precordial pain (NCCP) (also known as Syndrome X and nonspecific chest pain ) is defined as angina-like chest pain without evidence of epicardial coronary artery disease.

The finding that 82% of NCCP patients who had gastrointestinal causes were excluded as the cause of pain also met criteria for at least one other functional disorder highlights some of the challenges with a symptom-based classification approach.

Pathogenesis

As with all functional disorders, the pathogenesis of the symptoms is poorly understood. A series of studies have been conducted to explore the possible physiological mechanisms in NCCP. Carbon dioxide inhalation studies demonstrate pharmacologic provocation of anxiety-induced chest pain, and findings of increased pressure and pain sensitivity in the esophagus have been reported.

Neurobiological studies on the pathogenesis of anxiety disorders have suggested increased sensory responsiveness. Heartbeat perception (interoception) has been investigated as the mechanisms behind increased self-appraisal of somatic sensations and related dysfunctional cognitive appraisal of what these sensations mean. While interesting, these findings have not yet been translated into routine clinical practice.

Purely biological models fall short of the well-known and observed interrelationship between the psychological and physiological elements of persistent physical symptoms.

Health attributions may influence the development and persistence of symptoms, as patients with medically unexplained symptoms are more likely to attribute their illness to physical causes compared to other factors. The most compelling models consider multiple factors that contribute to the development and persistence of functional symptoms. Such models link the physiological impact of chronic stress with increased sensitization to physical symptoms, hypervigilance of resulting symptoms, and behavioral responses, including stress avoidance and symptom monitoring, and fewer coping strategies compared to healthy controls. and other patients with chronic pain.

The particular relevance of these findings to the clinician is that failure to explain what these symptoms are can increase anxiety, symptoms, and the focus of symptoms, perpetuating and worsening the cycle.

How common are these problems?

Reported prevalence rates vary depending on the study setting (e.g., primary care vs. secondary care) and the criteria used to quantify or classify clinical presentation. Estimates of medically unexplained symptoms seen in cardiology clinics have been reported in around 30-40% of presentations.

Within primary care, symptoms associated with the cardiopulmonary system consistently appear in the most common types of symptoms described by 3 to 10% of all adult patients who have medically unexplained persistent symptoms.

With the exception of the NCCP, epidemiological studies have tended to focus on medically unexplained symptoms more broadly rather than just cardiac presentations. Within this work, there are associations with female sex, younger age, and current employment; however, there are differences for those with persistent symptoms.

The epidemiology of NCCP, specifically, is relatively better studied. It is extremely common with a 1-year prevalence of 14%, accounting for 37-61% of emergency department presentations with chest pain. It is more common in younger adults and there are no significant gender differences.

Demographic clues may help reassure the physician providing a diagnosis to younger patients, but in older patients or those with more risk factors for coronary heart disease, they have minimal influence on clinical work and research choices.

Clinical and diagnostic approach

Unfortunately, the diagnosis of functional heart disorders is frequently delayed, and patients sometimes consult numerous healthcare professionals without receiving a satisfactory diagnosis.

The nonspecific nature of some cardiopulmonary symptoms and the overlap with physical symptoms of anxiety, somatic symptoms of depression, upper gastrointestinal disorders, and seizure disorders means that identification and management require a systematic approach.

This involves the exclusion of serious pathology along with consideration and evaluation of any comorbid mental health conditions from the outset.

This allows early identification of any psychiatric cause of symptoms and evaluation of comorbid psychiatric disorders, which are very common in heart disease. A rigorous history, judicious use of investigations, and good communication with the patient are essential.

The differential diagnoses for NCCP, syncope, and palpitations are broad and are described along with suggested investigations. Psychiatric differential diagnoses include affective disorders, substance abuse, and post-traumatic stress disorder.

Among patients presenting with NCCP, exclusion of acute coronary syndromes is the priority, followed by gastrointestinal causes.

Gastroesophageal reflux disease ( GERD) has been shown in 29-67% of people with NCCP, and frequency of heartburn is an independent risk factor for the development of NCCP. In those without GERD, there is a controversial relationship with esophageal dysmotility. However, there is a substantial proportion of patients who experience functional dyspepsia. Within this group of patients, NCCP could be considered a functional cardiac or gastrointestinal disease.

The high prevalence of symptoms, the likelihood of a mixed clinical picture, and the risks of harm from excessive investigation highlight the importance of a multidisciplinary approach with input from general practitioners, emergency medicine, cardiology, gastroenterology, and psychiatry. With current service configurations however, this level of integration and coordinated work is rarely achieved. In fact, it is usually initiated only after a patient has received multiple investigations and has inadvertently been subjected to sustained uncertainty, fragmented care, and inconsistent communication about the suspected cause of her symptoms.

The finding that patients with NCCP tend to receive more investigations than those with cardiac chest pain highlights the clinical and economic arguments for a multidisciplinary approach.

