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

Comparing the effectiveness of existing anxiety treatment options among patients evaluated for chest pain and anxiety in the emergency department setting: Study protocol for the PACER pragmatic randomized comparative effectiveness trial

BACKGROUND

Anxiety disorders are a common underlying cause of symptoms among low-risk chest pain patients evaluated in the emergency department setting. However, anxiety is often undiagnosed and undertreated in any setting, and causes considerable functional impairment to work, family, and social life.

OBJECTIVES

The Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) study is a pragmatic randomized trial to test the comparative effectiveness of existing anxiety treatments of graduated intensities and determine what options work best for patient subgroups based on anxiety severity and other comorbidities.

METHODS

The PACER trial will enroll 375 emergency department patients with low-risk chest pain and anxiety (GAD-7 score ≥ 8) and randomize them to either: 1) referral to primary care with enhanced care coordination, 2) online self-administered cognitive behavioral therapy with guided peer support, or 3) therapist-administered cognitive behavior therapy. Outcomes include anxiety symptoms (primary) as well as physical symptom burden, depression symptoms, functional impairment, ED recidivism, and occurrence of major adverse cardiac events. Statistical analyses will be conducted primarily using linear mixed models to perform a repeated measures analysis of patient-reported outcomes, assessed at 3, 6, 9, and 12-month follow-ups.

DISCUSSION

PACER is an innovative and pragmatic clinical trial that will compare the effectiveness of several evidence-based telecare-delivered treatments for anxiety. Results have the potential to inform clinical guidelines for evaluation and management of low-risk chest pain patients and promote adoption of findings in ED departments across the country.

Heart-Focused Anxiety Among Trauma-Exposed Latinx Young Adults: Relations to General Depression, Suicidality, Anxious Arousal, and Social Anxiety

Rates of traumatic event exposure, posttraumatic stress (PTS), and co-occurring mental health symptoms and disorders are conditionally higher among Latinx individuals compared to other racial/ethnic populations. Importantly, Latinx persons are a heterogeneous population, and certain subgroups endorse higher rates of negative mental health outcomes than others, including Latinx young adults born in the USA. Yet, there is little understanding of individual difference factors among trauma-exposed US born Latinx young adults that may be involved in mental health burden among this group. The present investigation sought to evaluate the potential explanatory relevance of heart-focused anxiety as an individual difference factor regarding some of the most common co-occurring mental health problems among trauma-exposed populations. Specifically, we tested whether heart-focused anxiety was related to increased co-occurring anxious arousal symptoms, depression, social anxiety, and suicidality among 169 (84% female, M_age=23.15 years, SD=6.07) trauma-exposed Latinx young adults. Results indicated that heart-focused anxiety was a statistically significant predictor of general depression (ΔR² = .02, F(1, 161) = 4.25, p = .041), suicidality (ΔR² = .10, F(1, 161) = 21.49, p < .001), anxious arousal (ΔR² = .11, F(1, 161) = 27.31, p < .001), and social anxiety (ΔR² = .03, F(1, 161) = 7.93, p = .005). Overall, this work offers empirical evidence that individual differences in heart-focused anxiety are related to more severe co-occurring anxiety and depressive symptomatology among a particularly at risk Latinx segment of the Latinx population (non-immigrant Latinx young adults s with previous trauma history).

Heart-Focused Anxiety Among Latinxs in Primary Care: Relations to Anxiety, Depression, Pain, and Functional Impairment

There is a public health need to better characterize the individual-based differences that may be involved in the expression and maintenance of psychological and related health problems among Latinx individuals. One individual difference factor that may be relevant to the nexus of psychological and physical concerns is heart-focused anxiety. The current study sought to evaluate the potential explanatory relevance of heart-focused anxiety as an important individual difference factor for anxiety, depression, pain experience, and functional impairment. Participants included 158 Latinx adults (Mage = 39.26, SD = 13.19; 85.4% female) from a primary health clinic. Results indicated that heart-focused anxiety was significantly related to anxious arousal, pain intensity, pain disability, and functional impairment. However, no significant effects were evident for depressive symptoms. These data indicate that heart-focused anxiety may be an underrecognized cognitive factor relevant to better understanding anxiety and pain among Latinx adults in primary care.

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

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.

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

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 self-identified "stress" or "anxiety" as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes.

Description of Unexplained Chest Pain and Its Influence on Daily Life In Men and Women

Background: Patients with unexplained chest pain have seldom organic pathology. Although both physical and psychological factors have been studied and suggested as causes of chest pain.

Aim: The aim was to describe the experience of unexplained chest pain and its influence on daily life situation in men and women.

Methods: Nine women and eleven men with unexplained chest pain, aged 31–62 years were interviewed. A qualitative descriptive design was used. The interviews were analyzed by content analysis focusing on experience by gender.

Results: The results embraced two domains descriptions and consequences of chest pain and daily life situation. Words like pressure, cramp, strong, or burning were used in the descriptions of the chest pain experienced with more similarities than variations between men and women. Physical, psychological and social consequences due to chest pain influenced daily life. The men specifically reported having a ‘fast tempo’ in their lives, with stress at work being seen as a feature experienced by both men and women.

