Group psychological treatment for chest pain with normal coronary arteries

Transcription

1 Q J Med 1999; 92:81 86 Group psychological treatment for chest pain with normal coronary arteries S.G. POTTS, R. LEWIN, K.A.A. FOX and E.C. JOHNSTONE From the University Department of Psychiatry, Royal Edinburgh Hospital, Edinburgh, UK Received 3 August 1998 Summary We used a psychological treatment package (educa- nificantly reduced chest pain episodes ( p<0.01) tion, relaxation, breathing training, graded exposure from median 6.5 to 2.5 per week. There were signi- to activity and exercise, and challenging automatic ficant improvements in anxiety and depression thoughts about heart disease) to treat 60 patients scores ( p<0.05), disability rating (p<0.0001) and who had continuing chest pain despite cardiological exercise tolerance ( p<0.05), and these were maintained reassurance following haemodynamically normal at six month follow-up. Treatment reduced angiography. The treatment was delivered in six the prevalence of hyperventilation from 54% to sessions over eight weeks to groups of up to 34% (p<0.01) but not the prevalence of ECG- six patients. The patients kept daily records of positive exercise tests. Patients continuing to attribute chest pain episode frequency and nitrate use. their pain to heart disease had poorer outcomes. Questionnaires were used to assess anxiety, depres- Group psychological treatment for non-cardiac sion and disability. Exercise tolerance was tested by chest pain is feasible, reduces pain, psychological treadmill electrocardiography, with capnographic morbidity and disability, and improves exercise assessment of hyperventilation. The results were tolerance. compared with waiting-list controls. Treatment sig- Introduction As many as 20% of patients investigated for chest non-cardiac chest pain, but scant resources limit the pain with coronary angiography have normal or availability of such labour-intensive treatment. A near-normal coronary arteries.1 Long-term follow-up programme which is similar in outline but delivered studies of this group reveal a low mortality2 but high in groups has been shown to be effective in chest morbidity in terms of chest pain and other physical pain with definite coronary artery disease.8 We symptoms.3 They are much disabled and make heavy therefore compared the effect of group psychological use of medical resources;4 yet little is known about treatment in patients with chest pain and normal how to treat them. Psychological studies have consistently coronary arteries against waiting-list controls. demonstrated levels of anxiety and depres- sion which are higher than in comparable patients with proven coronary artery disease at angiography,5 Methods and which persist at follow-up.6 It is therefore likely that these symptoms are not purely reactive, but Recruitment operate as causal or maintaining factors, suggesting Potentially eligible subjects were identified via a role for psychological intervention. Klimes et al.7 records of recent coronary angiograms in the have shown that individual cognitive behavioural Departments of Cardiology of the Royal Infirmary psychotherapy improves symptoms and disability in and Western General Hospitals in Edinburgh. Address correspondence to Dr S.G. Potts, Department of Psychological Medicine, Royal Edinburgh Hospital, 1 Lauriston Place, Edinburgh EH3 9YW Association of Physicians 1999