It is recommended that, where there are high levels of confidence in the probability of a functional presentation, research is kept to a minimum.

In reality, this is difficult because of the potential consequences of missing a life-threatening diagnosis and the mutual desire for peace of mind in both patient and doctor. Both the rigor and tranquility of a multidisciplinary opinion can help alleviate these difficulties. One caveat when considering early cessation of research is to ensure that clinicians are aware of the increased risk of cardiovascular disease in patients with mental health problems and the risk of the diagnosis overshadowing the care of these patients.

Do medically unexplained cardiac symptoms mean a psychiatric disorder exists?

Psychiatric conditions may be a comorbidity, consequence, or explanation for persistent cardiac symptoms.

In general, there is an increased risk of psychiatric comorbidity in those who have persistent and/or multiple unexplained symptoms. Within the literature specifically on NCCP, psychiatric comorbidity is common and one study reported that 61% of patients met criteria for a psychiatric disorder.

More specifically, cardiac symptoms may be a presenting symptom of an underlying psychiatric disorder, including depression, anxiety disorders, body distress disorder, post-traumatic stress disorder, and substance abuse.

A panic attack is a common reason for a young person to present to hospital with chest pain and is characterized by severe anxiety associated with signs of autonomic arousal, including palpitations or tachycardia, sweating, tremors, dry mouth, difficulty breathing and chest pain. Treatment involves explanation of the physiological responses in anxiety followed by cognitive behavioral therapy (CBT) and/or a selective serotonin receptor uptake inhibitor (SSRI).

The high prevalence of both coronary heart disease and anxiety/depression, and comorbidity with both conditions in the general population, may mean that the clinical picture is often complex with multiple factors contributing to the presentation. All patients with cardiovascular disease should be evaluated for the presence of depression and anxiety.

Comorbidity of cardiovascular diseases and psychiatric disorders and the coexistence of both organic and functional cardiac symptoms are common.

Approximately 30% of individuals with NCCP have a history of cardiac disease and it is those with a cardiac history who have the most psychological distress. The best strategy is to ensure that psychiatric comorbidities are identified, their treatment is optimized and multidisciplinary management clear the plan is in place.

Clinical evolution and prognosis of functional symptoms

When NCCP is appropriately investigated and diagnosed, mortality is low. However, in terms of ongoing chest pain, outcomes are often poor, with 28-90% of patients still experiencing symptoms months or years later. Predictors of ongoing chest pain are female sex, a higher total number of symptoms, and high levels of hypochondria.

Clinical management

Interventions

The most important aspect of treatment is patient-centered communication and an explanation of the diagnosis, which can be therapeutic in itself.

Many symptoms are transient, so watchful waiting for 2 weeks is often justified. Thereafter, a stepped care approach is recommended , in which less invasive interventions are tried first.

All patients should be offered psychoeducation and active monitoring. Groups and support with employment and education may also be offered. For those with persistent or moderately severe symptoms, cognitive behavioral therapy (CBT) has been recommended . Antidepressants, usually selective serotonin reuptake inhibitors, can also be used.

Explain the diagnosis of functional cardiac disorders.

With respect to NCCP, proton pump inhibitors (PPIs) produce an excellent response where GERD is present, but there is compelling evidence that they are no better than placebo when GERD is not present. A PPI may be useful as a diagnostic and therapeutic assay.

A Cochrane review of psychological interventions in the NCCP found that psychological therapy was associated with moderate benefit with improvements in chest pain in the first 3 months and at subsequent follow-up; There was more evidence for CBT, but hypnotherapy was also suggested as an alternative. No adverse effects were identified.

The use of antidepressants for NCCP is a plausible strategy as they could target comorbid depression and anxiety, and some have evidence of effectiveness on neuropathic pain. A systematic review of antidepressant medication use for NCCP found six randomized controlled trials, including sertraline, paroxetine, imipramine, venlafaxine, and trazodone. The meta-analysis found that there were significant reductions in symptoms with sertraline, venlafaxine and imipramine with improvement in chest pain independent of the antidepressant effect, but adverse effects were more frequent than in the placebo group.

Multimodal and multidisciplinary care approaches

Regarding functional gastrointestinal disorders, advances in the diagnosis and therapy of functional cardiac symptoms remain relatively underdeveloped and recommendations focus primarily on the exclusion of acute coronary syndrome or coronary artery disease.

The literature from specific cardiac functional symptoms and from the study of other persistent symptoms suggests that integrated care using a biopsychosocial approach to diagnosis and treatment is the most effective way to treat patients with these conditions.

Multidisciplinary treatment models have been tested and have shown positive results. A multidisciplinary biopsychosocial stepped care clinic for chest pain involving both cardiology and psychology demonstrated a reduction in symptom burden and utilization of unplanned medical care. In this service model, patients receive comprehensive assessment, a biopsychosocial formulation for their symptoms, and subsequent referral to CBT as indicated. Patient-reported benefits included a better understanding and experience of control over their symptoms.