Conclusions: This study shows that men and women had more similarities than variations in descriptions of chest pain. Their unexplained chest pain influenced their functions in daily life that led to, especially for the men, few contacts outside the family and therefore a weak social network.

Illness perceptions, negative emotions, and pain in patients with noncardiac chest pain

Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and pain-related life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development.

Attentional bias and anxiety in individuals with coronary heart disease

This study examined whether in an emotional Stroop task, individuals with coronary heart disease (CHD) would show greater attention towards the threatening words related to their disease than healthy persons, and if such an attentional bias is associated with anxiety. An emotional Stroop task with threatening words related to CHD as well as positive, negative and neutral words was administered to 35 individuals with CHD and 35 healthy controls. Additionally, the original Stroop task, the Beck anxiety inventory and the state-trait anxiety inventory were administered. The results indicated an attentional bias towards threatening words related to CHD in the individuals with CHD. They experienced higher interference than healthy participants from threatening words related to CHD but not from positive or negative words. Moreover, the level of interference was associated with their level of anxiety, and a vicious circle may exist in this association. In addition, results indicated a possible deficit of executive functioning among individuals with CHD. Attentional bias, as well as its association with anxiety, and an indication of deficit in executive functioning among individuals with CHD might be the risk factors for these individuals' quality of life and for further development of their disease.

Work values and job satisfaction

This study aimed to describe the effect of nursing profession work-related values on job satisfaction among a sample of Iranian nurses. We used in-depth interviews with 30 nurses who worked in university-affiliated and public hospitals in Tehran, Iran. The results of thematic analysis of interviews are reported in four themes to present the participants’ articulations in linking their work-related values to job satisfaction. The themes consist of values that “encourage tolerance,” “enhance inner harmony,” “reflect traditional commitment,” “enhance unity,” and are “centered around altruism and spiritual values.” The most satisfied participants considered nursing a divine profession and a tool by which they could gain spiritual pleasure and satisfaction. Our findings highlight the potential role of nursing work-related values in reducing dissatisfaction with one’s job. For the nursing profession, this may have implications in reducing job instability and turnover.

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.

A 1-year follow-up study of chest-pain patients with and without panic disorder

OBJECTIVE

The aims of this study were to (a) study the persistence of panic disorder (PD); (b) investigate the association between PD at baseline and outcome [chest pain, psychiatric morbidity, health care utilization, suicidal thoughts, work impairment and health-related quality of life (HRQOL)]; (c) study the course of pain, distress, symptom attribution and HRQOL; and (d) describe treatment and perceived treatment needs of patients with PD.

METHOD

A 1-year follow-up study of 199 chest-pain patients referred to cardiac outpatient investigation was completed. Assessments included Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID), Short-Form McGill Pain Questionnaire, Symptom Checklist-90-Revised, the Illness Attitude Scales, the 36-item Short-Form Health Survey and a chest-pain questionnaire.

RESULTS

At follow-up, 57 of the 153 patients reassessed with the SCID suffered from PD. Forty-three of the 55 patients (78%) who were diagnosed with PD at baseline still suffered from PD at follow-up. PD at baseline was associated with pain persistence, psychiatric morbidity (current major depression, pain disorder and simple phobia), significantly higher scores on psychological distress, hypochondriasis, negative outcome expectation, lower scores on seven of the eight dimensions of HRQOL and more general practitioner consultations. Only 6% of the patients with PD used effective treatment, and 3% reported a treatment need at follow-up.

CONCLUSION

Despite chronic distress and impairment, we found significant undertreatment of PD, which needs to be addressed in future studies.

Management of chest pain: exploring the views and experiences of chiropractors and medical practitioners in a focus group interview

BACKGROUND

We report on a multidisciplinary focus group project related to the appropriate care of chiropractic patients who present with chest pain. The prevalence and clinical management, both diagnosis and treatment, of musculoskeletal chest pain in ambulatory medical settings, was explored as the second dimension of the focus group project reported here.

METHODS

This project collected observational data from a multidisciplinary focus group composed of both chiropractic and medical professionals. The goals of the focus group were to explore the attitudes and experiences of medical and chiropractic clinicians regarding their patients with chest pain who receive care from both medical and chiropractic providers, to identify important clinical or research questions that may inform the development of 'best practices' for coordinating or managing care of chest pain patients between medical and chiropractic providers, to identify important clinical or research questions regarding the diagnosis and treatment of chest pain of musculoskeletal origin, to explore various methods that might be used to answer those questions, and to discuss the feasibility of conducting or coordinating a multidisciplinary research effort along this line of inquiry. The convenience-sample of five focus group participants included two chiropractors, two medical cardiologists, and one dual-degreed chiropractor/medical physician. The focus group was audiotaped and transcripts were prepared of the focus group interaction. Content analysis of the focus group transcripts were performed to identify key themes and concepts, using categories of narratives.

