Atypical chest pain - a review of latest research

G W W Tsoi 蔡惠宏

Dear Editor

I have read the above article published in July 2002 and would like to raise some points for discussion.

I have some worries about the implications of the author's recommendations contained in the article.

The article bears the title "Atypical Chest Pain - A Review of Latest Research". The author summarises the findings of about 30 research papers listed in the references (in several of which he/she had participated). The data reproduced by the author came from a tertiary referral centre where day case coronary angiography was performed for patients referred from GPs because of chest pain. Out of 829 consecutive patients, 250 had been selected for interview by the author. Patients were excluded if there were pathological Q waves or anything more than non-specific ST/T wave changes or regional wall motion abnormalities on the echocardiogram. Other exclusion criteria were anything more than mild valve disease, AF, abnormal LVEF after echocardiogram, left ventricular hypertrophy and renal failure. These 250 patients answered a questionnaire resulting in the creation of the Chest Pain Score.

Bearing in mind that this article is "A Review of Latest Research", I have the following questions:

1. Can we really apply the author's findings and recommendations to our daily practice in the primary care setting?
2. The study population has been screened and selected from GP referrals. Does the data remain valid and significant when projected onto the general population which GPs see everyday?
3. Are these findings and recommendations the consensus of cardiologists in general and ready to be recommended to GPs as guidelines for referral?
4. I quote "Patients with missed coronary artery disease (CAD) inevitably get seen by a cardiologist when they are having their myocardial infarction or coronary angiography.": what would be the medico-legal implications for the GP who missed CADs in such cases?
5. Reassurance is easier said than done. Is it really possible to adequately reassure our patients without those investigations that the author claimed as "harmful to the patient"? From the patients' perspective, there is often great anxiety about symptoms which may be caused by life threatening coronary disease. Therefore, can we really "reassure STRONGLY ... ... .. repeated statement of the lack of serious illness" as suggested by the author and send the patients away?

I have discussed this article and the above queries with two groups of FM trainees. Critical appraisal and reflective thinking are very important tools for our specialty to assimilate the ever-expanding medical knowledge for our professional development. I hope the author of the article can clarify the above questions and therefore assist our clinical decision-making with this very common symptom in general practice.

Thank you.

G W W Tsoi
MBBS(HK), FHKCFP, FHKAM(Family Medicine)
Family Physician in Private Practice.