Anxiety Associated With Increased Risk for Emergency Department Recidivism in Patients With Low-Risk Chest Pain

Abstract

Anxiety contributes to the chest pain symptom complex in 30% to 40% of patients with low-risk chest pain seen in the emergency department (ED). The validated Hospital Anxiety Depression Scale-Anxiety subscale (HADS-A) has been used as an anxiety screening tool in this population. The objective was to determine the prevalence of abnormal HADS-A scores in a cohort of low-risk chest pain patients and test the association of HADS-A score with subsequent healthcare utilization and symptom recurrence. In a single-center, prospective, observational cohort study of adult ED subjects with low-risk chest pain, the HADS-A was used to stratify participants into 2 groups: low anxiety (score <8) and high anxiety (score ≥8). At 45-day follow-up, chest pain recurrence was assessed by patient report, whereas ED utilization was assessed through chart review. Of the 167 subjects enrolled, 78 (47%) were stratified to high anxiety. The relative risk for high anxiety being associated with at least one 30-day ED return visit was 2.6 (95% confidence interval 1.4 to 4.7) and this relative risk increased to 9.1 (95% confidence interval 2.18 to 38.6) for 2 or more ED return visits. Occasional chest pain recurrence was reported by more subjects in the high anxiety group, 68% vs 47% (p = 0.029). In conclusion, 47% of low-risk chest pain cohort had abnormal levels of anxiety. These patients were more likely to have occasional recurrence of their chest pain and had an increased risk multiple ED return visits.

Hospitalised patients with unexplained chest pain: incidence and prognosis

“…Excessive diagnostic procedures, on the other hand, incur costs and utilize the time of healthcare personnel . Chest pain in 40% of patients or more indicates the presence of noncardiac causes , primarily reflecting gastro‐oesophageal dis‐orders, psychological distress/anxiety and respiratory disease.…”

The Relationship between Cognitive and Emotional Factors and Healthcare and Medication Use in People Experiencing Pain: A Systematic Review

“…However, the limited results for some of them point towards a confirmation of our hypotheses (i.e., ≥60% of the analyses confirm hypothesis). More specifically, concerning maladaptive CEF, there is potential for an, at least indirect, positive relationship between (1) general anxiety symptoms and the propensity to seek emergency care [ 110 ] and to use CAM services [ 115 ], (2) catastrophizing and the odds of using prescription pain medication [ 84 ], using opioids [ 84 , 122 ], having consultations with healthcare providers in general [ 7 , 89 ] and having tertiary care consultations in particular [ 56 ], (3) depressive symptoms and having hospitalizations [ 52 ], (4) fear-avoidance beliefs and the amount of pain medication use [ 126 ] and the chance of having a healthcare consultation [ 68 ], (5) frustration and using pain medication [ 59 ], (6) health worry and number of consultations with healthcare providers [ 132 ], (7) helplessness and the amount of healthcare consultations [ 128 ] and the odds for having secondary care consultations [ 116 ], (8) the level of beliefs of negative consequences of health condition and the propensity to use pain medication [ 59 ] and to have primary [ 59 ] and secondary care consultation [ 116 ], (9) negative illness beliefs and the chance of using pain medication [ 59 ], having healthcare consultations in general [ 68 ] and primary care consultations in particular [ 59 ] and the amount of HCU in general [ 120 ], (10) psychological distress and the number of emergency room visits [ 111 ] and hospital admissions [ 111 ] and the propensity of using pain medication in general [ 59 ] and prescription pain medication in particular [ 81 , 111 ], and of having primary care consultations [ 59 , 65 , 82 ] and (11) symptom vigilance and the amount of healthcare consultations [ 69 ].…”

“…The level of general anxiety symptoms was found to be consistently positively related with the amount of pain medication use in people experiencing pain, based on univariate analyses (4 analyses reporting a positive association [55,75,108,118] and 1 reporting no association [55]-80% agreement for a relationship), whereas it appeared to be unrelated with the number of consultations with healthcare providers (univariate: 1 analysis reporting a positive association [103], 2 a negative [125] and 5 no association [64,98,103,108]-13%; multivariate: 1 analysis reporting a positive association [103], 1 a negative [125] and 5 no association-14%) and the amount of emergency HCU (univariate: 1 analysis reporting a positive association [110] and 3 no association [85,125]-25%).…”