2 82 S.G. Potts et al. Eligibility was confirmed by obtaining their medical ized way. Clinical features of chest pain were records and applying the following criteria. Inclusion recorded with a modified version of the Master criteria: (i) aged 18 70; (ii) recent (within the last questionnaire.9 year) coronary angiography for the investigation of chest pain revealed coronary arteries which were Attributions either normal or <50% stenosed;3 (iii) chest pain Subjects attributions of the cause of their pain were continuing at least twice weekly after angiography, recorded on a five-point Likert scale, responses despite reassurance by the cardiology team; and ranging from definitely cardiac to definitely not (iv) residence within easy travelling distance of cardiac. Edinburgh. Exclusion criteria: (i) past history of myocardial infarction; or (ii) serious concurrent physical Questionnaires or psychiatric illness. The following self-report questionnaires were admin- Permission to approach subjects was sought from istered. (i) Hospital Anxiety and Depression scale.10 their general practitioners or consultant cardiologists A 14-item inventory covering non-somatic symptoms as appropriate. Subjects were then contacted in of anxiety and depression, intended for use in writing, with follow-up telephone calls to those medical populations. It yields separate scores for expressing interest. anxiety and depression, with cut-offs indicating caseness above 11. (ii) The Nijmegen hyperventilation Design scale.11 A 16-item inventory of physical symptoms associated with hyperventilation, yielding a numer- The study design is summarized in Figure 1. Subjects ical score, values above 22 indicating probable were randomized to two groups: one entered treat- abnormal breathing patterns. (iii) The Sickness Impact ment immediately after initial assessment, while the Profile (SIP).11 A 136-item inventory yielding meascontrol group was assigned to a waiting period ures of the impact of illness on various domains of before being reassessed and then entering treatment. everyday life, as well as an overall disability score. All subjects were reassessed after treatment finished, (iv) The Nottingham Health Profile (NHP).12 A and then again a further six months later. This design 24-item inventory quantifying the impairments due allows a controlled comparison of treatment versus to illness in six areas. a waiting period; and, since all subjects were treated eventually, it also allows an uncontrolled comparison Diaries of pre- and post-treatment status. Subjects were asked to complete chest-pain diaries for two consecutive one-week periods. They were Assessment asked to record, for each episode of pain, its duration, its severity (on a scale of 1 100), and the number After documenting informed consent, subjects under- of doses of nitrate they took in response. went a structured assessment comprising an interview, pain diaries, questionnaires, exercise tolerance testing, and capnography. Initial interview Demographic details, medical and psychiatric history and cardiac risk factors were recorded in a standard- Exercise electrocardiography All subjects underwent exercise ECG testing using the modified Bruce protocol13 on a treadmill. A positive test was defined as one where ST depression >2 mm occurred, accompanied by typical pain. The test was ended once unequivocally positive, or Figure 1. Study design.

3 Psychological treatment for chest pain 83 when the subject reached either their age-predicted maximum heart rate, or the limit of their exercise tolerance. Test duration was recorded in all cases. Results Demographics Capnography 60 patients were randomized (34 to immediate treatment, 26 to waiting control). Two subsequently Subjects were fitted with a face mask attached to a dropped out from each group. The treatment and portable CO monitor with which end-tidal P CO control groups did not differ as to age (mean A 2 was recorded at rest, throughout exercise testing, years (SD 8.6) vs (7.7) respectively, NS) or sex and for 5 min of recovery afterwards. Hyperthey differ on baseline variables of chest pain episode (59% and 63% female, respectively, NS). Nor did ventilation was defined as a sustained end-tidal P CO of <4.0 kpa.14 severity, frequency, duration or nitrate use, or any A 2 On subsequent assessments, all measures except of the psychological or functional measures. the initial interview were repeated, and, for the posttreatment assessment, subjects were asked to rate any changes in their general health and chest pain Controlled comparison on a five-point Likert scale, responses ranging from Table 1 summarizes the comparison between the Much better to Much worse. changes occurring with treatment and the changes occurring during the control waiting period. Treatment was associated with a significantly greater Treatment reduction in chest pain episode frequency, and a greater increase in pain-free days per week, than Treatment took place in small groups with a maxwaiting. There was no significant difference between imum of six subjects. Groups met weekly for 4 the treatment and control groups in changes in chest weeks, then every two weeks for a further 4 weeks. pain severity or duration, although there were non- Each session lasted 2 h, with a short break. Subjects significant trends to improvement in the treatment were asked to practice various exercises at home group, and the range of variation was very wide. between sessions, and to report their progress at the Treatment was also associated with significant beginning of subsequent sessions. Treatment was reductions in both the anxiety and depression subbroadly behavioural in orientation, based on a scales of the HAD, the total disability score of the manual developed via an initial pilot group, and was SIP, and two of the four sub-scales of the NHP (pain supplemented by written material given to subjects and energy). Exercise tolerance improved significat each session. antly, but the Nijmegen hyperventilation score did Components of treatment included: (i) opportuninot. ties for subjects to recount their experiences of pain and its management; (ii) education about heart disease and other causes of chest pain; (iii) relaxation Pre- and post-treatment comparison exercises, supplemented by the use of relaxation tapes, galvanic skin response biofeedback devices, Table 2 summarizes the overall changes with treat- and alarm watches to cue rapid relaxation exercises ment for all 56 subjects. There were significant through the day; (iv) breathing retraining (including improvements in chest pain episode frequency, hyperventilation provocation tests); (v) light physical nitrate use, and pain-free days per week, as well as exercise; (vi) graded exposure to activities avoided in the HAD, all subscales of the NHP, the SIP, the because of pain; and (vii) the use of thought diaries hyperventilation score, and exercise duration. Ten to record and challenge assumptions about heart patients were pain-free after treatment. One patient disease triggered by episodes of pain. in the control group became pain-free during the waiting period, but pain returned following treatment, although at a lower frequency (2.5 episodes/week) than when first assessed (6.5 episodes/week). Thirty- Analysis eight patients (76%) reported improvement in chest Categorical variables were analysed using x2 tests. pain after treatment, while 10 (20%) said it was Because nearly all continuous variables were highly unchanged and two (4%) said it was worse. As for dispersed and/or heavily skewed, non-parametric general health, 42 (84%) reported improvement, tests were used throughout, with values expressed in seven (14%) no change, and one (2%) a deterioration. medians. The Mann-Whitney test was used to compare There was no significant change in the proportion changes during treatment with changes during of exercise tests which were positive, but the propor- the control waiting period, and the Wilcoxon signed tion of subjects with capnographic evidence of rank test to compare pre- and post-treatment values. hyperventilation did improve with treatment (30/56

