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MSc in Clinical Psychology Non-cardiac Chest Pain and Psychological Morbidity among Patients at the Cardiac Emergency Department and the Emergency Centre December, 2018 Author: Kristín Eva Rögnvaldsdóttir ID number: 060391-2389 Supervisors: Erla Svansdóttir & Jón Friðrik Sigurðsson Department of Psychology School of Business NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 2 Forewords and acknowledgments This research thesis is submitted as a part of a MSc degree in Clinical Psychology at the Reykjavík University and is presented in the style of an article for submission to a peer-reviewed journal.
The research presented in this thesis comprises a culmination of work over four semesters.

The first semester consisted of the beginning of the data processing and the writing of a literature review about non- cardiac chest pain (NCCP).

In the second semester data processing continued and the first draft of the method section for the thesis was written.
The data processing was continued in the third semester and in the fourth semester data processing was completed along with the writing of the final draft of this thesis.

The thesis was executed under the supervision of Dr. Erla Svansdóttir a psychologist at The National University Hospital of Iceland and Dr. Jón Friðrik Sigurðsson, a professor at Reykjavík University.
The main purpose of the study was to evaluate the prevalence of non-cardiac chest pain and related visits among patients visiting the Cardiac Emergency (CED) and the Emergency Centre of the Landspitali National Hospital (LSH).

More specifically to examine the association between psychological morbidity and the number of non-cardiac related visits.

Data was collected at the CED and the Emergency Center of LSH.
This thesis yields information that is part of another study where the goal is to implement specialized treatment for this group of patients.

I want to thank all the patients that participated in the study and the staff at the CED and The National University Hospital of Iceland for collecting the data.

I also want to thank Sesselja Hreggviðsdóttir, a former psychological student for the pre- work on the data.
My advisors Erla Svansdóttir and Jón Friðrik Sigurðsson get my warmest thanks for their help and advice throughout the program.

I also want to NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 3 mention Sævar Már Gústafsson my statistical teacher for his time to help me and support when I needed.

At last, but not least, I want to give thanks to my friends in the program, my family and especially my boyfriend Jökull Viðar Gunnarsson for his support through the years.
NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 4 Abstract Objective: The aim of this study was to assess the association of non-cardiac related visits and psychological morbidity among patients seeking help at the Cardiac Emergency Department and the Emergency Centre.

Method: 390 patients aged 18-65 years old with presenting chest pain were contacted 1-8 month after discharge from the Cardiac Emergency Department and the Emergency Centre of the Landspitali National Hospital (LSH).
Participants answered multiple standardized questionnaires which measure various psychological factors.

Information about participants’ medical history was collected from medical files.

Results: Non-cardiac chest pain was prevalent in the emergency departments at the Hospital in Iceland.
Most participants (92%) who visited the CED or the Emergency Center of LSH with presenting chest pain, were diagnosed with non-cardiac chest pain and related diagnosis or had medical history of non-cardiac related visits.

Participants with no history of cardiovascular disease were 75% and coronary heart disease patients were 25%.
Depression and somatic symptoms were found to be significant predictors for non-cardiac related visits among CHD patients and somatic symptoms and health anxiety among NCCP patients Conclusion: The prevalence of non-cardiac related visits were associated with different psychological factors across groups, namely somatic symptoms and health anxiety among NCCP patients but somatic symptoms and depression among CHD patients.
Keywords: Non-cardiac chest pain, coronary heart disease, NCCP patients, CHD patients, number of non-cardiac related visits, health-care contacts NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 5 Cardiovascular Diseases and Non-Cardiac Chest Pains Cardiovascular disease (CVD) is a severe disease which constitutes a major cause of death worldwide, being responsible for over 17.9 million deaths every year (WHO, 2012).
Coronary Heart Disease (CHD) alone account for nearly half of all deaths from CVD overall, causing nearly two million deaths in Europe each year (Rayner, Allender, Scarborough, & for the British Heart Foundation Health Promotion Research Group, 2009) and seven million deaths worldwide (WHO, 2012).
The prevalence of CHD is 7.9% in the population of US adults 20 years of age and older and it is estimated that 50% of men and 64% of women who die suddenly from CHD have no previous symptoms of the disease (World Health Organization, 2016).