“…Cont. Gil (2004) [102] 1 1 1 NA 1 1 1 0 0 0 0 NA NA NA 1 1 1 NA 1 1 NA NA NA NA 1 1 0 13/18 Hadlandsmyth (2013) [103] 1 1 1 NA 0 1 1 1 1 0 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 0 0 0 11 /18 Jordan (2006) [104] 1 1 1 NA 1 1 1 0 0 1 0 NA NA NA 1 1 1 NA 1 0 NA NA NA NA 1 0 0 12/18 Keeley (2008) [105] 1 1 1 NA 1 1 1 0 1 1 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 0 0 13/18 Kuijper (2014) [106] 1 1 NA 1 1 1 0 1 1 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 1 0 16/18 Lentz (2018) [107] 1 1 1 NA 1 1 1 1 1 1 1 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 1 1 17/18 Levenson (2008) [108] 1 1 1 NA 1 1 1 1 1 0 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 0 0 13/18 McCracken (2005; Pain) [109] 1 1 1 NA 1 1 1 1 0 1 1 NA NA NA 0 0 1 NA 1 1 NA NA NA NA 1 0 0 13/18 Musey (2018) [110] 1 1 1 NA 1 1 1 0 1 0 0 NA NA NA 1 0 1 NA 1 0 NA NA NA NA 1 0 1 12/18 Navabi (2018) [111] 1 1 1 NA 1 1 1 0 0 1 0 NA NA NA 1 0 1 NA 1 0 NA NA NA NA 1 0 0 11/18 Pagé (2019) [112] 0 1 1 NA 1 1 1 0 1 1 1 NA NA NA 0 0 1 NA 1 1 NA NA NA NA 1 0 0 12/18 Tremblay (2018) [113] 1 1 1 NA 1 1 1 1 1 1 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 0 0 14/18 Ullrich (2013) [114] 1 1 1 NA 1 1 1 0 0 1 1 NA NA NA 1 0 1 NA 1 0 NA NA NA NA 1 0 0 12/18 Van Tilburg (2008) [115] 1 1 1 NA 1 1 1 0 0 1 1 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 0 0 12/18 Vervoort (2019) [116] 1 1 1 NA 1 1 1 1 1 1 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 1 0 15/18 Williams (2018) [117] 1 1 1 NA 1 1 1 0 1 1 0 NA NA NA 1 0 1 NA 0 1 NA NA NA NA 1 0 0 12/18 Wong (2019) [118] 1 0 1 NA 1 1 0 0 0 1 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 0 1 0 10/18 Woodhouse (2016) [119] 1 1 1 NA 1 1 1 0 1 1 0 NA NA NA 1 0 1 NA 1 1 NA NA NA NA 1 0 0 13/18…”

“… → Multivariable logistic regression Mourad (2018) [ 71 ] SE CS Non-cardiac chest pain 552 49/51 64 ± 17 y Symptom-related anxiety symptoms - Cardiac anxiety → Cardiac Anxiety Questionnaire - Fear of body sensations → Body Sensations Questionnaire Depressive symptoms → Patient Health Questionnaire-9 Patient-reported Retrospective (past year) Frequency of pain-related healthcare visits → categorized into: - 1 time - 2–3 times - >3 times (amount; consultations) To model the relationship between the listed CEF and frequency of pain-related healthcare visits while also accounting for somatization. → Structural equation modelling Musey (2018) 5 [ 110 ] US C Low-risk chest pain 163 32/68 47.4 ± 10.8 y Assessed at enrollment General anxiety symptoms → Hospital Anxiety and Depression Scale - Anxiety subscale (HADS-A) → dichotomized into: - High anxiety (HADS-A ≥ 8) - Low anxiety (HADS-A < 8) Database extraction Retrospective (past 12 m before enrollment) ER visits → yes/no (type; emergency HCU) To compare the proportion of patients having at least 1 ER visit (reference: no visit) between patients w/ high and low levels of anxiety symptoms. → Chi 2 Database extraction Prospective (30 d after enrollment) Number of ER return visits (ER recidivism) (amount; emergency HCU) To compare amount of ER recidivism between patients w/ high and low levels of anxiety symptoms.…”