Detecting panic disorder in emergency department chest pain patients: a validated model to improve recognition

A Brief Interview to Detect Panic Attacks and Panic Disorder in Emergency Department Patients with Cardiopulmonary Complaints

OBJECTIVES

Patients with panic-related anxiety often initially present to the emergency department (ED) complaining of respiratory or cardiac symptoms, but rates of detection of panic symptoms by ED physicians remain low. This study was undertaken to evaluate the relevance of panic attacks and panic disorder in ED patients who present with cardiopulmonary symptoms and to determine whether a brief symptom-based tool could be constructed to assist in rapid recognition of panic-related anxiety in the ED setting.

MATERIALS AND METHODS

English-speaking adult ED patients with a chief complaint of palpitations, chest pain, dizziness, or difficulty breathing were evaluated for the presence of panic attacks and panic disorder with the Structured Clinical Interview for DSM-IV Axis I Disorders. Participants completed self-report measures to assess panic-related symptoms, comorbid psychiatric conditions, health-related disability, and health service use.

RESULTS

In this sample (N=200), 23.5% had panic attacks and 23.0% had panic disorder. Both groups reported higher rates of panic attack symptoms, greater psychiatric comorbidity, greater health-related disability, and higher rates of ED and mental health service use compared with those without either condition. A brief 7-item tool consisting of panic symptoms identified patients with panic attacks or panic disorder with 85% accuracy (area under the curve=0.90, sensitivity=82%, specificity=88%).

CONCLUSIONS

Patients with panic attacks or panic disorder commonly present to the ED, but often go unrecognized. A brief 7-item clinician rating scale accurately identifies these patients among those ED patients presenting with cardiopulmonary complaints.

Anxiety and Cardiovascular Disease Risk: a Review

Unrecognized anxiety is a difficult clinical presentation in cardiology. Anxiety leads to recurring emergency department visits and the need for numerous diagnostic evaluations to rule out cardiovascular disease (CVD). This review focuses broadly on anxiety and its subtypes in relation to the onset and progression of CVD while describing helpful guidelines to better identify and treat anxiety. Potential mechanisms of cardiopathogenesis are also described. An emerging literature demonstrates that anxiety disorders increase the risk for incident CVD but a causal relationship has not been demonstrated. Anxiety portends adverse prognosis in persons with established CVD that is independent from depression. The level of clinical priority received by depression should be extended to research and clinical intervention efforts in anxiety. Anxiety holds direct relevance for uncovering mechanisms of cardiopathogenesis, developing novel therapeutic strategies, and initiating clinical interventions in the population at risk of developing heart disease, or those already diagnosed with CVD.

Panic disorder and incident coronary heart disease: a systematic review and meta-regression in 1131612 persons and 58111 cardiac events

BACKGROUND

Substantial healthcare resources are devoted to panic disorder (PD) and coronary heart disease (CHD); however, the association between these conditions remains controversial. Our objective was to conduct a systematic review of studies assessing the association between PD, related syndromes, and incident CHD.

METHOD

Relevant studies were retrieved from Medline, EMBASE, SCOPUS and PsycINFO without restrictions from inception to January 2015 supplemented with hand-searching. We included studies that reported hazard ratios (HR) or sufficient data to calculate the risk ratio and 95% confidence interval (CI) which were pooled using a random-effects model. Studies utilizing self-reported CHD were ineligible. Twelve studies were included comprising 1 131 612 persons and 58 111 incident CHD cases.

RESULTS

PD was associated with the primary incident CHD endpoint [adjusted HR (aHR) 1.47, 95% CI 1.24-1.74, p < 0.00001] even after excluding angina (aHR 1.49, 95% CI 1.22-1.81, p < 0.00001). High to moderate quality evidence suggested an association with incident major adverse cardiac events (MACE; aHR 1.40, 95% CI 1.16-1.69, p = 0.0004) and myocardial infarction (aHR 1.36, 95% CI 1.12-1.66, p = 0.002). The risk for CHD was significant after excluding depression (aHR 1.64, 95% CI 1.45-1.85) and after depression adjustment (aHR 1.38, 95% CI 1.03-1.87). Age, sex, length of follow-up, socioeconomic status and diabetes were sources of heterogeneity in the primary endpoint.