Chest pain is one of the main symptoms of heart disease, and thus reports of chest pain symptoms can cause major concerns to both patients and physicians (Ruigómez, Massó-González, Johansson, Wallander, & García-Rodríguez, 2009).
Every year numerous patients present to Emergency Centres with chest pain that have no cardiovascular cause, non-cardiac chest pain or NCCP (Fenster, 2004).

Findings suggest that even among high risk patients most instances of chest pain are not cardiac related.

Cases of chest pain that have no cardiovascular cause have increased over the past years where the annual prevalence is estimated around 20-30% (Eslick, Jones, & Talley, 2003; Thang et al., 2013).
In Cardiac Emergency Departments the prevalence is estimated between 50-75% (Chambers, Marks, Knisley, & Hunter, 2013) indicating that only 30% of chest pain cases presenting to hospitals have a cardiac related cause for their symptoms (Fruergaard et al., 1996; Castell, 2002; Flook et al., 2007).

It is also estimated that 15-30% of cases in Primary Health Care Centres, are attributable to medically unexplained symptoms, including NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 6 NCCP.
Non-cardiac chest pain is defined as recurrent chest pain, which after a reasonable clinical work-up has excluded a cardiac cause.

Distinguishing between chest pains of a cardiac cause from those with non-cardiac causes can be very challenging due to the identicalness of patient symptom complaints.

NCCP patients complain about squeezing or burning substernal chest pains, which are similar to complaints from cardiac patients (Fass & Achem, 2011).
It seems that most NCCP patients hospitalized at Cardiac Emergency Departments (CED) are not at a higher risk than people in the general population of getting a heart attack or dying from cardiovascular disease (Fagring, Lappas, Kjellgren, Welin, Manhem, & Rosengren, 2010; Fass & Achem, 2011).
Causes of non-cardiac chest pain can emerge from both physiological causes like gastrointestinal-, neuromusculoskeletal- and pulmonary diseases (Flook et al., 2007) and anxiety related disorders, such as health anxiety, panic disorder, depression and excessive need for medical help (Chambers, Marks, & Hunter, 2015; Fass & Achem, 2011).

Psychological factors may also affect the interpretation of a chest pain (Bass & Mayou, 2002).
A common feature among patients with NCCP is an increased attention to the heart, cognitions of a catastrophic situation, dysfunctional health assumptions, severe, persistent reassurance-seeking and high psychological stress (Schroeder, Schmid, & Martin, 2013).
For most patients with NCCP, standard medical care does not offer sufficient help for symptom relief (Glombiewski et al., 2010) and reassurance from doctors that examinations were negative are often insufficient to decrease or eliminate worries and fears these patients experience (Jonsbu, Martinsen, Morken, Moum, & Dammen, 2012; Robertson, Javed, Samani, & Khunti, 2008).
As a consequence, NCCP patients tend to continue to worry about NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 7 their chest pain and may continue to seek help in health care services, including cardiologists (Glombiewski, 2010; Jonsbu et al., 2012).

However, few studies have examined the association between repeated non- cardiac related visits at the hospital and psychological morbidity.
Consequently, it is undefined whether patients with repeated non-cardiac related visits have worse psychological morbidity than those who only have one visit.

Non-cardiac chest pain have also been found common in CHD patients where one in three chest pain hospitalization after acute myocardial infarction have no cardiovascular cause (Qintar et al., 2017).

According to the study of Robertson et al., (2008) anxiety levels among NCCP and CHD patients are higher than seen in the normal population.
However, two months after discharge, NCCP patients tend to remain clinically anxious by contrast with CHD patients.

This may possibly be caused by a dysfunctional illness representation that presents the patients’ perception of the controllability of the pain and his understanding of it.
According to previous study findings, it can be assumed that NCCP patients are dealing with restricting and enduring difficulties which may result in an increased burden on Emergency Centres and other health care services.

Indeed, NCCP patients continue to seek treatment regularly after their diagnosis (Tew et al., 1995).
It is important to identify NCCP patients because of their need for a detailed consultation and more intensive intervention to deal with fears, concerns and inappropriate beliefs about their condition.

