Unexplained chest pain in the ED: could it be panic?

Foldes-Busque, Guillaume; Marchand, André; Chauny, Jean‐Marc; Poitras, Julien; Diodati, Jean G.; Denis, Isabelle; Lessard, Marie-Josée; Pelland, Marie-Ève; Fleet, Richard

doi:10.1016/j.ajem.2010.02.021

Cited by 44 publications

(61 citation statements)

References 49 publications

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“…19 Furthermore, another study showed that in patients who presented to the emergency room with unexplained chest pains, 40% of patients were experiencing anxiety-like symptoms, 20 highlighting the potential to miss CAD symptoms that might also be apparent in these patients.…”

Section: S54 Circ Cardiovasc Qual Outcomesmentioning

confidence: 99%

Do Women With Anxiety or Depression Have Higher Rates of Myocardial Ischemia During Exercise Testing Than Men?

Paine

Bacon

Pelletier

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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W omen have been shown to have worse coronary artery disease (CAD) outcomes relative to men because more women (17%) than men (12%) die within 3 years of having their first myocardial infarction (MI), 1 and hospital mortality rates after an acute MI have been shown to be higher in women (16%) than in men (11%).2 Suggested reasons for this sex disparity include the unique presentation of CAD in women and delays associated with diagnosis and treatment onset among women relative to men.3-5 Sex differences are still evident when assessing laboratory-based proxies for CAD outcomes such as myocardial ischemia, with a higher prevalence in women rather than in men.6,7 However, the extent to which sex differences in psychiatric disorders could influence both the presentation of and the ability to detect CAD has not been fully explored.Psychiatric disorders, especially anxiety and mood disorders, seem to be more common in women than in men, 8 and there is a documented link between these disorders and worse cardiac outcomes. [9][10][11][12] In addition to more traditional physiological risk factors for CAD, having depression is now considered to be a key risk factor for CAD, 13,14 and there is emerging evidence linking anxiety to CAD development, 15,16 particularly among women. 17,18 We have recently demonstrated, in a sample of patients with premature acute coronary syndrome, that the presence of anxiety was a critical determinant of poorer access to clinical care procedures (such as ECG and fibrinolysis testing) among women, but not among men. 5This suggests that psychiatric disorders, particularly anxiety, may be a unique risk factor for diagnostic and treatment delays among women at risk for CAD. This may be because of similarities between the presentation of symptoms of anxiety disorders and CAD, and possible misinterpretation of symptoms of CAD as symptoms of anxiety only. Patients who attend the emergency department with noncardiac chest pain are more likely to be women, and combined with a lower overall rate of acute coronary syndrome in women, these symptoms could be mistaken for anxiety-related symptoms (eg, fatigue, chest pain, and shortness of breath), rather than conducting an Background-Women diagnosed with coronary artery disease (CAD) typically experience worse outcomes relative to men, possibly through diagnosis and treatment delays. Reasons for these delays may be influenced by mood and anxiety disorders, which are more prevalent in women and have symptoms (eg, palpitations and fatigue) that may be confounded with CAD. Our study examined sex differences in the association between mood and anxiety disorders and myocardial ischemia in patients with and without a CAD history presenting for exercise stress tests. Methods and Results-A total of 2342 patients (women n=760) completed a single photon emission computed tomographic exercise stress test (standard Bruce Protocol) and underwent a psychiatric interview (The Primary Care Evaluation of Mental Disorders) to assess mood and anxiety disorders. Ischemia was ...

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Section: S54 Circ Cardiovasc Qual Outcomesmentioning

confidence: 99%

Do Women With Anxiety or Depression Have Higher Rates of Myocardial Ischemia During Exercise Testing Than Men?

Paine

Bacon

Pelletier

et al. 2016

Circ: Cardiovascular Quality and Outcomes

View full text Add to dashboard Cite

show abstract

“…This is especially important, as studies suggest that the majority of patients with noncardiac chest pain may develop chronic chest pain and continue to seek medical attention despite negative cardiac evaluations and reassurance (24,25). Further, a significant number of these patients with noncardiac chest pain may have underlying anxiety or panic, which are driving their symptoms (7)(8)(9)(10)(11)(12)(13).…”