CONCLUSIONS

Meta-analysis showed that PD was independently associated with incident CHD, myocardial infarction and MACE; however, reverse causality cannot be ruled out and there was evidence of heterogeneity.

Panic disorder and incident coronary heart disease: a systematic review and meta-analysis protocol

BACKGROUND

The clinical presentation of panic disorder and panic attack overlaps many symptoms typically experienced in coronary heart disease (CHD). Etiological links between panic disorder and CHD are controversial and remain largely tenuous. This systematic review aims to pool together data regarding panic disorder with respect to incident CHD or myocardial infarction.

METHODS/DESIGN

Electronic databases (MEDLINE, EMBASE, PsycINFO and SCOPUS) will be searched using a search strategy exploding the topics for CHD and panic disorder. Authors and reference lists of included studies will also be contacted to identify additional published and unpublished studies. Eligibility criteria are as follows:

POPULATION

persons without CHD who meet criteria for panic disorder, panic attack, anxiety neurosis or elevated panic disorder symptoms; Comparison: persons without CHD who do not meet criteria for panic disorder, panic attack, anxiety neurosis or elevated panic disorder symptoms;

OUTCOME

verified fatal and non-fatal CHD at follow-up; including coronary revascularization procedure, coronary artery disease, and myocardial infarction. Studies adopting self-report CHD will be ineligible. Screening will be undertaken by two independent reviewers with disagreements resolved through discussion. Data extraction will include original data specified as hazard ratios, risk ratios, and original cell data if available. Risk of bias assessment will be undertaken by two independent reviewers. Meta-analytic methods will be used to synthesize the data collected relating to the CHD outcomes with Cochrane Review Manager 5.3.

DISCUSSION

This systematic review aims to clarify whether panic disorder is associated with elevated risk for subsequent CHD. An evaluation of the etiological links between panic disorder with incident CHD might inform evidence-based clinical practice and policy concerning triaging chest pain patients, diagnostic assessment, and psychiatric intervention with panic disorder patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014891 .

Prevalence and implications of severe anxiety in a prospective cohort of acute chest pain patients

Anxiety is a common condition which can manifest with symptoms of chest discomfort. Chest discomfort is one of the most common reasons to seek emergency medical care. We hypothesize that anxiety is highly prevalent, poorly diagnosed, and poorly treated in an acute care environment. We analyzed data from a prospective registry of chest pain patients with low to intermediate likelihood of acute coronary syndrome and coronary artery disease. Scores from the General Anxiety Disorder-7 questionnaire determined the prevalence of anxiety. Differences in presentation, evaluation, and 30-day outcomes were compared for subjects with and without severe anxiety. Of the 151 included subjects, severe anxiety was observed in 15%, moderate 14%, mild 30%, and 41% had no anxiety symptoms. Subjects with severe anxiety had similar baseline characteristics, cardiac risk factors, and symptoms to those without severe anxiety, except for the current use of tobacco (50.0% vs. 18.6%; P = 0.001). Anxiety was self-reported by 54.5% of subjects with severe anxiety and 27.3% were on antianxiety medications. Hospital admission (P = 0.888) and repeated emergency department visits within 30 days (P = 0.554) were not different between the 2 groups. Anxiety is common among patients seeking emergency evaluation of chest pain. Half of patients with severe anxiety were diagnosed and roughly one quarter were medically treated. Cardiac risk factors and symptoms are not different for patients with severe anxiety; these patients warrant a similar evaluation for heart disease as those patients without anxiety.

Diagnostic indicators of non-cardiovascular chest pain: a systematic review and meta-analysis

BACKGROUND

Non-cardiovascular chest pain (NCCP) has a high healthcare cost, but insufficient guidelines exist for its diagnostic investigation. The objective of the present work was to identify important diagnostic indicators and their accuracy for specific and non-specific conditions underlying NCCP.

METHODS

A systematic review and meta-analysis were performed. In May 2012, six databases were searched. Hand and bibliography searches were also conducted. Studies evaluating a diagnostic test against a reference test in patients with NCCP were included. Exclusion criteria were having <30 patients per group, and evaluating diagnostic tests for acute cardiovascular disease. Diagnostic accuracy is given in likelihood ratios (LR): very good (LR+ >10, LR- <0.1); good (LR + 5 to 10, LR- 0.1 to 0.2); fair (LR + 2 to 5, LR- 0.2 to 0.5); or poor (LR + 1 to 2, LR- 0.5 to 1). Joined meta-analysis of the diagnostic test sensitivity and specificity was performed by applying a hierarchical Bayesian model.

