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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　February 8, 2010 — 根據發表於2月8日內科醫學誌(Archives of Internal Medicine)的一篇前瞻、一般內科醫師為基礎的世代研究結果，標準醫療照護可能無法緩解非特定胸痛的症狀。
　　
　　德國馬堡Philipps大學的Julia Anna Glombiewski博士等人寫道，在一線照護中常看到非特定胸痛，然而，關於它的療程和結果，以及其最適當健康照護的知識很少，我們觀察到以下情況：(1)一線照護中出現非特定胸痛的許多病患其症狀持續6個月，(2)許多非特定胸痛病患顯示有過度檢查的情況，以及(3)許多慢性胸痛病患被轉診到心智健康專科醫師。
　　
　　從2005年10月1日至2006年7月31日，約有190,000人次的病患在德國Hessen的74處一般內科醫師診所就診。由一個專家委員會辨識其中807名病患為非特定胸痛，沒有潛在的心臟問題。在6週和6個月時進行追蹤，退出率約為2.7%。
　　
　　主要研究終點是，6個月追蹤期的持續胸痛以及6個月時的健康照護使用情況。「不適當的健康照護使用」定義為至少2次就診心臟科醫師或者至少3次心臟診斷檢查。
　　
　　在追蹤6個月時，55.5%的病患有持續胸痛，10.7%的病患有不適當的健康照護使用，大約2%的病患被轉診給心智健康專科醫師，多數持續非特定胸痛病患被轉診給心臟科醫師。
　　
　　研究作者們寫道，對於多數非特定胸痛病患，標準照護並未提供足夠的幫助或症狀緩解，十分之一的持續胸痛病患接受沒有已知臨床助益的額外診斷檢查。心理學轉診相當少，這倒是令人驚訝，因為已知心理因素會造成發生胸痛，而德國的健康照護制度有包括心理諮商在內。
　　
　　研究限制包括，一般開業醫師對於參加此研究的反應率低，對於不適當的健康照護使用提出新的分界點，一般性有限，使用非正式定義的非特定胸痛。
　　
　　研究作者們結論表示，心理因素引起非特定胸痛的病患，在尋求健康照護的行為上比較多問題，但是比較少被轉診給心智健康專家。病患、一般開業醫師對於納入心理介入方式都感到猶豫。後續研究應探討發展有效的非特定胸痛介入方式，以及將它們納入健康照護體系。
　　
　　德國聯邦教育與研究部支持本研究，研究作者皆宣告沒有相關財務關係。


Standard Medical Care May Not Relieve Symptoms of Nonspecific Chest Pain

By Laurie Barclay, MD
Medscape Medical News

February 8, 2010 — Standard medical care may not relieve symptoms of nonspecific chest pain, according to the results of a prospective, general physician–based cohort study reported in the February 8 issue of the Archives of Internal Medicine.

"Nonspecific chest pain is common in primary care, yet knowledge is sparse about its course and outcome and how they relate to optimum health care usage," write Julia Anna Glombiewski, PhD, from Philipps-University of Marburg, Germany, and colleagues. "We investigated the following observations: (1) many patients who present with nonspecific chest pain in primary care show symptom persistence for 6 months, (2) many patients with nonspecific chest pain showed signs of overinvestigation, and (3) many patients with chronic chest pain were referred to mental health specialists."

From October 1, 2005, to July 31, 2006, approximately 190,000 consecutive patients visited their general physicians at 74 primary care offices in Hessen, Germany. An expert committee identified 807 of these patients as having nonspecific chest pain, with no underlying heart condition. Follow-ups were performed at 6 weeks and 6 months, with a dropout rate of 2.7%.

The primary study endpoints were persistent chest pain at 6-month follow-up and healthcare use at 6 months. Inappropriate healthcare use was defined as at least 2 visits to a cardiologist or at least 3 cardiac diagnostic investigations.

At 6-month follow-up, 55.5% of patients had persistent chest pain, 10.7% of patients had inappropriate healthcare use, and fewer than 2% were referred to mental health specialists. Most patients with persistent nonspecific chest pain were referred to a cardiologist.

"For most patients with nonspecific chest pain, standard medical care does not offer sufficient help for symptom relief," the study authors write. "One-tenth of patients with persistent chest pain underwent additional diagnostic testing of no known clinical benefit. Psychological referrals were rarely given...[which] is surprising because psychological factors are known to contribute to the development of chronic pain, and psychological consultations are covered by the health care system in Germany."

Limitations of this study include the low response rate of general practitioners approached to participate in the study, use of a proposed new cutoff for inappropriate healthcare use, limited generalizability, and use of an informal definition of nonspecific chest pain.

"Patients with psychologically caused non-specific chest pain showed more problematic health care–seeking behavior but were rarely referred to mental health professionals," the study authors conclude. "Patients, general practitioners or both seem to be hesitant to involve psychological interventions.... Future research should investigate the development of effective interventions for non-specific chest pain and their implementation within health care systems."

The German Federal Ministry of Education and Research supported this study. The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:251-255.