Knowledge of which psychological factors contribute to continued health care consultation among these patients would be helpful to hinder more frequent visits and assist with their psychological morbidity NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 8 The purpose of this study was twofold.
Firstly, to estimate the prevalence of repeated non-cardiac related visits among CHD patients and NCCP patients presenting with chest pain to the CED and Emergency Centre of Landspitali National Hospital (LSH).

Secondly, to investigate the association of the number of non-cardiac related visits with psychological morbidity and health care utilization among these patients.
Method Participants and procedure Participants in the study were patients who visited the CED and the Emergency Centre at LSH presenting with chest pain from October 2015 through July 2016.

Participants were contacted 1-8 months after they were discharged from the hospital via phone and invited to participate in the study.

Participants were 390 in total, 150 females (38,5%) and 240 males (61,5%).

Age of participants ranged from 18-66 (M = 51,5, SD = 11).
Measures and procedures Study Questionnaires All participants were invited to visit the Landspitali National Hospital (LSH) and were administered multiple standardized questionnaires that measure various psychological factors.

Short Health Anxiety Inventory (SHAI) is an 18-item scale, designed to assess health anxiety independently of physical health status (Salkovskis, Rimes, Warwick, & Clark, 2002).
SHAI includes items estimating worries about health, NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 9 awareness or changes of bodily sensations and feared consequences of having an illness.

The SHAI scale has demonstrated good psychometric properties (Salkovskis et al., 2002).

The Icelandic version has high test-retest reliability in a community sample and its internal consistency is good for both clinical and community samples (Viðarsson, 2016).
Scores range from 0-42 and the cut-off point of 15-18 has been used in studies of patients in clinics for chronic pain (Rode, Salkovskis, Dowd, & Hanna, 2006), but score of 18 is the cut-off score commonly used.

Generalized Anxiety Disorder (GAD-7) is a seven-item self-report scale that reflects most symptom criteria for generalized anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
Total scores range between 0-21, with higher scores indicate more symptoms of generalized anxiety.

The psychometric properties of the scale is good and it is recommended for clinical use in the UK and US to measure anxiety, also among cardiac patients (Kroenke, Spitzer, Williams, & Löwe, 2010; Li, Lukai, Rongjing, Dayi, & Sheng, 2014; Löwe et al., 2008).

Patient Health Questionnaire (PHQ-9) is a nine-item scale, designed to span the diagnostic criteria for major depressive disorder in the DSM–IV manual.
The items are rated from 0-3 according to increased frequency of experiencing difficulties in each area covered.

Total scores range from 0 to 27 and indicate severity of depressive symptoms from no depression to severe depression (Cameron, Crawford, Lawton, & Reid, 2008).

Studies have indicated good psychometric properties for the scale and it constitutes a good measurement for depression in cardiac patients (Cameron et al., 2008; Li et al., 2014).
The ideal cut-off score for major depressive has been estimated at 12 in the Icelandic population (Pálsdóttir, 2007).

NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 10 Perceived Stress Scale (PSS) is a 14-item scale measuring the perception of stress.

The questions on the PSS ask about feelings and thoughts for the past three weeks and items are rated by how often they felt a certain way.
Measures of the scale have shown good reliability and validity (Cohen, Karmarck, & Mermelstein, 1983; Cohen & Williamson, 1988; Svansdóttir, 2006).

The Icelandic version of the scale has comparable psychometric properties to the original version (Davíðsdóttir & Bachman, 1991) and good internal consistency (Svansdóttir, 2006).

Somatic Symptom Scale (SSS-8) is a standardized scale developed to estimate the somatic symptom burden of patients (Gierk et al., 2014).
It includes eight-items that estimate the burden of physical symptoms such as back pain, sleep troubles and headaches.

Patients answer the questions of how much they have been bothered by the problem, where higher score indicates more symptoms.

The SSS-8 scale has shown good psychometric properties (Gierk et al., 2014, 2015; Huang, Chung, Kroenke, Delucchi, & Spitzer, 2006).
Medical Records Information about participants’ medical history was extracted from electronic medical records at LSH after their participation in the study.