RESULTS

Out of 6,316 records, 260 were reviewed in full text, and 28 were included: 20 investigating gastroesophageal reflux disorders (GERD), 3 musculoskeletal chest pain, and 5 psychiatric conditions. Study quality was good in 15 studies and moderate in 13. GERD diagnosis was more likely with typical GERD symptoms (LR + 2.70 and 2.75, LR- 0.42 and 0.78) than atypical GERD symptoms (LR + 0.49, LR- 2.71). GERD was also more likely with a positive response to a proton pump inhibitor (PPI) test (LR + 5.48, 7.13, and 8.56; LR- 0.24, 0.25, and 0.28); the posterior mean sensitivity and specificity of six studies were 0.89 (95% credible interval, 0.28 to 1) and 0.88 (95% credible interval, 0.26 to 1), respectively. Panic and anxiety screening scores can identify individuals requiring further testing for anxiety or panic disorders. Clinical findings in musculoskeletal pain either had a fair to moderate LR + and a poor LR- or vice versa.

CONCLUSIONS

In patients with NCCP, thorough clinical evaluation of the patient's history, symptoms, and clinical findings can indicate the most appropriate diagnostic tests. Treatment response to high-dose PPI treatment provides important information regarding GERD, and should be considered early. Panic and anxiety disorders are often undiagnosed and should be considered in the differential diagnosis of chest pain.

A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department

INTRODUCTION

Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain.

METHODS AND ANALYSIS

The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument.

ETHICS AND DISSEMINATION

This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.

Two-year follow-up status of emergency department patients with chest pain: Was it panic disorder?

OBJECTIVES

We previously reported that 25% (108/441) of consecutive patients presenting to the emergency department (ED) of the Montreal Heart Institute with a chief complaint of chest pain suffered from panic disorder (PD). The purpose of the present study was to re-examine these patients (with and without PD) 2 years after their initial ED visit to determine their psychiatric and psychosocial status.

METHODS

An interviewer, who was kept blind to patients' initial medical and psychiatric diagnoses, attempted to contact all patients who participated in the initial study by phone. Patients who completed the phone interview were sent a battery of psychological questionnaires by mail.

RESULTS

A total of 301 (70%) patients completed the phone interview, and 228 (52%) patients completed the self-report questionnaires. Participants and non-participants did not differ with respect to age, gender, initial self-report scores, or initial cardiac or psychiatric diagnoses. At follow-up, significantly (p < 0.05) more PD+ than non-PD (PD-) patients reported: 1) chest pains in the last month (57% vs. 31%); 2) one or more ED consultations in the past year for chest pain (40% vs. 14%); 3) one or more hospitalizations in the past year (31% vs. 11%); and 4) perceiving their general health as "poor" (22% vs. 9%). PD+ patients displayed a significant (p < 0.05) worsening of their panic symptoms, agoraphobic avoidance, depression, and trait anxiety, and reported significantly (p < 0.05) greater suicidal ideation compared to PD- patients (32% vs. 9%). Of all PD+ patients, only 22% (18/82) reported receiving some form of mental health treatment for their symptoms.

CONCLUSIONS

Unrecognized and untreated PD has a chronic and disabling course. Greater efforts should be made to screen for PD in patients complaining of chest pain in EDs.

The association between panic disorder and coronary artery disease among primary care patients presenting with chest pain: an updated literature review

CONTEXT

Although panic disorder is linked to hypertension and smoking, the relationship between panic disorder and coronary artery disease (CAD) is unclear.

OBJECTIVE

To extend our understanding about the strength of the association between panic disorder and coronary artery disease and known cardiovascular risk factors.

DATA SOURCES

Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.

STUDY SELECTION

The diagnosis of panic disorder in eligible studies was based on DSM-IV criteria, and studies must have used objective criteria for CAD and risk factors. Only case-control and cohort studies were included.

