‘I am very pleased to tell you that your coronary arteries are normal’ – these were the only words that Joan remembered the cardiologist telling her after her angiogram. Perhaps the amnesic effect of midazolam had an influence of this; or perhaps not. As reassuring as this sounded, it did not feel like the conclusion to the problem that she was hoping to achieve. Today was the culmination of a journey which had started with an ambulance trip to A&E, 6 weeks earlier, following a ‘111’ call; after two normal ECGs a 12 hour stay on the clinical decision unit and a negative troponin she was back with her GP describing her episodic central chest pain – sometimes exertional, sometimes not. She was 65 and had a few ischaemic risk factors – certainly enough to justify a referral to the chest pain clinic. A proforma was completed, an exercise test was equivocal, and an angiogram was performed with surprising speed and efficiency. ‘What should I do if I get it again?’ – she asked the nurse who handed her the discharge paperwork. ‘You will have to discuss that with your GP…..’.
Her son, a family acquaintance of mine, read the cardiology discharge summary out to me over the phone: ‘It says she has atypical chest pain’ – incidentally the same diagnosis she had been given in A&E 6 weeks earlier – ‘so what does that actually mean?’. An interesting question indeed.
‘Rule-out medicine’
It’s easy to have a pop at specialists with a case like this, but that is not the intention of this blog. If we are honest, most hospital clinicians have been guilty of making a ‘non-diagnosis’ once or twice. The phenomenon of ‘rule-out medicine’ was even the subject of a symposium at an acute medicine conference that I attended in London a few years ago; erudite speakers described the increasing sensitivity of testing strategies in conditions such as pulmonary embolism (PE), acute coronary syndrome (ACS) and sub-arachnoid haemorrhage (SAH). Never again would patients be sent away from the acute medical unit with even a remote possibility of one of these life-threatening conditions. Our indemnity insurers could breathe easily in their beds at night once more.
Of course, our patients’ breathing may not be quite so relaxed. A symptom severe enough to justify a visit to the hospital, deserves an explanation; but how often does the medical clerking – and even the consultant ward round – conclude with the words ‘Plan: exclude PE’ (or ACS / SAH)? Exclusion of a serious diagnosis may provide the reassurance we need to discharge a patient from hospital; however it is equally important to consider what is causing the symptoms. Chest pain should never be described as ‘non-cardiac’ or (worse still) ‘atypical’.
When we wrote up our first year’s experience of outpatient management for patients with suspected PE, almost 10 years ago, we concluded that a group of patients could be managed without hospital admission. All of the (albeit carefully selected) patients in whom pulmonary embolism was identified over this period had been managed safely in the community, with no readmissions or unexpected deaths; however there was a small group of patients in whom the outcome was less positive. All of these were patients in whom PE was excluded, but where no explanation for the symptoms had been identified. Many returned to hospital soon after discharge, and although only a small number were subsequently found to have a significant condition, the message was clear: a positive diagnosis is important. ‘Not a PE is Not a Diagnosis’ became my mantra.
Of course medicine is not always that simple; it is often much easier to tell a patient what is isn’t, than to tell them what it is. Sometimes there remains a list of possibilities: a differential diagnosis with pointers towards several different causes – to pick one would be disingenuous; furthermore there is no test which will prove that a pain is of musculoskeletal or oesophageal origin with the degree of certainty with which we can exclude a cardiac cause. Communicating uncertainty to a patient without raising anxiety is a skill which all acute physicians, and other hospital specialists need to develop. But, equally important is that we make the effort to think about the cause of a patient’s symptoms; ruling out serious pathology should not be the conclusion of our role.
Providing advice on what to do if a symptom recurs following discharge is another crucial component of hospital care. Chest pain resulting from of oesophageal spasm can be severe, tends to be recurrent and invariably happens at rest. If a patient phones 111, it is very likely that the call will result in an ambulance trip to A&E, particularly if they have cardiac risk factors. A clear explanation of the likely cause of the patient’s symptoms, combined with a management strategy in the event of recurrence may prevent repeated visits to hospital, which tend to raise anxiety and uncertainty yet further. General Practitioners are highly skilled in communicating and managing uncertainty, but the practicality of the advice to ‘discuss that with your GP’ and the likelihood of recurrence while awaiting an appointment needs to be questioned.
Joan was fortunate to have a fantastic General Practitioner – one of the best in the area. He listened to her symptoms, which sometimes related to exertion, but were also exacerbated by certain movements and posture. He also noted that they often occurred when she was tired or stressed and that their onset coincided with the anniversary of her husband’s death. She fought back tears as she described how lonely she felt at times since then. Reassured by her normal coronary arteries, a diagnosis of musculoskeletal chest pain, exacerbated by anxiety and depression, was made; a management plan was instigated, which saved further visits to A&E, or calls to 111. Joan had reached a satisfactory – but sadly atypical – conclusion, to her fairly typical chest pain.