RESULTS

Six key themes emerged from the analysis of the focus group interaction, including issues surrounding (1) Diagnosis; (2) Treatment and prognosis; (3) Chest pain as a chronic, multifactorial, or comorbid condition; (4) Inter-professional coordination of care; (5) Best practices and standardization of care; and (6) Training and education.

CONCLUSION

This study carries implications for chiropractic clinical training relative to enhancing diagnostic competencies in chest pain, as well as the need to ascertain and improve those skills, competencies, and standards for referrals and sharing of clinical information that may improve cross-disciplinary coordination of care for chest pain patients.

Cardiac syndrome X

Cardiac syndrome X, the triad of angina pectoris, a positive exercise electrocardiogram for myocardial ischaemia and angiographically smooth coronary arteries, is frequently associated with debilitating symptomology, increased psychological morbidity and a poor quality of life. While various avenues of research have been undertaken, there are as yet no definitive conclusions regarding the exact pathogenesis of the condition. A number of physiological mechanisms have been explored, including the existence of underlying myocardial ischaemia, suggested endothelial dysfunction, abnormal pain perception, hormonal irregularities and insulin resistance, while the psychological impact of the condition has also been explored. Various treatment regimens have also been the subject of research with varying degrees of success. The heterogeneous nature of the patient population suggests that the mechanistic pathway may be multifactorial, while a comprehensive treatment regimen including both psychosocial and pharmacological interventions may offer the best outcome for patients with cardiac syndrome X.

A study of lifetime prevalence of anxiety and depressive disorders in patients presenting with chest pain to emergency medicine

We studied the prevalence of anxiety and depressive disorders in patients with chest pain presenting to an emergency department. Majority of the patients had coronary artery disease (CAD). Twenty-three percent of patients with chest pain had a diagnosable psychiatric disorder according to ICD-10 research criteria. Anxiety and depressive disorders were equally distributed among patients with concomitant psychiatric syndrome. The level of psychological distress as measured on hospital anxiety and depression scale in patients of CAD with comorbid psychiatric syndrome was significantly more than patients with CAD alone and similar to non-CAD patients with psychiatric disorder. This finding is in agreement with an earlier study suggesting that the psychological distress seen in patients with CAD is related to the comorbid psychiatric condition and not to CAD.

Heart-focused anxiety and chest pain in postangiography medical patients

The present cross-sectional study sought to examine the extent to which heart-focused anxiety is associated with the co-occurrence of coronary artery disease (CAD) and a history of regular smoking in a sample of 148 postangiography patients from a cardiology unit. Individuals with CAD who regularly smoked demonstrated significantly greater heart-focused attention, but no greater degree of avoidance and fear of heart-focused sensations, than did nonsmoking persons with CAD and smokers without CAD. We also found evidence that heart-focused attention and fear incrementally predicted (above and beyond demographic variables and body mass index) intensity of average chest pain. Overall, this study provides some of the first empirical evidence that the occurrence of regular smoking and CAD is associated with specific dimensions of health anxiety. We discuss these findings in relation to models of panic pathology and anxious responding to bodily sensations.

Differential fear of cardiopulmonary sensations in emergency room noncardiac chest pain patients

Fear of bodily sensations has received extensive attention in relation to panic disorder, and more recently, other types of anxiety pathology and chronic pain problems. Extending this work, the present study examined fear of bodily sensations and its underlying dimensions in emergency room patients with Noncardiac Chest Pain (NCCP; n = 63). We posited a "differential specificity" hypothesis, expecting that specific cardiopulmonary fears would be more strongly associated with NCCP symptoms relative to other bodily fears. As hypothesized, participants reported cardiopulmonary sensations as significantly more fear-provoking than numbness, dissociation, and gastrointestinal sensations. Additionally, regression analysis indicated that after accounting for theoretically relevant demographic variables and health status, cardiopulmonary fear was the best predictor of a composite index of cardiac complaints intensity, even after removing variance related to the absolute number of cardiac complaints. We discuss these findings in relation to the specific role for the fear of cardiopulmonary sensations in chest pain complaints, with implications for better understanding the underlying psychological processes involved in NCCP.

Panic disorder among Cambodian refugees attending a psychiatric clinic. Prevalence and subtypes

This study surveys Khmer refugees attending two psychiatric clinics to determine both the prevalence of panic disorder as well as panic attack subtypes in those suffering panic disorder. A culturally valid adaptation of the SCID-panic module, the Cambodian Panic Disorder Survey (CPDS), was administered to 89 consecutive Cambodian refugees attending these psychiatric clinics. Utilizing culturally sensitive panic probes, the CPDS provides information regarding both the presence of panic disorder and panic-attack subtypes during the month prior to interview. Of 89 patients surveyed at two psychiatric clinics, 53 (60%) currently suffered panic disorder. Among the 53 patients suffering panic disorder, the most common panic attack subtypes during the previous month were the following: "sore neck" [51% of the 53 panic disorder patients (PDPs)], orthostatic dizziness (49% of PDPs), gastrointestinal distress (26% of PDPs), effort induced (21% of PDPs), olfactory induced (21% of PDPs), and "while-sitting dizziness" (16% of PDPs).