DATA SYNTHESIS

Concerning the relationship between panic disorder and CAD, studies conducted in emergency departments found a relative risk [RR] of 1.25 (95% CI = 0.87 to 1.80), while those conducted in cardiology settings found an inverse relationship (RR = 0.19, 95% CI = 0.10 to 0.37). However, there is an inverse relationship between the prevalence of CAD in the study and the RR (r = -.554, p = .097), suggesting that, in primary care settings in which the prevalence of CAD is low, there may be a significant association between panic disorder and CAD.

CONCLUSION

The association between panic disorder and CAD has several implications for primary care physicians managing patients with chest pain. When comorbid, the panic attacks may cause the patient with coronary disease to seek care but could also provoke a cardiac event. If one condition is recognized, a search for the other may be warranted because of the potential consequences if left undetected. The treatment approach to the panic disorder should be adjusted in the presence of comorbid CAD.

Preliminary investigation of the Panic Screening Score for emergency department patients with unexplained chest pain

OBJECTIVES

The objective was to demonstrate the derivation and the preliminary validation of a brief screening score to improve recognition of panic-like anxiety in emergency department (ED) patients with unexplained chest pain.

METHODS

This cross-sectional study included 507 ED patients with unexplained chest pain randomly assigned to the derivation condition (n = 201) or the validation condition (n = 306). The Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) acted as the criterion standard for panic diagnosis. Receiver operating characteristic (ROC) curves were used to determine which of the sociodemographic, medical, and questionnaire response variables best predicted the presence of panic-like anxiety in the derivation condition. The selected predictors were entered in a logistic regression analysis to determine variables to be included in the screening score. The predictive validity of the resulting score was evaluated in both conditions.

RESULTS

The four-item Panic Screening Score (PSS) identified panic-like anxiety with a sensitivity of 63% (95% confidence interval [CI] = 52% to 73%) and a specificity of 84% (95% CI = 76% to 90%) in the derivation phase. The positive predictive value was 74% (95% CI = 62% to 93%) and the negative predictive value was 76% (95% CI = 68% to 89%). In the validation phase, the sensitivity and specificity were 53% (95% CI = 44% to 62%) and 85% (95% CI = 78% to 89%), respectively. The positive predictive value was 72% (95% CI = 62% to 80%) and the negative predictive value was 71% (95% CI = 65% to 77%).

CONCLUSIONS

The PSS may be useful to identify patients with unexplained chest pain who could benefit from referral to mental health professionals or their primary care providers for evaluation of panic attack and panic disorder. Prospective studies to improve and validate the PSS, followed by impact analysis, are mandatory before clinical implementation.

Barriers to treatment seeking for anxiety disorders: initial data on the role of mental health literacy

BACKGROUND

Anxiety disorders represent the single largest mental health problem in the United States [Greenberg et al., 1999. J Clin Psychiatry 60:427-435; Rice and Miller, 1998. Br J Psychiatry 173:4-9]. However most individuals with anxiety disorders never seek treatment [Henderson et al., 2002. Can J Psychiatry 47:819-824; Mojtabai et al., 2002. Arch Gen Psychiatry 59:77-84; Roness et al., 2005. Acta Psychiatr Scand 111:51-58]. Deficits in the ability to recognize anxiety disorders and beliefs about them, (i.e., "mental health literacy") may contribute to low levels of help seeking.

METHODS

Survey data assessing mental health literacy for multiple anxiety disorders and for depression were collected from 284 undergraduate students enrolled in psychology courses at a public university in the United States. Specifically, respondents were presented with vignettes portraying individuals experiencing various forms of mental illness and were asked to label the disorder, its cause and whether or not they would recommend treatment.

RESULTS

Findings showed that social phobia and obsessive compulsive disorder (OCD) were associated with recognition rates that were generally high and similar to depression (approximately 80%). In contrast, less than half of the respondents labeled panic disorder or generalized anxiety disorder (GAD) correctly. Symptoms of OCD were attributed to mental illness by approximately 50% of respondents, but such attributions were rare for the other anxiety disorders studied (<12%). Finally, data on help-seeking recommendations suggested that such recommendations are far from universal and varied between different anxiety disorders and according to perceptions of the causes of symptoms.

CONCLUSIONS

Given that the current sample was well-educated young adults, mental health literacy of the general public may be even lower.