4 84 Table 1 S.G. Potts et al. Changes with treatment versus changes on waiting list Treatment group Control group p* (n=32) (n=24) Chest pain Episodes/week Duration (min) NS Severity (1 100) NS GTN use (dose/week) NS Pain-free days/week HAD anxiety HAD depression NHP problem scores Energy Pain Emotion 0 0 NS Sleep 0 0 NS Special isolation 0 0 NS Mobility 0 0 NS SIP disability Exercise duration (min) Nijmegen HV score NS All values are medians, negative values indicating reductions. * Mann-Whitney test. Table 2 Pre- and post-treatment comparison (n=56) Before treatment After treatment p* Chest pain Episodes/week Duration (min) NS Severity (1 100) NS GTN use (dose/week) Pain-free days/week HAD anxiety HAD depression NHP problem scores Energy Pain Emotion Sleep Social isolation 0 0 Mobility SIP disability Exercise duration (min) ECG-positive ETT 13/54 10/53 NSx Nijmegen HV score HV-positive capnography 30/56 19/ x * Wilcoxon signed rank test, except for x2 test as indicated by x. All values are medians, except for absolute numbers as indicated. hyperventilating before treatment, 19/56 after, x2= who maintained this belief (or remained uncertain, 7.0, p<0.01). n=4) had significantly fewer pain-free days per Subjects were significantly less likely to believe week than those who did not (median 3.5 vs. 5.5, they had heart disease after treatment (11/56, 20%) Mann-Whitney z= 2.1, p<0.05). They also had than before (25/56, 45%, x2=10.9, p<0.05). Those higher problem scores on the NHP subscales for

5 Psychological treatment for chest pain 85 Discussion pain (median 29.2 vs. 0, z= 2.2, p<0.05) and energy (60.8 vs. 0, z= 2.8, p<0.01). There were non-significant trends to worse outcomes for SIP These results provide preliminary evidence that, in disability ( p=0.06), NHP sleep problems ( p=0.08), this patient population, group psychological treat- and change in general health ( p=0.07). On all ment is effective in improving both physical and other measures, patients who continued to believe psychological symptoms and associated disability. they had heart disease did worse, but the differences Further work is required to establish which elements were not significant. of the treatment package are the most effective, and the mechanisms by which they operate, although the model underpinning the treatment approach Follow-up results postulates a set of complex interactions between Figure 2 shows the typical pattern of change with physiological, affective, cognitive, behavioural and waiting, treatment, and follow-up, for selected vari- iatrogenic factors. The patient group is heterogenous,14 ables (pain episode frequency, exercise tolerance, which is to be expected, since it is defined disability ratings, and combined anxiety and depres- purely in terms of physical symptoms and negative sion scores) in the treatment and control groups. investigations: individual elements of the treatment There was little change during the 2-month control may therefore be most appropriate for particular waiting period, but on all four variables there was a subgroups, such as breathing exercises for the hyper- substantial improvement with treatment, which was ventilators, or relaxation for those with anxiety disorders. maintained during the 6-month follow-up. Similar The occurrence, and indeed persistence, of patterns were observed for other variables. Five of abnormal exercise ECG tests in one subgroup, albeit the ten patients who were pain-free after treatment with improved exercise duration after treatment, remained so on follow-up, mean episode frequency requires further explanation, which this study amongst the remainder rising to two episodes/week, cannot provide. as compared with 2.2 before treatment. Six other The degree of improvement observed, in terms of patients (whose episode frequency had been chest pain symptoms, is broadly comparable to that 2.8/week after treatment) became pain-free during produced by individual psychological treatment,7 the follow-up period. and by imipramine in analgesic, rather than anti- Figure 2. Patterns of change with treatment, waiting and follow-up.

