Limits...
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.

Show MeSH

Related in: MedlinePlus

Summary receiver operating characteristic (ROC) curve of proton pump inhibitor (PPI) studies.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4226211&req=5

Figure 2: Summary receiver operating characteristic (ROC) curve of proton pump inhibitor (PPI) studies.

Mentions: For joint meta-analysis only studies were considered with similar study design. Therefore, the active treatment arms of six studies were available for further analysis [31-36]. The model could be extended to include study-specific covariates such as the percentage of female patients or mean age to reduce unexplained heterogeneity on study level. However, due to the small number of studies available for pooling we refrained from including covariates. FigureĀ 2 shows the summary receiver operating characteristic (ROC) curve. Considering the GERD prevalence and the fact that no perfect reference test is available for GERD (sensitivity of the 24-h pH-metry in endoscopy-negative patients <71% [57]), the posterior mean sensitivity of what was 0.89 (95% credible interval, 0.28 to 1). The posterior mean of the specificity was 0.88 (95% credible interval, 0.26 to 1), respectively.


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

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

Summary receiver operating characteristic (ROC) curve of proton pump inhibitor (PPI) studies.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 2: Summary receiver operating characteristic (ROC) curve of proton pump inhibitor (PPI) studies.
Mentions: For joint meta-analysis only studies were considered with similar study design. Therefore, the active treatment arms of six studies were available for further analysis [31-36]. The model could be extended to include study-specific covariates such as the percentage of female patients or mean age to reduce unexplained heterogeneity on study level. However, due to the small number of studies available for pooling we refrained from including covariates. FigureĀ 2 shows the summary receiver operating characteristic (ROC) curve. Considering the GERD prevalence and the fact that no perfect reference test is available for GERD (sensitivity of the 24-h pH-metry in endoscopy-negative patients <71% [57]), the posterior mean sensitivity of what was 0.89 (95% credible interval, 0.28 to 1). The posterior mean of the specificity was 0.88 (95% credible interval, 0.26 to 1), respectively.

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