Cardiophobia: a critical analysis

Cardiophobia, a clinical syndrome that affects hundreds of thousands of individuals in the USA, is characterized by abrupt, recurrent sensations and pain in the chest in the absence of physical pathology. This conceptual article seeks to address the significance of cardiophobia in western culture and to distinguish it from related disorders. In addition, a model of cardiophobia that highlights the role of heart-focused anxiety and interoceptive conditioning in the generation of limited-symptom panic attacks and acute chest pain is presented and vulnerability factors for cardiophobia are discussed. Future research directions relevant to the assessment and treatment of this clinically significant phenomenon are reviewed.

Silent ischemia: silent after all?

OBJECTIVE

To examine the association of nonpain symptoms in men and women with exercise-related silent ischemia, as well as the independence of these findings from other clinical factors.

METHODS

A prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging. Analyses were performed on 60 women and 155 men with no angina but medical perfusion imaging evidence of ischemia during exercise.

MEASURES

The presence of various non-pain-related symptoms. Ischemia is indicated by myocardial perfusion defects on exercise stress testing with single photon emission computed tomography.

RESULTS

Women reported more nonangina symptoms than men (P<0.05). They experienced fatigue, hot flushes, tense muscles, shortness of breath and headaches more frequently (P<0.05). Symptoms relating to muscle tension and diaphoresis were associated with ischemia after controlling for pertinent clinical covariates. However, the direction of association differed according to sex and history of coronary artery disease events or procedures. Sensitivity of the detection models showed modest improvements with the addition of these symptoms.

CONCLUSIONS

While patients who experience silent ischemia experience a number of nonpain symptoms, those symptoms may not be sufficiently specific to ischemia, nor sensitive in detecting ischemia, to be of particular help to physicians in the absence of other clinical information.

Chest pain and its importance in patients with panic disorder: an updated literature review

CONTEXT

Chest pain is a common symptom in primary care settings, associated with considerable morbidity and health care utilization. Failure to recognize panic disorder as the source of chest pain leads to increased health care costs and inappropriate management.

OBJECTIVE

To identify characteristics of the chest pain associated with the presence of panic disorder, review the consequences and possible mechanisms of chest pain in panic disorder, and discuss the recognition of panic disorder in patients presenting with chest pain.

DATA SOURCES

Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.

STUDY SELECTION

The diagnosis of panic disorder in eligible studies was based on DSM criteria, and studies must have used objective criteria for coronary artery disease and risk factors. Only case control and cohort studies were included.

DATA SYNTHESIS

Although numerous chest pain characteristics (believed to be both associated and not associated with coronary artery disease) have been reportedly linked to panic disorder, only nonanginal chest pain is consistently associated with panic disorder (relative risk = 2.03, 95% CI = 1.41 to 2.92).

CONCLUSION

Chest pain during panic attacks is associated with increased health care utilization, poor quality of life, and phobic avoidance. Because the chest pain during panic attacks may be due to ischemia, the presence of panic attacks may go unrecognized. Ultimately, the diagnosis of panic disorder must be based on DSM criteria. However, once panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.

Economic burden of not recognizing panic disorder in the emergency department

The objective of this cohort study was to examine the diagnostic patterns and resource utilization of patients presenting to the Emergency Department with chest pain of unknown origin who may be experiencing a panic attack. Patients were excluded if they had coronary artery disease. In the 155 patients meeting study criteria, unspecified chest pain (78%) was the most common diagnostic code assigned. Total charges for the index hospitalization were $1,263,391 (median/visit = $7340). During the 1-year follow-up, 41% of patients had at least one repeat hospital visit and generated $1.6 million in charges. Patients on Medicare or Medicaid were more likely to have multiple hospital visits during the follow-up (odds ratio = 11.7). In conclusion, Emergency Department patients admitted with non-cardiac chest pain account for a significant amount of hospital resource use.

A long-term follow-up study of chest pain patients: effect of panic disorder on mortality, morbidity, and quality of life

AIMS

The aim was to assess the association between panic disorder (PD) and the long-term outcome of chest pain patients with or without coronary artery disease (CAD).

METHODS

Patients (n = 199) consecutively referred to a cardiology outpatient clinic because of chest pain were reassessed after 9 years. At the initial examination 16% suffered from CAD and 38% from PD. Data were collected on mortality, cardiac events, cardiac risk factors, chest pain, anxiety and depression (SCL-90-R), and health-related quality of life (SF-36).

RESULTS

The death rate in the study population was not significantly different from that in the general population and no significant associations were found between PD at baseline and mortality and cardiac morbidity at follow-up. PD was associated with significantly higher follow-up scores of chest pain intensity (p = 0.025), depression (p = 0.005), anxiety (p = 0.039), and poorer health-related quality of life: physical functioning (p = 0.004), role physical (p = 0.001), body pain (p = 0.007), and general health (p < 0.001).

CONCLUSIONS

PD has a negative long-term effect on psychological and physical well-being of chest pain patients which emphasizes the necessity of identifying PD patients and offering them adequate treatment.

Detection of exercise-induced myocardial ischemia from symptomatology experienced during testing in men and women

BACKGROUND AND OBJECTIVES

To examine the capacity of angina and related symptoms experienced during exercise-stress testing to detect the presence of ischemia, controlling for other clinical factors.

METHOD

The authors undertook a prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging. One hundred forty-six women and 127 men reported chest pain, and of these, 25% of women and 66% of men had myocardial perfusion imaging evidence of ischemia during testing. The present article focuses on patients with chest pain during testing.

MAIN OUTCOME MEASURES

Outcome measures included chest pain localization, extension, intensity and quality, as well as the presence of various nonpain-related symptoms. Backward logistical regression analyses were performed separately on men and women who had experienced chest pain during testing.

RESULTS

Men who described their chest pain as 'heavy' were 4.6 times more likely to experience ischemia during testing (P=0.039) compared with other men, but this pain descriptor only slightly improved accuracy of prediction beyond that provided by control variables. In women, several symptoms added to the sensitivity of the prediction, such as a numb feeling in the face or neck region (OR 4.5; P=0.048), a numb feeling in the chest area (OR 14.6; P=0.003), muscle tension (OR 5.2; P=0.013), and chest pain that was described as hot or burning (OR 4.3; P=0.014).

CONCLUSIONS

A more refined evaluation of symptoms experienced during testing was particularly helpful in improving detection of ischemia in women, but not in men. Attention to these symptoms may favour timely diagnosis of myocardial perfusion defects in women.

Angina symptoms in men and women with stable coronary artery disease and evidence of exercise-induced myocardial perfusion defects

BACKGROUND

To examine sex differences in pain and associated symptoms in patients with exercise-related ischemia, as well as the independence of these findings from other clinical factors.

METHODS

Prospective study of 482 women and 425 men (mean age 58 years) undergoing exercise stress testing with myocardial perfusion imaging (MPI). Analyses were performed on 38 women and 94 men with both angina and MPI evidence of ischemia during exercise.

MEASURES

Chest pain localization, extension, intensity, quality, and presence of various non-pain-related symptoms.

RESULTS

Women rated their pain as more intense, used different words to describe it, and reported more non-pain-related symptoms than men (P < .05). They experienced pain and other sensations in the neck area more frequently (P < .05). Most of these differences remained after controlling for clinical or psychological variables, with the exception of pain intensity measures.

CONCLUSIONS

Sex differences in the experience of symptoms associated with MPI evidence of myocardial ischemia may complicate timely and accurate diagnosis of ischemia in women.

Panic in the emergency room

OBJECTIVE

This paper examines the relation between coronary artery disease (CAD) and panic disorder (PD), discusses the implications of this relation to the general medical system, and suggests future assessment and intervention strategies for emergency departments.

METHOD

We reviewed the literature on CAD and PD using Medline and PsycINFO.

RESULTS

PD is more expensive to our nonpsychiatric, general medical system than any other psychiatric condition. The main reason for PD patients' continued use of general medicine for their psychological symptoms is that their PD remains undiagnosed. In the emergency room (ER), PD patients with chest pain have their PD go undiagnosed about 98% of the time. By having ERs implement specific assessment and intervention strategies for patients presenting with chest pain, the savings to the general medical system could be substantial.

CONCLUSIONS

By improving recognition of PD in the ER, there is the potential to generate large savings in general medical care. With the availability of empirically supported or effective psychological and pharmacologic treatments for PD, appropriately diagnosing and subsequently treating patients with PD may prevent them from experiencing many years of disability and higher rates of fatal coronary events.

