Noncardiac chest pain: epidemiology, natural course and pathogenesis

Ronnie Fass, Sami R Achem, Ronnie Fass, Sami R Achem

Abstract

Noncardiac chest pain is defined as recurrent chest pain that is indistinguishable from ischemic heart pain after a reasonable workup has excluded a cardiac cause. Noncardiac chest pain is a prevalent disorder resulting in high healthcare utilization and significant work absenteeism. However, despite its chronic nature, noncardiac chest pain has no impact on patients' mortality. The main underlying mechanisms include gastroesophageal reflux, esophageal dysmotility and esophageal hypersensitivity. Gastroesophageal reflux disease is likely the most common cause of noncardiac chest pain. Esophageal dysmotility affects only the minority of noncardiac chest pain patients. Esophageal hypersensitivity may be present in non-GERD-related noncardiac chest pain patients regardless if esophageal dysmotility is present or absent. Psychological co-morbidities such as panic disorder, anxiety, and depression are also common in noncardiac chest pain patients and often modulate patients' perception of disease severity.

Keywords: Chest pain; Esophageal motility disorders; Esophagus; Heartburn.

Conflict of interest statement

Conflicts of interest: None.

References

    1. Jerlock M, Welin C, Rosengren A, Gaston-Johannson F. Pain characteristics in patients with unexplained chest pain and patients with ischemic heart disease. Eur J Cardiovasc Nurs. 2007;6:130–136.
    1. Fass R, Navarro-Rodriguez T. Noncardiac chest pain. J Clin Gastroenterol. 2008;42:636–646.
    1. Fenster PE. Evaluation of chest pain: a cardiology perspective for gastroenterologists. Gastroenterol Clin North Am. 2004;33:35–40.
    1. Fenster PE, Sorrell VL. Evaluation of chest pain - a cardiology perspective for the gastroenterologist. In: Fass R, Eslick GD, editors. Noncardiac chest pain - a growing medical problem. San Diego: Plural Publishing; 2007. pp. 15–23.
    1. Ockene IS, Shay MJ, Alpert JS, Weiner BH, Dalen JE. Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status. N Engl J Med. 1980;303:1249–1252.
    1. Dumville JC, MacPherson H, Griffith K, Miles JN, Lewin RJ. Non-cardiac chest pain: a retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic. Fam Pract. 2007;24:152–157.
    1. Sekhri N, Feder GS, Junghans C, Hemingway H, Timmis AD. How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients. Heart. 2007;93:458–463.
    1. Robertson N, Javed N, Samani NJ, Khunti K. Psychological morbidity and illness appraisals of patients with cardiac and non-cardiac chest pain attending a Rapid Access Chest Pain Clinic: a longitudinal cohort study. Heart. 2008;94:e12.
    1. Galmiche JP, Clouse RE, Balint A, et al. Functional esophageal disorders. In: Drossman DA, Corazziari E, Delvaux M, Spiller RC, Talley NJ, Thompson WG, et al., editors. Rome III: The functional gastrointestinal disorders third edition. McLean, VA: Degnon Associates, Inc.; 2006. pp. 369–418.
    1. Mudipalli RS, Remes-Troche JM, Andersen L, Rao SS. Functional chest pain - esophageal or overlapping functional disorder. J Clin Gastroenterol. 2007;41:264–269.
    1. Nevens F, Janssens J, Piessens J, Ghillebert G, De Geest H, Vantrappen G. Prospective study on prevalence of esophageal chest pain in patients referred on an elective basis to a cardiac unit for suspected myocardial ischemia. Dig Dis Sci. 1991;36:229–235.
    1. Richter JE. Chest pain and gastroesophageal reflux disease. J Clin Gastroenterol. 2000;30(3 suppl):S39–S41.
    1. Ruigómez A, Massó-González EL, Johansson S, Wallander MA, García-Rodríguez LA. Chest pain without established ischaemic heart disease in primary care patients: associated comorbidities and mortality. Br J Gen Pract. 2009;59:e78–e86.
    1. Faybush EM, Fass R. Gastroesophageal reflux disease in noncardiac chest pain. Gastroenterol Clin North Am. 2004;33:41–54.