This included information about ICD-10 diagnoses given at discharge from the CED or Emergency Centre, and all other ICD-10 diagnoses assigned during admissions to LSH in the past five- years pre- and one- year post participation.
Information about the frequency of health-care contacts (visits to general practitioners) were collected from the Healthcare Use Registry of the Icelandic Directorate of Health over the same period of time.

NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 11 Data Analysis IBM SPSS Statistics (version 24) was used for all statistical analysis.

Prior to data analyses all participants where categorized into three patient groups based on their diagnosis history.
The categorization was based on the causes of their chest pain as determined by the ICD-10 diagnosis.

The three groups were “non-cardiac chest pain” (or NCCP), “coronary heart disease” (or CHD) and “OTHER” (other explanation for the chest pain).

Participants were categorized by their medical history and diagnoses given at discharge.
Participants with no history of cardiovascular disease who were discharged with diagnoses indicative of non-cardiac chest pain (for example chest pain unspecified (R07.4), other chest pain (R07.3) myalgia (M79.1), gastroesophageal reflux disease (GERD) (K21.0), anxiety, and over breathing)) were categorized as NCCP patients.
In cases where no decisive diagnosis was assigned at discharge but cardiovascular causes of the chest pain were deemed unlikely, tests did not give any decisive results, or where angiography results indicated non-obstructive coronary artery disease (defined as stenosis <75%) (Lipinski, Do, Morise, & Froelicher, 2002) were also categorized as NCCP patients.
Patients with a history of a cardiovascular disease (previous myocardial infarction, STEMI, NSTEMI, previous coronary artery bypass surgery or percutaneous coronary intervention with a vasoconstriction ≥75%) or who were assigned a diagnosis of cardiac disease at discharge they were categorized as CHD patients.
The third group was defined as OTHER, and consisted of patients with other acute medical illnesses which posed as probable causes for the current chest pain and called for appropriate acute treatment.

These included for instance gall bladder infection, appendicitis or pulmonary embolism, gallstones, or pneumonia.

Participants grouped in the OTHER group were excluded from all analyses (N=357).
NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 12 To assess the number of non-cardiac related visits to LSH, medical records of all hospitalizations due to chest pain were reviewed over the five years prior to and until one year past participation.
Definition of a non-cardiac related visits included the following: a) Given diagnosis of R07.4 or other ICD-10 diagnosis indicative of non- cardiac chest pain (as mentioned in the definition of NCCP patients above); b) medical examination at CED or the Emergency Centre yielded negative or unlikely cardiac related cause.

Three additional measures were created from the medical registry data to estimate participant’s health care utilization.
Firstly: Unique diagnoses: the total number of unique ICD-10 diagnoses for each participant was counted from the total number of previous diagnoses they had received at LSH during the past six years (five prior until one year past participation).

This was done to create an estimate or alternate measure of the extent of hospital utilization at LSH.
Secondly: Psychiatric diagnosis: the number of unique psychiatric ICD-10 diagnoses was counted for the same time period, to estimate extent of psychological morbidity.

Thirdly: Health-care contacts: the number of visits and contacts to primary physicians and nurses during the same past six years was counted (from the medical registry of the Icelandic Directorate of Health), in efforts to estimate the magnitude of health care utilization in primary care.
Descriptive statistics was examined for the main variables in the study for each patient group.

Difference between groups in number of ICD-10 unique or psychiatric diagnoses or questionnaire measures of psychological factors was estimated with independent t-test across both CHD and NCCP patients, and stratified by the number of non-cardiac related visits.
Pearson correlation coefficient was used NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 13 to evaluate association between continuous variables in the study in both patient groups.

Linear regression models were conducted to test whether psychological variables were associated with the number of non-cardiac related visits.

Two linear regression model were conducted, one for each patient group.

In both models, the step wise method was used, with age and gender inserted at the first step.
At the second step, the psychological predictors were added.

These analyses were conducted both for univariate analyses (with one psychological predictor at the second step at each run), and multivariate analyses (with all psychological factors included at the second step).

Statistical significance was assessed at p < .05.


Results In Table 1, descriptive statistics between groups is presented for the average number of non-cardiac related visits, unique diagnosis, number of psychiatric diagnosis and health-care contacts.