Predicting panic disorder among patients with chest pain: an analysis of the literature

As many as 25% of patients with chest pain who come to hospital emergency departments have panic disorder. Rates of panic disorder are even higher among those who present for outpatient evaluation of their chest pain. Unfortunately, panic disorder remains largely undiagnosed and untreated in these settings. The authors reviewed studies published between 1970 and 2001 that addressed the prevalence of panic disorder among persons who seek treatment for chest pain in an emergency department or outpatient cardiology clinic. A meta-analysis of the findings revealed five variables that appear to correlate with higher rates of panic disorder among persons who present with chest pain: 1). absence of coronary artery disease, 2). atypical quality of chest pain, 3). female sex, 4). younger age, and 5). a high level of self-reported anxiety. Further studies of these and other variables associated with panic disorder should aid in the detection of this disabling but treatable cause of chest pain.

Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management

Approximately one quarter of patients who present to physicians for treatment of chest pain have panic disorder. Panic disorder frequently goes unrecognized and untreated among patients with chest pain, leading to frequent return visits and substantial morbidity. Panic attacks may lead to chest pain through a variety of mechanisms, both cardiac and noncardiac in nature, and multiple processes may cause chest pain in the same patient. Panic disorder is associated with elevated rates of cardiovascular diseases, including hypertension, cardiomyopathy, and, possibly, sudden cardiac death. Furthermore, patients with panic disorder and chest pain have high rates of functional disability and medical service utilization. Fortunately, panic disorder is treatable; selective serotonin reuptake inhibitors, benzodiazepines, and cognitive-behavioral psychotherapy all effectively reduce symptoms. Preliminary studies have also found that treatment of patients who have panic disorder and chest pain with benzodiazepines results in reduction of chest pain as well as relief of anxiety.

Psychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit

STUDY OBJECTIVES

We sought to measure psychologic morbidity and health-related quality of life among patients attending the hospital with acute chest pain both at presentation and 1 month after rigorous assessment for cardiac disease.

METHODS

Consecutive patients undergoing assessment on the chest pain observation unit of a large, urban emergency department were asked to complete 3 questionnaires: the Short Form-36 Health Survey (SF-36), the Euroqol Health Utility Questionnaire, and the Hospital Anxiety and Depression Scale. The same questionnaires were mailed 1 month later, along with a questionnaire documenting subsequent pain and reassurance.

RESULTS

At enrollment (n=166), 32 (19%) participants (95% confidence interval [CI] 15% to 26%) were experiencing moderate levels of anxiety, and 21 (13%, 95% CI 8% to 19%) were experiencing moderate levels of depression. Health utility and all SF-36 dimensions of quality of life were substantially below age-adjusted normal values. One month after assessment (n=110), only the Pain dimension score of SF-36 had significantly improved. Most scores were unchanged, and the Physical Role and Mental Health dimension scores of SF-36 had significantly deteriorated. Seventy (64%) patients (95% CI 54% to 72%) had further pain after discharge. Despite these findings, 98 (86%) patients (95% CI 78% to 91%) responded that their assessment was "completely reassuring" or "quite reassuring."

CONCLUSION

Patients with acute, undifferentiated chest pain have substantial psychologic morbidity and impairment of quality of life. Although patients respond that they are reassured by chest pain observation unit assessment, anxiety and depression remain prevalent and quality of life remains impaired 1 month after assessment.

Panic disorder in primary care: patients' attributions of illness causes and willingness to accept psychiatric treatment

OBJECTIVE

This study assessed the causes that primary care patients with panic disorder (PD) attribute to their panic symptoms, and their acceptance of various psychiatric treatment options.

METHODS

In a cross-sectional assessment of 306 patients treated at two primary care clinics, 42 met criteria for DSM-IV PD in the past year. The authors classified these 42 PD-positive patients to one of two groups: those receiving both primary and specialty mental health care (PC+MH; n = 19) and those receiving only primary care (PC-only; n = 23). Patients rated the probability of four possible causes of their panic symptoms, and level of acceptability of three psychiatric and two medical treatments for PD. To place primary care patients' ratings into a broader context, a third contrast group of PD-positive patients, recruited from clinical trials of investigational PD pharmacotherapies (n = 31), also rated causes and treatment acceptability.