    1. Potokar JP, Nutt DJ. Chest pain: panic attack or heart attack? Int J Clin Pract. 2000;54:110–114.
    1. Katerndahl DA, Trammell C. Prevalence and recognition of panic states in STARNET patients presenting with chest pain. J Fam Pract. 1997;45:54–63.
    1. Locke GR, 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ., 3rd Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmstead County, Minnesota. Gastroenterology. 1997;112:1448–1456.
    1. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569–1580.
    1. Eslick GD. Noncardiac chest pain: epidemiology, natural history, health care seeking, and quality of life. Gastroenterol Clin North Am. 2004;33:1–23.
    1. Eslick GD, Jones MP, Talley NJ. Non-cardiac chest pain: prevalence, risk factors, impact and consulting - a population-based study. Aliment Pharmacol Ther. 2003;17:1115–1124.
    1. Chiocca JC, Olmos JA, Salis GB, et al. Prevalence, clinical spectrum and atypical symptoms of gastro-oesophageal reflux in Argentina: a nationwide population-based study. Aliment Pharmacol Ther. 2005;22:331–342.
    1. Wong WM, Lai KC, Lam KF, et al. Prevalence, clinical spectrum and health care utilization of gastro-oesophageal reflux disease in a Chinese population: a population-based study. Aliment Pharmacol Ther. 2003;18:595–604.
    1. Kennedy JW, Killip T, Fisher LD, Alderman EL, Gillespie MJ, Mock MB. The clinical spectrum of coronary artery disease and its surgical and medical management, 1974-1979. The Coronary Artery Surgery study. Circulation. 1982;66(5 Pt 2):III16–III23.
    1. Mousavi S, Tosi J, Eskandarian R, Zahmatkesh M. Role of clinical presentation in diagnosing reflux-related non-cardiac chest pain. J Gastroenterol Hepatol. 2007;22:218–221.
    1. Tew R, Guthrie E, Creed F, Cotter L, Kisely S, Tomenson B. A long-term follow-up study of patients with ischemic heart disease versus patients with nonspecific chest pain. J Psychosom Res. 1995;39:977–985.
    1. Wong WM, Risner-Adler S, Beeler J, et al. Noncardiac chest pain: the role of the cardiologist - a national survey. J Clin Gastroenterol. 2005;39:858–862.
    1. Wong WM, Beeler J, Risner-Adler S, Habib S, Bautista J, Fass R. Attitudes and referral patterns of primary care physicians when evaluating subjects with noncardiac chest pain - a national survey. Dig Dis Sci. 2005;50:656–661.
    1. Eslick GD, Talley NJ. Non-cardiac chest pain: predictors of health care seeking, the types of health care professional consulted, work absenteeism and interruption of daily activities. Aliment Pharmacol Ther. 2004;20:909–915.
    1. Richter JE, Bradley LA, Castell DO. Esophageal chest pain: current controversies in pathogenesis, diagnosis, and therapy. Ann Intern Med. 1989;110:66–78.
    1. Eslick GD, Talley NJ. Non-cardiac chest pain: squeezing the life out of the Australian healthcare system? Med J Aust. 2000;173:233–234.
    1. Wielgosz AT, Fletcher RH, McCants CB, McKinnis RA, Haney TL, Williams RB. Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon. Am Heart J. 1984;108:67–72.
    1. Potts S, Bass CM. Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study. Psychol Med. 1995;25:339–347.
    1. Gurevitz O, Jonas M, Boyko V, Rabinowitz B, Reicher-Reiss H. Clinical profile and long-term prognosis of women < or = 50 years of age referred for coronary angiography for evaluation of chest pain. Am J Cardiol. 2000;85:806–809.
    1. Launbjerg J, Fruergaard P, Hesse B, Jørgensen F, Elsborg L, Petri A. [The long-term prognosis of patients with acute chest pain of various origins] Ugeskr Laeger. 1997;159:175–179. [Danish]
    1. Kisely S, Guthrie E, Creed F, Tew R. Predictors of mortality and morbidity following admission with chest pain. J R Coll Physicians Lond. 1997;31:177–183.
    1. Karlson BW, Wiklund I, Bengtson A, Herlitz J. Prognosis, severity of symptoms, and aspects of well-being among patients in whom myocardial infarction was ruled out. Clin Cardiol. 1994;17:427–431.
    1. Hallani H, Eslick GD, Cox M, Wyatt JM, Lee CH. Chest pain? Cause. Lancet. 2004;363:452.
    1. Ward BW, Wu WC, Richter JE, Hackshaw BT, Castell DO. Long-term follow-up of symptomatic status of patients with noncardiac chest pain: is diagnosis of esophageal etiology helpful? Am J Gastroenterol. 1987;82:215–218.
    1. Williams JF, Sontag SJ, Schnell T, Leya J. Non-cardiac chest pain: the long-term natural history and comparison with gastroesophageal reflux disease. Am J Gastroenterol. 2009;104:2145–2152.
    1. Wilhelmsen L, Rosengren A, Hagman M, Lappas G. "Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in Göteborg, Sweden. Clin Cardiol. 1998;21:477–482.
    1. Eslick GD, Talley NJ. Natural history and predictors of outcome for non-cardiac chest pain: a prospective 4-year cohort study. Neurogastroenterol Motil. 2008;20:989–997.
    1. Stahl WG, Beton RR, Johnson CS, Brown CL, Waring JP. Diagnosis and treatment of patients with gastroesophageal reflux and noncardiac chest pain. South Med J. 1994;87:739–742.
    1. Fass R, Fennerty MB, Ofman JJ, et al. The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology. 1998;115:42–49.
    1. Dickman R, Emmons S, Cui H, et al. The effect of a therapeutic trial of high-dose rabeprazole on symptom response of patients with non-cardiac chest pain: a randomized, double-blind, placebo-controlled, crossover trial. Aliment Pharmacol Ther. 2005;22:547–555.
    1. Bautista J, Fullerton H, Briseno M, Cui H, Fass R. The effect of an empirical trial of high-dose lansoprazole on symptom resonse of patients with non-cardiac chest pain - a randomized, double-blind, placebo-controlled, crossover trial. Aliment Pharmacol Ther. 2004;19:1123–1130.
    1. Beedassy A, Katz PO, Gruber A, Peghini PL, Castell DO. Prior sensitization of esophageal mucosa by acid reflux predisposes to a reflux-induced chest pain. J Clin Gastroenterol. 2000;31:121–124.
    1. DeMeester TR, O'Sullivan GC, Bermudez G, Midell AI, Cimochowski GE, O'Drobinak J. Esophageal function in patients with angina-type chest pain and normal coronary angiograms. Ann Surg. 1982;196:488–498.
    1. Pandak WM, Arezo S, Everett S, et al. Short course of omeprazole: a better first diagnostic approach to noncardiac chest pain than endoscopy, manometry, or 24-hour esophageal pH monitoring. J Clin Gastroenterol. 2002;35:307–314.
    1. Xia HH, Lai KC, Lam SK, et al. Symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy-negative patients with non-cardiac chest pain. Aliment Pharmacol Ther. 2003;17:369–377.
    1. Singh S, Richter JE, Hewson EG, Sinclair JW, Hackshaw BT. The contribution of gastroesophageal reflux to chest pain in patients with coronary artery disease. Ann Intern Med. 1992;117:824–830.
    1. Hsia PC, Maher KA, Lewis JH, Cattau EL, Jr, Fleischer DE, Benjamin SB. Utility of upper endoscopy in the evaluation of noncardiac chest pain. Gastrointest Endosc. 1991;37:22–26.
    1. Frøbert O, Funch-Jensen P, Jacobsen NO, Kruse A, Bagger JP. Upper endoscopy in patients with angina and normal coronary angiograms. Endoscopy. 1995;27:365–370.
    1. Dickman R, Mattek N, Holub J, Peters D, Fass R. Prevalence of upper gastrointestinal tract findings in patients with noncardiac chest pain versus those with gastroesophageal reflux disease (GERD)-related symptoms: results from a national endoscopic database. Am J Gastroenterol. 2007;102:1173–1179.
    1. Smith JL, Opekun AR, Larkai E, Graham DY. Sensitivity of the esophageal mucosa to pH in gastroesophageal reflux disease. Gastroenterology. 1989;96:683–689.
    1. Hollerbach S, Bulat R, May A, et al. Abnormal cerebral processing of oesophageal stimuli in patients with noncardiac chest pain (NCCP) Neurogastroenterol Motil. 2000;12:555–565.
    1. Hu WH, Martin CJ, Talley NJ. Intraesophageal acid perfusion sensitizes the esophagus to mechanical distension: a Barostat study. Am J Gastroenterol. 2000;95:2189–2194.
    1. Sarkar S, Aziz Q, Woolf CJ, Hobson AR, Thompson DG. Contribution of central sensitisation to the development of non-cardiac chest pain. Lancet. 2000;356:1154–1159.
    1. Balaban DH, Yamamoto Y, Liu J, et al. Sustained esophageal contraction: a marker of esophageal chest pain identified by intraluminal ultrasonography. Gastroenterology. 1999;116:29–37.
    1. Pehlivanov N, Liu J, Mittal RK. Sustained esophageal contraction: a motor correlate of heartburn symptom. Am J Physiol Gastrointest Liver Physiol. 2001;281:G743–G751.
    1. Dogan I, Puckett JL, Padda BS, Mittal RK. Prevalence of increased esophageal muscle thickness in patients with esophageal symptoms. Am J Gastroenterol. 2007;102:137–145.
    1. Kushnir VM, Sayuk GS, Gyawali CP. Abnormal GERD parameters on ambulatory pH monitoring predict therapeutic success in noncardiac chest pain. Am J Gastroenterol. 2010;105:1032–1038.
    1. Katz PO, Dalton CB, Richter JE, Wu WC, Castell DO. Esophageal testing of patients with noncardiac chest pain or dysphagia. Results of three years' experience with 1161 patients. Ann Intern Med. 1987;106:593–597.
    1. Dekel R, Pearson T, Wendel C, De Garmo P, Fennerty MB, Fass R. Assessment of oesophageal motor function in patients with dyspepsia or chest pain - the Clinical Outcomes Research Initiative experience. Aliment Pharmacol Ther. 2003;18:1083–1089.
    1. Lam HG, Dekker W, Kan G, Breedijk M, Smout AJ. Acute noncardiac chest pain in a coronary care unit. Evaluation by 24-hour pressure and pH recording of the esophagus. Gastroenterology. 1992;102:453–460.
    1. Rencoret G, Csendes A, Henríquez A. [Esophageal manometry in patients with non cardiac chest pain] Rev Med Chil. 2006;134:291–298. [Spanish]
    1. Fass R. Chest pain of esophageal origin. Curr Opin Gastroenterol. 2002;18:464–470.
    1. Peters L, Maas L, Petty D, et al. Spontaneous noncardiac chest pain. Evaluation by 24-hour ambulatory esophageal motility and pH monitoring. Gastroenterology. 1988;94:878–886.
    1. Breumelhof R, Nadorp JH, Akkermans LM, Smout AJ. Analysis of 24-hour esophageal pressure and pH data in unselected patients with noncardiac chest pain. Gastroenterology. 1990;99:1257–1264.
    1. Achem SR, Kolts BE, Wears R, Burton L, Richter JE. Chest pain associated with nutcracker esophagus: a preliminary study of the role of gastroesophageal reflux. Am J Gastroenterol. 1993;88:187–192.
    1. DiMarino AJ, Jr, Allen ML, Lynn RB, Zamani S. Clinical value of esophageal motility testing. Dig Dis. 1998;16:198–204.
    1. Fass R, Naliboff B, Higa L, et al. Differential effect of long-term esophageal acid exposure on mechanosensitivity and chemosensitivity in humans. Gastroenterology. 1998;115:1363–1373.
    1. Handwerker HO, Reeh PW. Nociceptors: chemosensitivity and sensitization by chemical agents. In: Willis WD Jr, editor. Hyperalgesia and allodynia. New York: Raven Press; 1992. p. 107.
    1. Barish CF, Castell DO, Richter JE. Graded esophageal balloon distention. A new provocative test for noncardiac chest pain. Dig Dis Sci. 1986;31:1292–1298.
    1. Richter JE, Barish CF, Castell DO. Abnormal sensory perception in patients with esophageal chest pain. Gastroenterology. 1986;91:845–852.
    1. Rao SS, Gregersen H, Hayek B, Summers RW, Christensen J. Unexplained chest pain: the hypersensitive, hyperreactive, and poorly compliant esophagus. Ann Intern Med. 1996;124:950–958.
    1. Rao SS, Hayek B, Summers RW. Functional chest pain of esophageal origin: hyperalgesia or motor dysfunction. Am J Gastroenterol. 2001;96:2584–2589.
    1. Börjesson M, Pilhall M, Eliasson T, Norssell H, Mannheimer C, Rolny P. Esophageal visceral pain sensitivity: effects of TENS and correlation with manometric findings. Dig Dis Sci. 1998;43:1621–1628.
    1. Lembo AJ. Visceral hypersensitivity in noncardiac chest pain. Gastroenterol Clin North Am. 2004;33:55–60.
    1. Mehta AJ, De Caestecker JS, Camm AJ, Northfield TC. Sensitization to painful distension and abnormal sensory perception in the esophagus. Gastroenterology. 1995;108:311–319.
    1. Sarkar S, Thompson DG, Woolf CJ, Hobson AR, Millane T, Aziz Q. Patients with chest pain and occult gastroesophageal reflux demonstrate visceral pain hypersensitivity which may be partially responsive to acid suppression. Am J Gastroenterol. 2004;99:1998–2006.
    1. Mujica VR, Mudipalli RS, Rao SS. Pathophysiology of chest pain in patients with nutcracker esophagus. Am J Gastroenterol. 2001;96:1371–1377.
    1. Nasr I, Attaluri A, Hashmi S, Gregersen H, Rao SS. Investigation of esophageal sensation and biomechanical properties in functional chest pain. Neurogastroenterol Motil. 2010;22:520–526. e116.
    1. Hoff DA, Gregersen H, Ødegaard S, Hjertaker BT, Hatlebakk JG. Sensation evoked by esophageal distension in functional chest pain patients depends on mechanical stress rather than on ischemia. Neurogastroenterol Motil. 2010;22:1170–1176. e309–e311.
    1. Bass C, Wade C, Hand D, Jackson G. Patients with angina with normal and near normal coronary arteries: clinical and psychosocial state 12 months after angiography. Br Med J (Clin Res Ed) 1983;287:1505–1508.
    1. Bass C, Wade C. Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity. Psychol Med. 1984;14:51–61.
    1. Channer KS, Papouchado M, James MA, Rees JR. Anxiety and depression in patients with chest pain referred for exercise testing. Lancet. 1985;2:820–823.
    1. Costa PT., Jr Influence of the normal personality dimension of neuroticism on chest pain symptoms and coronary artery disease. Am J Cardiol. 1987;60:20J–26J.
    1. McCroskery JH, Schell RE, Sprafkin RP, Lantinga LJ, Warner RA, Hill N. Differentiating anginal patients with coronary artery disease from those with normal coronary arteries using psychological measures. Am J Cardiol. 1991;67:645–646.
    1. Flugelman MY, Weisstub E, Galun E, et al. Clinical, psychological and thallium stress studies in patients with chest pain and normal coronary arteries. Int J Cardiol. 1991;33:401–408.
    1. Mayou R, Bryant B, Forfar C, Clark D. Non-cardiac chest pain and benign palpitations in the cardiac clinic. Br Heart J. 1994;72:548–553.
    1. Chignon JM, Lepine JP, Ades J. Panic disorder in cardiac outpatients. Am J Psychiatry. 1993;150:780–785.
    1. Tennant C, Mihailidou A, Scott A, et al. Psychological symptom profiles in patients with chest pain. J Psychosom Res. 1994;38:365–371.
    1. Wong WM, Lam KF, Cheng C, et al. Population based study of noncardiac chest pain in southern Chinese: prevalence, psychosocial factors and health care utilization. World J Gastroenterol. 2004;10:707–712.
    1. Clouse RE, Lustman PJ. Psychiatric illness and contraction abnormalities of the esophagus. N Engl J Med. 1983;309:1337–1432.
    1. Cannon RO, 3rd, Benjamin SB. Chest pain as a consequence of abnormal visceral nociception. Dig Dis Sci. 1993;38:193–196.
    1. Fleet RP, Dupuis G, Marchand A, Burelle D, Arsenault A, Beitman BD. Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition. Am J Med. 1996;101:371–380.
    1. Demiryoguran NS, Karcioglu O, Topacoglu H, et al. Anxiety disorder in patients with non-specific chest pain in the emergency setting. Emerg Med J. 2006;23:99–102.
    1. Jones M, Lewis A. Effort syndrome. Lancet. 1941;237:813–818.
    1. Huffman JC, Pollack MH. Predicting panic disorder among patients with chest pain: an analysis of the literature. Psychosomatics. 2003;44:222–236.
    1. Alexander PJ, Prabhu SG, Krishnamoorthy ES, Halkatti PC. Mental disorders in patients with noncardiac chest pain. Acta Psychiatr Scand. 1994;89:291–293.
    1. Carter CS, Maddock RJ. Chest pain in generalized anxiety disorder. Int J Psychiatry Med. 1992;22:291–298.
    1. Dammen T, Ekeberg O, Arnesen H, Friis S. Personality profiles in patients referred for chest pain. Investigation with emphasis on panic disorder patients. Psychosomatics. 2000;41:269–276.
    1. Husser D, Bollmann A, Kühne C, Molling J, Klein HU. Evaluation of noncardiac chest pain: diagnostic approach, coping strategies and quality of life. Eur J Pain. 2006;10:51–55.
    1. Stollman NH, Bierman PS, Ribeiro A, Rogers AI. CO2 provocation of panic: symptomatic and manometric evaluation in patients with noncardiac chest pain. Am J Gastroenterol. 1997;92:839–842.
    1. Cooke RA, Anggiansah A, Wang J, Chambers JB, Owen W. Hyperventilation and esophageal dysmotility in patients with noncardiac chest pain. Am J Gastroenterol. 1996;91:480–484.
    1. Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA, Hill NE. One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries. Am J Cardiol. 1988;62:209–213.
    1. Hotopf M, Mayou R, Wadsworth M, Wessely S. Psychosocial and development antecedents of chest pain in young adults. Psychosom Med. 1999;61:861–867.
    1. Dammen T, Arnesen H, Ekeberg O, Friis S. Psychological factors, pain attribution and medical morbidity in chest-pain patients with and without coronary artery disease. Gen Hosp Psychiatry. 2004;26:463–469.
    1. Katon W, Hall ML, Russo J, et al. Chest pain: relationship to psychiatric illness to coronary arteriographic results. Am J Med. 1988;84:1–9.
    1. Eken C, Oktay C, Bacanli A, et al. Anxiety and depressive disorders in patients presenting with chest pain to the emergency department: a comparison between cardiac and non-cardiac origin. J Emerg Med. 2010;39:144–150.
    1. Cormier LE, Katon W, Russo J, Hollifield M, Hall ML, Vitaliano PP. Chest pain with negative cardiac diagnostic studies. Relationship to psychiatric illness. J Nerv Ment Dis. 1988;176:351–358.
    1. García-Campayo J, Rosel F, Serrano P, et al. Different psychological profiles in non-cardiac chest pain and coronary artery disease: a controlled study. Rev Esp Cardiol. 2010;63:357–361.
    1. Beitman BD, Basha I, Flaker G, et al. Atypical or nonanginal chest pain. Panic disorder or coronary artery disease? Arch Intern Med. 1987;147:1548–1552.
    1. Cheng C, Wong WM, Lai KC, et al. Psychosocial factors in patients with noncardiac chest pain. Psychosom Med. 2003;65:443–449.
    1. Jerlock M, Kjellgren KI, Gaston-Johansson F, et al. Psychosocial profile in men and women with unexplained chest pain. J Intern Med. 2008;264:265–274.
    1. Fagring AJ, Gaston-Johannson F, Kjellgren KI, Welin C. Unexplained chest pain in relation to psychosocial factors and health-related quality of life in men and women. Eur J Cardiovasc Nurs. 2007;6:329–336.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel