Increased cardiovascular risk associated with non-cardiac chest pain in patients with a prior psychiatric hospitalization: an opportunity and challenge for both the psychiatrist and the cardiologist.

The evaluation of patients with chest pain is a common problem for every cardiologist and one of the most frequent reasons for presentation to the emergency room. After diagnostic evaluation, only 15–25% of patients with chest pain are found to have an acute coronary artery syndrome (ACS). Improved strategies for stress testing, myocardial imaging, and the availability of sensitive biomarkers for myocardial damage such as high sensitivity troponin have reduced the risk of missing the diagnosis of an ACS. Once coronary artery disease, myocardial ischaemia, and/ or injury are ruled out, both the patient and the physician often feel relieved. A specific diagnosis such as oesophageal reflux, peptic ulcer disease, herpes zoster, costochondritis, pulmonary embolism, or panic disorder often leads to specific therapy and pain relief. However, in many instances, despite intensive evaluation and reassurance as to the usually benign nature of noncardiac chest pain (NCCP), the cause of the pain remains uncertain and/or the pain may reoccur with consequent patient frustration and distress. In these instances, the patient may be prescribed an antidepressant and/or enrolled in pain coping skills training (CST). For example, in a recent study, Keefe et al. randomized patients with a diagnosis of NCCP to one of four treatments: (i) CST plus the antidepressant sertraline; (ii) CST plus placebo; (iii) sertraline alone; or (iv) placebo alone. CST and sertraline either alone or in combination were found to reduce pain intensity and pain unpleasantness significantly. The authors suggest that the combination of CST and sertraline may have the greatest promise in that when compared with placebo alone it reduced not only pain but also pain catastrophizing and anxiety. Thus it appears that there may be an important role for the psychiatrist in the care of patients with NCCP. However, there may also be an important role for the cardiologist in the care of patients with a psychiatric hospitalization. Gillies et al., on the basis of a population-based retrospective cohort study of . 150 000 first hospital discharges for NCCP in Scotland during the period between 1991 and 2006, have found that 3514 (4.4%) men and 3136 (3.9%) woman who had a first NCCP hospitalization had a prior psychiatric hospitalization during the 10 years preceding the incident hospitalization for NCCP. Patients with a diagnosis of NCCP and a prior psychiatric hospitalization, after adjusting for socio-economic deprivation and co-morbid diabetes mellitus and hypertension, had a significantly higher incidence of all-cause and cardiovascular disease-specific death at 1 year compared with those without a prior psychiatric hospitalization. The relative risk of total and cardiovascular-specific mortality associated with a prior psychiatric hospitalization was present in both men and woman, especially in the younger age groups. For example, the 1 year hazard ratio for all-cause death for men ,40 years of age with NCCP and a prior psychiatric hospitalization was 3.71, and 2.81 for cardiovascular mortality, whereas in woman ,40 years of age the hazard ratio for all-cause mortality was 2.94, and 3.71 for cardiovascular mortality compared with those without a prior psychiatric hospitalization. In part, the increased risk associated with NCCP in patients with a prior psychiatric hospitalization may have been due to the failure to detect coronary artery