Association of social support during emergency department evaluation for acute coronary syndrome with subsequent posttraumatic stress symptoms

Awareness with paralysis and symptoms of post-traumatic stress disorder among mechanically ventilated emergency department survivors (ED-AWARENESS-2 Trial): study protocol for a pragmatic, multicenter, stepped wedge cluster randomized trial

BACKGROUND

Awareness with paralysis (AWP) is memory recall during neuromuscular blockade (NMB) and can cause significant psychological harm. Decades of effort and rigorous trials have been conducted to prevent AWP in the operating room, where prevalence is 0.1-0.2%. By contrast, AWP in mechanically ventilated emergency department (ED) patients is common, with estimated prevalence of 3.3-7.4% among survivors given NMB. Longer-acting NMB use is a critical risk for AWP, and we have shown an association between ED rocuronium use and increased AWP prevalence. As NMB are given to more than 90% of ED patients during tracheal intubation, this trial provides a platform to test an intervention aimed at reducing AWP. The overall objective is to test the hypothesis that limiting ED rocuronium exposure will significantly reduce the proportion of patients experiencing AWP.

METHODS

This is a pragmatic, stepped wedge cluster randomized trial conducted in five academic EDs, and will enroll 3090 patients. Per the design, all sites begin in a control phase, under observational conditions. At 6-month intervals, sites sequentially enter a 2-month transition phase, during which we will implement the multifaceted intervention, which will rely on use of nudges and defaults to change clinician decisions regarding ED NMB use. During the intervention phase, succinylcholine will be the default NMB over rocuronium. The primary outcome is AWP, assessed with the modified Brice questionnaire, adjudicated by three independent, blinded experts. The secondary outcome is the proportion of patients developing clinically significant symptoms of post-traumatic stress disorder at 30 and 180 days after hospital discharge. We will also assess for symptoms of depression and anxiety, and health-related quality of life. A generalized linear model, adjusted for time and cluster interactions, will be used to compare AWP in control versus intervention phases, analyzed by intention-to-treat.

DISCUSSION

The ED-AWARENESS-2 Trial will be the first ED-based trial aimed at preventing AWP, a critical threat to patient safety. Results could shape clinical use of NMB in the ED and prevent more than 10,000 annual cases of AWP related to ED care.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05534243 . Registered 06, September 2022.

Positive psychological profiles based on perceived health clustering in patients with cardiovascular disease: a longitudinal study

OBJECTIVES

Psychological well-being and sociodemographic factors have been associated with cardiovascular health. Positive psychological well-being research is limited in the literature; as such, this study aimed to investigate how patients with cardiovascular disease could be classified according to their perceived mental and physical health, and to identify positive psychological profiles based on this classification and test their stability over time.

DESIGN AND SETTING

Longitudinal study with patients from a public hospital located in Córdoba (Spain).

PARTICIPANTS

This study comprised 379 cardiovascular patients (87.3% men) tested at three measurement points.

OUTCOME MEASURES

Participants reported their sociodemographic variables (age, sex, educational level, employment and socioeconomic status) at phase 1, while their perceived health and variables relating to positive psychological well-being were tested at this and two subsequent time points (average interval time: 9 months).

RESULTS

The two-step cluster analysis classified participants into three groups according to their mental and physical health levels, p<0.001: high (n=76), moderate (n=113) and low (n=189) perceived health clusters. Low perceived health was the largest cluster, comprising almost half of patients. Clusters significantly differed according to sex, p=0.002, and socioeconomic level, p=0.004. The profile analysis indicated that participants in the high perceived health cluster showed high positive affect, positivity, life satisfaction, and self-efficacy in emotion regulation, and less negative affect and use of passive strategies over the three measurement points (95% CI, all ps<0.01). Moreover, psychological profile stability for each cluster was generally found over an 18-month period, all ps<0.05.