Section: Discussionmentioning

confidence: 99%

“…However, between 80% and 95% of all patients presenting to EDs with complaints of chest pain do not have cardiac disease, or any other cardiopulmonary emergency by conventional testing (2)(3)(4)(5)(6). Further, previous findings indicate that up to 55% of patients with non-cardiopulmonary chest pain may be suffering from anxiety or panic disorders, and these psychiatric disorders remain undiagnosed in almost 90% of cases (7)(8)(9)(10)(11)(12)(13). Costs associated with the evaluation of chest pain found not to be related to an emergent cardiopulmonary condition have been estimated to be between $315 million and $8 billion per year, usually with no definitive cause contributing to recurrent ED visits (14,15).…”

Section: Introductionmentioning

confidence: 99%

Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety

Musey

Kline

2017

The Journal of Emergency Medicine

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, Abstract-Background: Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%-95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. Objective: Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. Methods: Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. Results: Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to ''stress'' or ''anxiety''; their mean ACS pretest probability was 4% (95% confidence interval 2.9%-5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. Conclusions: Without prompting, 8% of patients selfidentified ''stress'' or ''anxiety'' as the etiology for their chest pain. Most had low pretest probability, were overinvestigated for ACS and PE, and not investigated for anxiety syndromes. Ó

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“…anxiety and depression is not a part of the routine care, there is a risk that psychological distress can go unrecognized. In the absence of formal screening, healthcare providers tend to underestimate depression (71,143) and anxiety (74). Yet, patients experience recurrent chest pain that they think is cardiac-related and seek care repeatedly, leading to great costs.…”

Section: Psychological Distress Healthcare Utilization and Societal mentioning

confidence: 99%

“…Anxiety disorders are common among patients with chronic pain (73). About four out of ten of patients with NCCP have an anxiety disorder (19,52,74), and about 35-55 % have a lifetime anxiety disorder (19,62). Patients with multiple pain conditions experience more severe anxiety, worse physical performance, and bodily symptoms (73).…”

Section: Cardiac Anxietymentioning

confidence: 99%

Improving care for patients with non-cardiac chest pain : Description of psychological distress and costs, and evaluation of an Internet-delivered intervention

Mourad¹

2015

Linköping University Medical Dissertations

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Introduction: More than half of all patients seeking care for chest pain do not have a cardiac cause for this pain. Despite recurrent episodes of chest pain, many patients are discharged without a clear explanation of the cause for their pain. A lack of explanation may result in a misinterpretation of the pain as being cardiac-related, causing worry and uncertainty, which in turn leads to substantial use of healthcare resources. Psychological distress has been associated with non-cardiac chest pain (NCCP), but there is limited research regarding the relationship between different psychological factors and their association with healthcare utilization. There is a need for interventions to support patients to manage their chest pain, decrease psychological distress, and reduce healthcare utilization and costs. Aim: The overall aim of this thesis was to improve care for patients with non-cardiac chest pain by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention. Designs and methods: This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. The studies used the same initial cohort. Patients were consecutively approached within 2 weeks from the day of discharge from a general hospital in southeast Sweden. In study I, 267 patients participated (131 with NCCP, 66 with acute myocardial infarction (AMI), and 70 with angina pectoris (AP)). Out of these, 199 patients (99 with NCCP, 51 with AMI, 49 with AP) participated in study II. Participants were predominantly male (about 60 %) with a mean age of 67 years. Data was collected on depressive symptoms (Study I), healthcare utilization (Study I, II), and societal costs (Study II). Study III had a cross-sectional explorative and descriptive design. Data was collected consecutively on depressive symptoms, cardiac anxiety and fear of body sensations in 552 patients discharged with diagnoses of NCCP (51 % women, mean age 64 years) from four hospitals in southeast Sweden. Patients were approached within one month from the day of discharge. Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years, who were randomly assigned to an intervention (n=7) or control group (n=8). The intervention consisted of a four-session guided Internet-delivered cognitive behavioural therapy (CBT) program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. Data was collected on chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. Results: Depressive symptoms were prevalent in 20 % (Study IV) and 25 % (Study I, III) of the patients, and more than half of the patients still experienced depressive symptoms one year later (Study I). There were no significant differences in prevalence and severity of depressive symptoms between patients diagnosed with NCCP, AMI or AP. Living a...

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Unexplained chest pain in the ED: could it be panic?

Cited by 44 publications

References 49 publications

Do Women With Anxiety or Depression Have Higher Rates of Myocardial Ischemia During Exercise Testing Than Men?

Do Women With Anxiety or Depression Have Higher Rates of Myocardial Ischemia During Exercise Testing Than Men?

Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety

Improving care for patients with non-cardiac chest pain : Description of psychological distress and costs, and evaluation of an Internet-delivered intervention

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