Table 1.

Comparison between groups.
Mean (standard deviation) CHD patients (n=91) NCCP patients (n=266) p - value Mean age Gender (% female) 57.6 (6.9) 25.5 (23) Education (% college) 78.0 (71) Non-cardiac related visits 1.4 (1.8) Health-care contacts 32.3 (36.7) Psychiatric diagnosis 0.2 (0.8) Psychiatric diagnosis (%) Unique diagnosis 12 12.5 (10.1) 49.5 (11.4) 43.6 (116) 81.2 (216) 1.5 (1.8) 30.2 (28.1) 0.3 (1.5) 11 6.6 (6.3) .000 .001 .924 .829 .620 .455 .688 .000 NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 14 CHD patients were older and had higher number of unique diagnosis compared to NCCP patients.
They have similar number of non-cardiac related visits on average and similar number of psychiatric diagnosis.

Among CHD patients 12% had psychiatric diagnosis and 11% of NCCP patients.

Of those who had any psychiatric diagnosis had three on average.

CHD patients had two psychiatric diagnosis on average and NCCP patients had three.

Prevalence of non-cardiac chest pain Of the total included in the sample, 75% of participants were categorized as NCCP patients and 25% as CHD patients.
Non-cardiac related visits were common in the total sample, where 92% of participants had attended the CED or Emergency Centre due to such symptoms.

Naturally, all participants in the NCCP group had at least one visit due to non-cardiac related chest pain, but 70% of heart patients had also presented to LSH with non-cardiac chest pain.

In total, 24% of participants had two or more non-cardiac related visits (34% of heart patients and 23% of NCCP patients).
In total 10% of participants had one or more psychiatric diagnosis.

Comparison between groups based on the number of non-cardiac related visits As seen in Table 2, comparison between groups was estimated based on the number of non-cardiac related visits.

Table 2.
Comparison between patient groups based on number of non-cardiac related visits CHD patients NCCP patients No non-cardiac related visit (n=27) Non-cardiac related visit (n=64) One non- cardiac related visit (n=203) More than one non- cardiac related visit (n=61) M M p-value Anxiety Depression 3.2 (2.9) 4.2 (4.0) 3.6 (3.5) 5.2 (4.8) Health Anxiety 10.7 (5.9) 11.4 (7.6) Perceived Stress 20.1 (5.6) 18.8 (7.5) Somatic Symptoms 7.8 (5.6) 10.5 (7.1) Health-care contacts 19.9 (17.4) 37.5 (41.3) Psychiatric diagnosis 0.1 (0.6) 0.3 (0.9) Unique diagnosis 9.6 (6.3) 13.7 (11.1) Correlation is significant at the 0.01 level (2-tailed).
** Correlation is significant at the 0.05 level (2-tailed).

* .649 .347 .927 .401 .079 .035* .302 .078 M 4.5 4.9 28.8 20.3 8.5 27.8 0.3 5.9 M 5.6 5.8 32.8 23.2 12.7 37.3 0.6 9.0 p-value .093 .175 .000** .019* .000** .020* .147 .001* CHD patients who had history of at least one non-cardiac related visit to the CED or Emergency Centre, had significantly more frequent contacts to the primary health care compared to CHD patients that had no history of non-cardiac related visit.
Among NCCP patients who had history of two or more non-cardiac related visits, had higher health anxiety, perceived stress, somatic symptoms, had more frequent contacts to the primary health care and more unique diagnosis, compared to NCCP patients with only one non-cardiac related visit.

All were significant at p < 0,05.

In total 11% of participants in the study had the score of 12 or higher on the PHQ-9 questionnaire and met the diagnostic criteria for Major Depressive Disorder.
The prevalence was the same for the two patient groups or 11%.

Health anxiety was also common among participants in general where 18% of CHD patients scored 18 or higher on the SHAI questionnaire compared to 15% among NCCP patients.

Correlation between the number of non-cardiac related visits and variables in the study As seen in Table 3, correlation between number of non-cardiac related visits with psychological factors and health care contacts was evaluated for CHD patients and NCCP patients.
NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 17 Table 3.
Correlation of the total number of non-cardiac related visits with psychological measures and health care contacts among CHD and NCCP patients Anxiety Depression Health Anxiety Perceived Stress Somatic Symptoms Health-care contacts Psychiatric diagnosis Unique diagnosis CHD patients NCCP patients .207 .395** .224* .067 .415** .217* .180 .398** .149* .102 .327** .083 .227** .198** .411** .548** Correlation is significant at the 0.01 level (2-tailed).
** Correlation is significant at the 0.05 level (2-tailed).

* Among CHD patients the number of non-cardiac related visits had a positive correlation with number of unique diagnosis, more frequent contact with primary health care, somatic symptoms, and depression.

Among NCCP patients the number non-cardiac related visits were positively correlated with number of unique diagnosis, more frequent contact to primary health care, number of psychiatric diagnosis, somatic symptoms, anxiety and health anxiety.
Predictors for non-cardiac chest pain in the CED and the Emergency Centre In Table 4, significant predictors for number of non-cardiac related visits are presented for both groups.

Among CHD patients, depression and somatic symptoms NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 18 were significant predictors.

The overall model fit was R2 = 0.329.


When number of non-cardiac related visits was viewed among NCCP patients, it was found that somatic symptoms and health anxiety were significant predictors.

The overall model fit was R2 = 0.145.

Table 4.
Predictors for number of non-cardiac related visits among both patient groups CHD patients NCCP patients Univariate Multivariate Univariate Multivariate Beta (standardized coefficients) p-value Gender (male) Age Anxiety Depression - - 0.247 0.429 Health anxiety 0.239 Perceived Stress 0.113 - - .023 .000 .037 .307 Beta (standardized coefficients) -0.211 0.161 0.058 0.342 -0.072 -0.252 Somatic Symptoms 0.480 .000 0.378 p-value Beta (standardized coefficients) p-value Beta (standardized coefficients) p-value .035 .106 .629 .039 .531 .064 .008 - - .120 0.073 0.305 0.051 0.223 - - .058 .254 .000 .423 .001 -0.023 -0.070 0.035 -0.177 0.296 -0.026 0.231 .722 .275 .712 .125 .000 .798 .007 Discussion The aim of this study was to evaluate the prevalence of non-cardiac related visits among patients visiting the CED and the Emergency Centre at LSH due to chest pain, and to estimate the association of repeated non-cardiac related visits with psychological morbidity and health care utilization among CHD patients and NCCP patients.
Results of this study indicate that non-cardiac related visits are considerably prevalent in the emergency departments at the LSH in Iceland.

Most participants (92%) had either been diagnosed with non-cardiac chest pain or had a history of at least one non-cardiac related visit.

The majority of participants had no history of cardiovascular diseases or 75%.

This number of patients with NCCP is consistent with previous studies on the prevalence of NCCP (Qintar et al., 2017).
In this study, one in four of all participants had repeated non-cardiac related visits, which is slightly higher than in previous studies (Karlsson, Lehtinen & Joukamaa, 1995; Reid, 2002).

On average, CHD patients had similar number of non- cardiac related visits as NCCP patients, but CHD patients had more frequent health- care contacts and higher number of unique diagnosis on average.
Interestingly, frequent non-cardiac related visits (two or more) were relatively more prevalent among CHD patients than NCCP patients.

CHD patients who had visited LSH due to non-cardiac chest pain in the past six years, had twice as many health-care contacts compared to CHD patients with no previous visits due to non-cardiac chest pain.

Both CHD patients and NCCP patients with repeated non-cardiac related visits to LSH had more frequent health-care contacts.
These findings give some indication that frequent attenders might have complex health issues and to some degree more complex compared to those patients that have fewer or no history of non-cardiac related visits.

NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 21 The prevalence of non-cardiac related visits among heart patients was also associated with more depression, somatic symptoms, the number of health care contacts and the number of unique ICD-10 diagnosis at LSH.
This suggests that CHD patients with a history of non-cardiac related visits may be dealing with multifarious health issues, they experience depression, have higher somatic symptom burden that may result in more health care utilization.

In the NCCP patient group, participants with more prevalent non-cardiac related visits (two or more) had worse psychological morbidity on average than those who had only one such visit.
They experienced more health anxiety, reported more somatic symptom burden, and perceived more stress.

They also had more frequent health-care contacts and a greater number of unique ICD-10 diagnosis compared with NCCP patients with only one visit due to non- cardiac chest pain.

These findings are consistent with other studies were the cause of NCCP has been associated with psychological factors (Chambers et al., 2015; Fass & Achem, 2011).
In correlation analyses, the total number of non-cardiac related visits had a moderate positively correlation with anxiety, health anxiety and somatic symptoms among NCCP patients.

It was moreover moderately or strongly correlated with more the prevalence of psychiatric ICD-10 diagnosis and unique ICD-10 diagnosis.

It may be that repeated visits to the LSH result in a diverse diagnosis criteria given to these patients.

It cannot though be excluded that they have a worse or more complex medical history.
It would be interesting to explore these associations adjusting for the medical history of participants.

In multivariate analyses, adjusting for age and gender, somatic symptoms were significantly associated with more number of non-cardiac related visits in both patient NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 22 groups.

This is in line with previous studies regarding the association between somatic symptoms and more frequent non-cardiac related visits among both patient groups.
It is well known that frequent attenders of health- care services are characterized by high rates of physical and psychiatric illness as well as social problems (Karlsson, Joukamaa, Lahti, Lehtinen, & Kokki-Saarinen, 1997).

Many frequent attenders have chronic or recurrent physical symptoms that cannot be explained adequately by somatic disease.

However, aside from somatic symptoms, distinct different psychological variables emerged as the strongest predictors of frequency of non-cardiac related visits.
Among NCCP patients, health anxiety was the psychological factor which was significantly associated with more number of non-cardiac related visits.

As the burden of somatic symptoms was higher among NCCP patients and they reported more health anxiety, the more previous visits they had due to non-cardiac chest pain at the CED and the Emergency Centre.

Conversely, depression was the main psychological factor associated with a higher prevalence of non-cardiac related visits among CHD patients.
This indicates that different psychological factors may be driving CHD and NCCP patients to seek health care due to chest pain.

CHD patients with a history of visits due to non-cardiac chest pain seem to be experiencing more symptoms of depression and this may push them to seek help more frequently to the cardiac emergency.

In this study over a tenth of CHD patients fulfilled diagnostic criteria for major depressive disorder.
On the other hand, NCCP patients with repeated non- cardiac related visits seemed to be more preoccupied with beliefs or fear of having a serious illness.

Such fear seems mainly to arise from physical symptoms that the individual misinterprets as an evidence of a serious illness (APA, 1994).
People with NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 23 health anxiety have tendency to seek reassurance from physicians where it often fails because of no tenable causation for their condition (Salkovskis et al., 2002).

Based on these findings, it appears different psychological factors may be associated with health care seeking due to benign chest pain sensations between the two groups.

Interpretation of these findings need to be evaluated in light of the limitation of this study.
The main limitation is that participants answered the questionnaires retrospectively which might affect their accuracy in responses.

Furthermore their condition might be influenced by different factors than during hospitalization.

Hence, we are not able to allege about predicted factors of number of non-cardiac related visits, only its association to other variables tested in the study.
However, the retrospective answering demonstrate that patients still experience considerable psychological problems up to eight months after discharge from the hospital.

Another limitation is the inconstancy between the two groups where NCCP patients where almost threefold the number of CHD patients in the study.

Conclusion Non-cardiac related visits due to chest pain are very common at the CED and Emergency Centre in Iceland, both among CHD and NCCP patients.
The prevalence of non-cardiac related visits was associated with different psychological factors across groups, namely somatic symptoms and health anxiety among NCCP patients but somatic symptoms and depression among CHD patients.

Different psychological state could contribute to health care seeking due to non-cardiac chest pain symptoms among heart patients and NCCP patients.
Approaches to address the support and NON-CARDIAC CHEST PAIN AND PSYCHOLOGICAL MORBIDITY 24 assistance needed for these patients, frequent attendees at the emergency ward with non-cardiac chest pain, may need to be tailored to the different needs their psychological states require.

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