6 86 S.G. Potts et al. depressant, doses,15 although there is little evidence angiographically normal and insignificantly narrowed about relapse rates following drug discontinuation. coronary arteries. Am J Cardiol 1986; 58: However, the much larger improvement in disability 4. Potts SG, Bass CM. Psychosocial outcome and use of medical resources in patients with chest pain and normal or ratings may be of greater significance: it suggests near-normal coronary arteries: a long-term follow-up study. that some patients experience pain as frequently after Q J Med 1993; 86: treatment as before, but are less anxious and less 5. Bass C, Cawley R, Wade C, Ryan KC, Gardner WN, likely to limit their activity, perhaps because they no Hutchison DCS, Jackson G. Unexplained breathlessness and longer believe their pain to come from the heart. psychiatric morbidity in patients with normal and abnormal The tentative evidence of an association between coronary arteries. Lancet 1983; i: poorer symptomatic and functional outcome and a 6. Potts SG, Bass CM. Psychological morbidity in patients with continuing attribution of pain to a cardiac cause chest pain and near-normal coronary arteries: a long-term follow-up study. Psychol Med 1995; 25: would support this. 7. Klimes I, Mayou RA, Pearce MJ, Coles L, Fagg JR. There is now a need for further studies to compare Psychological treatment for atypical non-cardiac chest pain: the effects of psychological treatment with drugs, a controlled evaluation. Psychol Med 1990; 20: and with both combined, on symptoms, disability, 8. Lewin R, Cay E, Todd I, et al. The angina management and medical resource use, both acutely and in the programme: a rehabilitation treatment. Br J Cardiol 1995; long term. 2: Master AM. The spectrum of anginal and non-cardiac chest pain. JAMA 1964; 187: Zigmond AS, Snaith PR. The Hospital Anxiety and Acknowledgements Depression Scale. Acta Psych Scand 1983; 67: We thank the patients, their GPs and consultants, as 11. van Doorn P, Folgering H, Colla P. Contribution of end-tidal well as Kathryn Watt and Zoe Clyde for their P CO in the hyperventilation syndrome: effects of A 2 invaluable contribution. The study was funded by biofeedback and breathing instructions compared. Bull Eur Physiopathol Resp 1982; 18: the Cohen Bequest and the Scottish Office, Home & 12. Hunt SM. A quantitative approach to perceived health Health Department. status: a validation study. J Epidemiol Comm Health 1980; 34: Bruce RA, Clarke LJ. Exercise stress testing. In: Fishman AP, References ed. Heart Failure. New York, McGraw Hill, Cooke RA, Chambers JB, Anggiansah A, Henderson RA, 1. Chambers JB, Bass C. Chest pain with normal coronary Sowton E, Owen W. Chest pain and normal coronary anatomy: a review of natural history and possible etiologic arteries: a clinical evaluation with oesophageal function factors. Prog Cardiovasc Dis 1990; 33: tests, exercise ECG, end-tidal CO measurement and 2. Proudfit WL, Bruschke AVG, Sones FMJ. Clinical course of 2 psychiatric scores. Eur Heart J 1991; 12 (suppl):103. patients with normal or slightly or moderately abnormal 15. Cannon RO, Quyyumi AA, Mincemoyer R, Stine AM, coronary arteriograms: 10 year follow-up of 152 patients. Gracely RH, Smith WB, et al. Imipramine in patients with Circulation 1980; 62: chest pain despite normal coronary angiograms. N Engl 3. Papanicolau MN. Prognostic implication of J Med 1994; 330: