Unexplained chest pain in men and women - symptom perception and outcome

Abstract: Patients with chest pain account for a large number of all patients seeking health care. The majority of these patients are referred to emergency departments (ED) and many of them are given a discharge diagnosis of unexplained chest pain (UCP). Our knowledge of this increasing number of patients with UCP is limited. The overall aim of the thesis was to describe and analyse symptom perception, psychosocial factors, health-related quality of life (HRQOL) and outcome of unexplained chest pain (UCP) in men and women. The UCP patients’ symptoms and their influence on daily life in a gender perspective were explored in Paper I using open interview questions (11 men and 9 women). A cross-sectional design was used in Paper II, assessing pain characteristics using the Pain-O-Meter and measuring psychosocial factors and HRQOL with a self-administered questionnaire. The results were based on 101 men and 78 women consecutively admitted to an ED. In Paper III, psychosocial factors and HRQOL were compared between the UCP patients (127 men and 104 women) and a reference group, i.e. a subsample (490 men and 579 women) from the INTERGENE population study. Paper IV was a register study with data from the Swedish National Hospital Discharge Register, investigating trends in incidence and outcome among patients hospitalised with UCP, angina pectoris or acute myocardial infarction (AMI) in Sweden in 1987-2003 (n=559 879). The results showed that the men and women with UCP are generally middle-aged. More than a third of both UCP men and women were born outside Sweden and, compared with the reference group, the percentage of immigrants was significantly higher. UCP impacted negatively on the patients’ daily life, which was filled with worries due to the chest pain. Feelings of panic and fear of death in connection with the chest pain were reported. Words like “pressure” and “cramp” were used when describing the chest pain, with few gender differences. Significant correlations were found between pain intensity and smoking in men (p<0.01) and between pain intensity and age in women (p<0.05). Chest pain intensity was not significantly associated with the UCP patients’ reported HRQOL, apart from physical functioning in men (p<0.05), but it was rated lower than the reference group of both UCP men and women. The UCP men in particular reported stress at work. The women with UCP presented more depressive symptoms and more symptoms of trait anxiety than the men. Mental strain in marriage/cohabitation and a low level of social integration were significant risk factors only among women. Compared with the reference group, both men and women with UCP perceived more stress at work, symptoms of depression and trait anxiety and had less social interaction. Gender differences in physical activity during leisure time were reported, as more UCP males than females were physically active, although the UCP patients, both genders, were significantly more sedentary compared with the reference group. The UCP patients, both sexes, had a higher BMI and reported a lower alcohol consumption/week than the reference group. After increasing until about 2000, the number of hospitalisations with a discharge diagnosis of UCP appears to have stabilised, while hospitalisations for angina and AMI have continuously declined. Compared with patients with angina and AMI, the overall one-year observed mortality rate in UCP patients was lower. Between 1997 and 2003 the oneyear mortality among men with UCP was elevated by about one third, whereas women with UCP had no significant increase. In conclusion, UCP was related to symptoms that influenced life in several ways. In general the gender differences were few and the mortality within one year was low. The thesis illustrates the importance of a deeper understanding of symptom perception to achieve an individualised care of patients with UCP.