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Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis.

Wertli MM, Ruchti KB, Steurer J, Held U - BMC Med (2013)

Bottom Line: Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders.Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

View Article: PubMed Central - HTML - PubMed

Affiliation: Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, CH-8032, Zurich, Switzerland. Maria.Wertli@usz.ch.

ABSTRACT

Background: Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.

Methods: A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.

Results: Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.

Conclusions: In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

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Related in: MedlinePlus

Study flow.
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Figure 1: Study flow.

Mentions: Figure 1 summarizes the search and inclusion process. Out of 6380 records, 260 were reviewed in full text, resulting in exclusion of 232 studies. In total, the analysis included 28 studies. The reasons for exclusion of the 232 studies are given in Figure 1 and overview of excluded studies reviewed in full text is give in Appendix 3.


Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis.

Wertli MM, Ruchti KB, Steurer J, Held U - BMC Med (2013)

Study flow.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4226211&req=5

Figure 1: Study flow.
Mentions: Figure 1 summarizes the search and inclusion process. Out of 6380 records, 260 were reviewed in full text, resulting in exclusion of 232 studies. In total, the analysis included 28 studies. The reasons for exclusion of the 232 studies are given in Figure 1 and overview of excluded studies reviewed in full text is give in Appendix 3.

Bottom Line: Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders.Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

View Article: PubMed Central - HTML - PubMed

Affiliation: Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, CH-8032, Zurich, Switzerland. Maria.Wertli@usz.ch.

ABSTRACT

Background: Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.

Methods: A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.

Results: Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.

Conclusions: In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

Show MeSH
Related in: MedlinePlus