RESULTS

Participants of the three treatment groups attributed psychiatric causes for their panic symptoms in approximately the same proportion (78 percent to 90 percent; p = ns). PC-only participants attributed medical causes for panic symptoms more frequently than PC+MH and PD Clinical Trials participants (48 percent vs. 5 percent and 32 percent; p = .01). Remarkably, the great majority of patients across all groups expressed willingness to see psychiatrists (84 percent to 94 percent) and psychotherapists (95 percent to 100 percent), and to take psychotropic medications (87 percent to 100 percent).

CONCLUSIONS

In this study most patients attributed a psychiatric cause for panic symptoms and communicated strong acceptance of psychiatric treatment. Thus, we recommend that primary care clinicians more assertively inform their patients of PD diagnoses and recommend psychiatric treatments with less fear about stigmatizing and alienating them.

Recognition and acute management of patients with panic attacks in the emergency department

Patients with panic attacks commonly present to emergency departments. If the disorder is identified early, intervention can be begun, even during the evaluation phase. Effective therapies significantly improve these patients' health and quality of life.

Panic disorder and the heart: a cardiology perspective

Panic disorder is a common condition that includes symptoms that may masquerade as a primary cardiovascular disorder. In addition, many patients with cardiovascular disease may also have panic disorder. To date, no definitive pathophysiological mechanism for panic disorder has been found; however, there are several hypotheses in the literature. Patients with syndrome X, coronary artery disease and/or palpitations, in addition to panic disorder all present to cardiologists. However, many patients go undiagnosed and ultimately place large costs on the health care system as a result. Panic disorder is a treatable condition, and cardiologists could easily identify patients with panic disorder and initiate appropriate therapy and/or referral.

Cardiac exposure history as a determinant of symptoms and emergency department utilization in noncardiac chest pain patients

Although comparative studies differentiate noncardiac chest pain (NCCP), panic disorder, and coronary artery disease (CAD), little research has examined the defining features of NCCP, such as cardiac complaints, medical utilization, and learning history. We administered self-report measures to 80 Emergency Department (ED) patients with a primary complaint of chest pain who were subsequently found to not have CAD. Forty-eight percent of the ED utilization variance was accounted for by NCCP duration, age, cardiac distress symptoms, and prior exposure to both siblings' and friends' cardiac distress symptoms. In turn, 67% of the variance in cardiac distress symptoms was explained by education, age, NCCP duration, number of illnesses, noncardiac panic symptoms, prior exposure (friends), and prior observation of others' cardiac distress. No effects emerged for gender, ethnicity, avoidance, or depression. Results suggest that beyond the effects of age and distress intensity, prior exposure to other people's cardiac distress may influence NCCP.

The detection of panic disorder in chest pain patients

The aims of this study were to 1) develop a detection model for recognizing panic disorder (PD), 2) develop a simple questionnaire as a screening instrument for PD detection, and 3) test in an outpatient cardiological chest pain population a detection model for panic disorder previously described by Fleet et al. [20]. Logistic regression analysis was performed to explore factors predictive of panic disorder and to test the cross-cardiological setting constancy of the Fleet model in 199 chest pain patients without previously known heart disease referred to cardiological outpatient investigation of chest pain. The SCL-90 somatization subscale, Agoraphobia Cognitions Questionnaire, chest pain quality, pain localization, and age were the best predictors of the presence of panic disorder. This model correctly classified 78% of the subjects. The sum-score of a three-item questionnaire correctly classified 74% of the subjects, while the previously described model by Fleet et al. correctly classified 73% of the subjects. A detection model and a screening questionnaire are proposed to improve the recognition of PD in this chest pain population. This study partly supports the cross-setting validity of a previously described detection model.

Unexplained chest pain: when is it panic disorder?

Noncardiac chest pain is a common costly phenomenon in the cardiology setting. Recent research suggests that panic disorder, a highly distressful yet treatable anxiety disorder, occurs in a significant proportion of noncardiac chest pain patients. This article reviews research on the prevalence of panic disorder in patients seen in cardiology settings for unexplained chest pain. Financial, psychosocial, and historical aspects of noncardiac chest pain are described. Panic disorder and the potential consequences of its nonrecognition by physicians are examined. Current psychological and pharmacologic treatments are reviewed. Recommendations on the management of panic patients in the cardiology setting are provided.