CONCLUSION

Cardiovascular patients may differ in terms of their perceived health and, accordingly, in terms of other relevant variables. Perceived health clusters generated varying and generally stable psychological profiles based on positive psychological well-being variables. Psychological interventions should be adapted to patients' requirements.

Posttraumatic Stress Disorder Following Myocardial Infarction: A Systematic Review

The objective of the present review is to provide an overview of existing research that has reported on the association between posttraumatic stress disorder (PTSD) and ischemic heart disease. Specific focus is given to the incidence of PTSD following myocardial infarction (MI). A systematic review using Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines was performed by searching four bibliographic databases: PubMed, PsychINFO, ScienceDirect, and ProQuest Dissertations and Theses. A total of 39 articles were included in this literature review. The results of these studies suggest that the occurrence of an acute cardiac event is likely to contribute to the development of PTSD. Not only is this type of psychiatric disorder associated with significant suffering and impaired quality of life, but it is also a predictor of an increased risk of recurrent adverse cardiovascular events and mortality. Screening, assessment, and treatment of PTSD and posttraumatic stress symptoms following a major cardiac event are critical for offsetting potential deleterious psychological and physical consequences.

Examining the impact of emergency care settings on suicidal patients: A call to action

OBJECTIVE

The emergency department (ED) offers a critical and unique opportunity to assess and intervene on suicide risk. Despite its potential benefits, the ED setting presents several potential sources of stress. The present paper calls attention to how suicidal patients may be especially vulnerable to stressful ED experiences.

METHOD

This research synthesis cites the growing literature on ED-related stressors, as they have been shown to affect both psychiatric and nonpsychiatric patient populations.

RESULTS

We identified specific interpersonal, physical, and temporal features of the ED that have been shown to affect multiple patient populations, including suicidal individuals. Beyond this, there appears to be broad underutilization of therapeutic care in ED settings.

CONCLUSIONS

It is important to consider how the ED setting may be both helpful and harmful toward suicidal patients. We conclude with recommended domains of study and methodological considerations when pursuing these future directions. The proposed research agenda would help address this known high risk period around hospitalization and discharge, and ultimately optimize suicide prevention efforts.

Early Exposure to Cardiac Treatment and Distress Among Patients and Their Caregiving Partners

Background: The experience of an acute coronary event (ACE), including early care and evaluation, can be a distressing and traumatic experience for patients and their romantic partners, who also act as caregivers. We hypothesized that, among partners who were present during the ACE, those who were also present during (1) transportation to the hospital and (2) initial medical treatment would experience greater (a) anxiety early post-event and (b) posttraumatic stress symptoms (PSS) related to the event 4 months later. The associations between partner presence with patient anxiety and PSS were also explored.

Methods: Participants were ACE patients and their partners recruited between March 2015 and December 2016 from the Intensive Cardiac Care Unit (ICCU) of the Sheba Medical Center in Israel (N = 143; all patients were males and partners were females). Partners self-reported whether or not they were present during the cardiac event, the hospital drive, and initial care. Patients and partners self-reported anxiety in-hospital and PSS, keyed to the ACE, an average of 4 months later. Data were analyzed using General Estimating Equations (GEE) and Multilevel Modeling.

Results: Neither patient anxiety nor PSS differed according to partner presence during the drive to the hospital. In contrast, partners had higher anxiety when they were not present at all (difference = 3.65, p = 0.019) and when present during the event and during the drive (difference = 2.93, p = 0.029) as compared to when they were present for the event but not for the drive. Partners who were present during the event, but not the drive, had lower PSS than those who were present for both the event and the drive (difference = −4.64, p = 0.026).

Conclusions: Partners who accompany patients on the drive to the hospital may inadvertently put themselves at risk for greater distress following their loved one’s cardiac event. Future research should enroll couples in an acute care context to inform couple-targeted tailored interventions to reduce distress in patients and their caregiving partners.

Partner presence in the emergency department and adherence to daily cardiovascular medications in patients evaluated for acute coronary syndrome

Stressful health situations may compromise spouses'/partners' ability to provide patients with support. We tested whether partner status/partner presence in the emergency department (ED) were associated with patients' adherence to daily cardiovascular medications and whether effects differed by age/gender. Participants were 189 patients evaluated for acute coronary syndrome at an urban academic ED (M_Age = 62.18; 57.1% male; 58.7% Hispanic). Participants self-reported partner status/partner presence. Medication adherence was measured using an electronic pillcap. For male patients, having a partner was associated with increased adherence in the first month post-discharge, OR 1.94, p < .001, but having a partner present in the ED was associated with lower adherence, OR 0.33, p < .001. The opposite effect was evident for female patients. Partner status/partner presence in the ED are associated with medication adherence during the first month post discharge, with opposing effects for male and female patients.

Short Sleep Duration After Hospital Evaluation for Acute Coronary Syndrome Is Associated With Increased Risk of 6-Month Readmission

OBJECTIVE

Hospital readmission after acute coronary syndrome (ACS) is associated with worsened patient outcomes and financial burden. Short sleep duration is a risk factor for cardiovascular events and may therefore represent a behavioral factor that increases risk of adverse posthospitalization outcomes. This study examined whether short sleep duration in the month after hospital evaluation for ACS is associated with 6-month all-cause emergency department (ED) and hospital readmission.

METHODS

The current analyses entail a secondary analysis of a larger prospective observational cohort study. Sleep duration during the month after hospital evaluation for ACS was assessed subjectively and dichotomized as short (<6 hours) or not short (≥6 hours). A Cox proportional hazards model was used to assess the association between short sleep duration during the month after ACS hospital evaluation and 6-month all-cause ED/hospital readmission.

RESULTS

A total of 576 participants with complete data were included in analyses. Approximately 34% of participants reported short sleep duration during the month after ACS evaluation. Short sleep duration was significantly associated with 6-month all-cause ED/hospital readmission (hazard ratio = 2.03; 95% confidence interval = 1.12-3.66) in the model adjusted for age, sex, race/ethnicity, clinical severity, cardiac and renal markers, depression, acute stress, and including a sleep duration by ACS status interaction.

CONCLUSIONS

Short sleep duration after ACS hospital evaluation is prevalent and is associated with increased risk of all-cause readmission within 6 months of discharge. Current findings suggest that short sleep duration is an important modifiable behavioral factor to consider after hospital evaluation for ACS.

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

OBJECTIVES

Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work.

METHODS

A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N > 2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N = 1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD.

CONCLUSIONS

Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery.

The impact of support provided by close others in the emergency department on threat perceptions

Objective: Having close others present in the emergency department (ED) can cause patients significant distress. The present study tested the hypothesis that close others provide more negative support than non-close others as a potential explanation for this effect.Design: Participants were 493 patients evaluated for an acute coronary syndrome (ACS) in the ED (M_Age = 62.01, SD_Age = 13.55; 49.49% male) and who arrived with close others (i.e. spouse/partner, child) or non-close others (e.g. neighbour). Patients self-reported support from companions and threat perceptions (in-ED and at recall approximately three days later).Main outcome measures: Positive support (comfort, responsiveness); negative support (made patients anxious, required comforting); threat perceptions (feeling helpless, vulnerable).Results: Close (vs non-close) others provided patients with marginally more positive support, but also required more comfort, B = 0.32, p = .050, and caused patients more anxiety, B = 0.24, p = .009. Anxiety was associated with patients' Threat Perceptions: in-ED, B = 0.11, p = .002; recall, B = 0.14, p < .001; as was provision of comfort to support partners: recall, B = .06, p = .005.Conclusion: Negative support may be one mechanism underlying the association between close others and patient distress in the ED.

Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study

PURPOSE

We tested the hypothesis that, during a life-threatening medical emergency, patient perception of healthcare provider (HCP) compassion is associated with the subsequent development of post-traumatic stress disorder (PTSD) symptoms.

METHODS

Prospective cohort study in the emergency department (ED) of an urban academic medical center. We included adult patients presenting with a life-threatening medical emergency, defined as respiratory or cardiovascular instability requiring a potentially life-sustaining intervention in the ED. We measured patient perception of HCP compassion in the ED using the Consultation and Relational Empathy (CARE) measure, a validated 40-point scale. Blinded to clinical outcomes (including the CARE measure), we assessed PTSD symptoms 1 month post-discharge using the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5.

RESULTS

Of the 99/113 (88%) patients who completed follow-up, 25% (95% CI 17-35%) had PTSD symptoms at 1 month. In a multivariable model adjusting for potential confounders (e.g. severity of illness score in ED, need for intensive care unit admission, ED overcrowding, and family member emotional support in the ED), patient perception of greater HCP compassion in the ED was independently associated with lower PTSD symptoms at 1 month [odds ratio 0.93 (95% CI 0.89-0.98)]. A one-point increase in the CARE measure was associated with a 7% decrease in the odds of developing PTSD symptoms.

CONCLUSIONS

PTSD symptoms are common among ED patients with life-threatening medical emergencies. Patient perception of greater HCP compassion during the emergency is independently associated with lower risk of developing PTSD symptoms.

Bringing close others to the emergency department for an acute coronary event is associated with increased patient perception of threat

OBJECTIVE

Relationship quality is one of the most consistent psychosocial predictors of physical and mental health. Yet, little research examines relationship types or support within the immediate context of acute health events. We tested the unexplored role that close others play in patients' experience of threat during evaluation for acute coronary syndrome (ACS) in the Emergency Department (ED), as well as the indirect effect of close others on ACS-induced posttraumatic stress disorder (PTSD).

METHOD

Participants were 871 patients evaluated for ACS at an urban academic ED (60.86 years old; 54.08% male; 56.37% Hispanic, 19.86% Black, 16.65% White). Threat perceptions were assessed in-ED and median 3 days later. ACS-induced PTSD was assessed median 41 days later using the PTSD checklist cued to a specific stressor. Non-overlapping categories were created representing close others in the ED (i.e., spouse/significant other, child), non-close others (e.g., neighbor), or no one.

RESULTS

Patients who brought close others recalled experiencing greater threat in the ED: vs. no one, b = 0.11, p = .072; vs. non-close others, b = 0.16, p = .030. There was no direct effect of close others on ACS-induced PTSD; however, recalled threat mediated the effect of close others on development of ACS-induced PTSD, ps < .05.

CONCLUSIONS

Close others were associated with recalling greater threat during ED evaluation, which predicted ACS-induced PTSD. ACS-induced PTSD is associated with medication nonadherence, event recurrence, and mortality, highlighting the need to develop a greater understanding of the impact stressful medical environments have on patients and close others.

Development and Validation of a Measure to Assess Patients' Threat Perceptions in the Emergency Department

OBJECTIVE

Threat perceptions in the emergency department (ED; e.g., patients' subjective feelings of helplessness or lack of control) during evaluation for an acute coronary syndrome (ACS) are associated with the development of posttraumatic stress disorder (PTSD), and PTSD has been associated with medication nonadherence, cardiac event recurrence, and mortality. This study reports the development and validation of a seven-item measure of ED threat perceptions in English- and Spanish-speaking patients evaluated for ACS.

METHODS

Participants were drawn from an observational cohort study of 1,000 patients evaluated for ACS between 2013 and 2016 in a large New York City hospital. Participants reported on threat perceptions in the ED and during inpatient stay (using 12 items previously identified as predictive of PTSD) and reported on cardiac-induced PTSD 1 month postdischarge. Exploratory and confirmatory factor analyses were used to establish the factor structure and test measurement invariance. Validity and reliability were examined, as was the association of ED threat perceptions with cardiac-induced PTSD.

RESULTS

Factor analyses identified a seven-item measure of ED threat perceptions (e.g., "I feel helpless," "I am worried that I am going to die") for both English- and Spanish-speaking patients. ED threat perceptions demonstrated convergent validity, correlating with ED stress and ED crowdedness (r = 0.29 and r = 0.14), good internal consistency (α = 0.82), and stability (r = 0.61). Threat perceptions were associated with cardiac-induced acute stress at inpatient and PTSD symptoms at 1 month (r = 0.43 and r = 0.39).

CONCLUSIONS

This brief tool assessing ED threat perceptions has clinical utility for providers to identify patients at risk for developing cardiac-induced PTSD and is critical to inform research on whether threat may be modified in-ED to reduce PTSD incidence.

Can I Send This Patient with Stroke Home? Strategies Managing Transient Ischemic Attack and Minor Stroke in the Emergency Department

BACKGROUND

While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions.

OBJECTIVE OF THE REVIEW

The goal of this clinical review was to summarize and present recommendations regarding the disposition of TIAMS patients in the ED (e.g., admission vs. discharge).

DISCUSSION

An estimated 250,000 to 300,000 TIA events occur each year in the United States, with an estimated near-term risk of subsequent stroke ranging from 3.5% to 10% at 2 days, rising to 17% by 90 days. While popular and easy to use, reliance solely on risk-stratification tools, such as the ABCD2, should not be used to determine whether TIAMS patients can be discharged safely. Additional vascular imaging and advanced brain imaging may improve prediction of short-term neurologic risk. We also review various disposition strategies (e.g., inpatient vs. outpatient/ED observation units) with regard to their association with neurologic outcomes, such as 30-day or 90-day stroke recurrence or new stroke, in addition to other outcomes, such as hospital length of stay and health care costs.

CONCLUSIONS

Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.

Depressive Symptoms and Perceptions of ED Care in Patients Evaluated for Acute Coronary Syndrome

INTRODUCTION

Posttraumatic stress disorder (PTSD) develops in 1 out of 8 survivors of acute coronary syndrome (ACS) events, and these persons have a doubling of risk for recurrent ACS and mortality. Overcrowding in the emergency department during ACS evaluation has been associated with increased risk for PTSD, and depressed patients have been found to be particularly vulnerable. Little is known about the mechanisms by which overcrowding increases PTSD risk in depressed patients. Our aim was to evaluate one possible mechanism, patient perception of crowding and care, in depressed and nondepressed ED patients evaluated for ACS.

METHODS

We enrolled 912 participants in the REactions to Acute Care and Hospitalization study, an ongoing observational cohort study assessing patients evaluated for ACS. Participants completed the Emergency Department Perceptions questionnaire. Depressive symptoms were screened using the Personal Health Questionnaire Depression Scale. Objective ED crowding was calculated using the Emergency Department Work Index (EDWIN).

RESULTS

EDWIN scores did not significantly differ between groups. Although perceptions of ED crowding did not differ between groups, depressed patients perceived the emergency department as more stressful [t = 4.45, P < .001] and perceived poorer care [t = 3.03, P = .003]. Multiple regression modeling found a significant interaction between EDWIN scores and depression, predicting participants' perception of stress in the emergency department (F[7,904] = 7.93, P < .001).

DISCUSSION

We found that depressed patients experienced the emergency department as more stressful as objectively measured crowding increased. Our study highlights the complex interplay between cardiovascular disease and mental health in impacting patient health outcomes in the emergency department.

The role of perceived threat during emergency department cardiac evaluation and the age-posttraumatic stress disorder link

Evaluation for acute coronary syndrome (ACS) can trigger posttraumatic stress symptoms (PSS). Research suggests that younger, versus older, individuals may be at elevated risk for PSS after ACS evaluation. It has been proposed that younger individuals may be at greater risk because they perceive the suspected ACS event as more threatening than their older counterparts; however, this has yet to be tested. We examined whether perceived threat during ACS evaluation mediated the association between age and PSS after ACS evaluation in an observational cohort study of patients presenting to the emergency department (ED) with suspected ACS. Demographics and perceived threat were assessed in the ED. PSS were measured upon inpatient transfer or by phone 3 days later. The analytic sample comprised 871 adult participants. Multiple linear regression was used to examine (1) associations of age and perceived threat with PSS and (2) whether perceived threat mediated the association. Bootstrapping with percentile-based confidence intervals (CIs) was used to test the indirect effect. Each year of age was associated with lower PSS (b = - 0.12, p < .001), independent of covariates. Older age was associated with lower perceived threat during ACS evaluation (b = - 0.05, p < .001). Greater threat perceptions predicted greater PSS (b = 0.94, p < .0001). The indirect effect (- 0.04) was statistically significant (95% CI - 0.07, - 0.02). Younger, versus older, individuals are at risk for greater PSS after ACS evaluation, and elevated perceived threat partially mediated this association. Understanding age differences in PSS development risk and the potential impact of age on threat perceptions may help inform ED treatment.

Cardiac patients' perceptions of neighboring patients' risk: influence on psychological stress in the ED and subsequent posttraumatic stress

Background

As many as 12% of acute coronary syndrome (ACS) patients screen positive for post-traumatic stress disorder (PTSD) symptoms due to their cardiac event, and emergency department (ED) factors such as overcrowding have been associated with risk for PTSD. We tested the association of patients’ perceptions of their proximity to a critically ill patient during ED evaluation for ACS with development of posttraumatic stress symptoms (PSS) in the month after hospital discharge.

Methods

Participants were enrolled in the REactions to Acute Care and Hospitalization (REACH) study during evaluation for ACS in an urban ED. Participants reported whether they perceived a patient near them was close to death. They also reported their current fear, concern they may die, perceived control, and feelings of vulnerability on an Emergency Room Perceptions questionnaire. One month later, participants reported on PTSD symptoms specific to the cardiac event and ED hospitalization.

Results

Of 763 participants, 12% reported perceiving a nearby patient was likely to die. In a multivariate linear regression model [F(9757) = 19.69, p < .001, R² adjusted = .18] with adjustment for age, sex, GRACE cardiac risk score, discharge ACS diagnosis, Charlson comorbidity index, objective ED crowding, and depression symptoms at baseline, perception of a nearby patients’ likely death was associated with a 2.33 point (95% CI, 0.60–4.61) increase in 1 month PTSD score. A post hoc mediation analysis with personal threat perceptions [F(10,756) = 25.28, p < .001, R² adjusted = .24] showed increased personal threat perceptions during the ED visit, B = 0.71 points on the PCL per point on the personal threat perception questionnaire, β = 0.27, p = .001, fully mediated association of participants’ perceptions of nearby patients’ likely death with 1-month PTSD score (after adjustment for ED threat perceptions,) B = 0.89 (95% CI, −1.33 to 3.12), β = 0.03, p = .43, accounting for 62% of the adjusted effect and causing the main effect to become statistically nonsignificant.

Conclusions

We found patients who perceived a nearby patient was likely to die had significantly greater PTSD symptoms at 1 month. Awareness of this association may be helpful for designing ED patient management procedures to identify and treat patients with an eye to post-ACS psychological care.

Enduring somatic threat perceptions and post-traumatic stress disorder symptoms in survivors of cardiac events

Post-traumatic stress disorder due to acute cardiovascular events may be uniquely defined by enduring perceptions of somatic threat. We tested whether post-traumatic stress disorder at 1 month post-acute coronary syndrome indeed required both high peritraumatic threat during the acute coronary syndrome and ongoing cardiac threat perceptions. We assessed peritraumatic threat during emergency department enrollment of 284 patients with a provisional acute coronary syndrome diagnosis and cardiac threat perceptions and post-traumatic stress disorder symptoms 1 month post-discharge. In a multiple regression model with adjustment for important covariates, emergency department threat perceptions were associated with higher 1 month post-traumatic stress disorder symptoms only among those with high levels of ongoing cardiac threat.