Panic disorder and the heart: a cardiology perspective

Sex differences in patterns of referral and resource utilization in the cardiology clinic: an outpatient analysis

Aims

Women may have different management patterns than men in specialised care. Our aim was to assess potential sex differences in referral, management and outcomes of patients attending outpatient cardiac consultations.

Methods and results

Retrospective observational analysis of patients ≥18 years referred for the first time from primary care to a tertiary hospital cardiology clinic in 2017-2018, comparing reasons for referral, decisions and post-visit outcomes by sex.A total of 5,974 patients, 2,452 (41.0%) men aged 59.2 ± 18.6 years and 3,522 (59.0%) women aged 64.5 ± 17.9 years (P < 0.001) were referred for a first cardiology consultation. The age-related referral rates were higher in women. The most common reasons for consultation were palpitations in women (n = 676; 19.2%) and ECG abnormalities in men (n = 570; 23.2%). Delays to cardiology visits and additional tests were similar. During 24 months of follow-up, women had fewer cardiology hospitalisations (204; 5.8% vs. 229; 9.3%; P = 0.003) and lower mortality (65; 1.8% vs. 66; 2.7%; P = 0.028), but those aged <65 years had more emergency department visits (756; 48.5% vs. 560; 39.9%, P < 0.001) than men.

Conclusion

There are substantial sex differences in primary care cardiology referral patterns, including causes, rates, decisions and outcomes, which are only partially explained by age differences. Further research is needed to understand the reasons for these differences.

Cognitive-Behavioral Therapy for Panic Disorder in Patients with Stable Coronary Artery Disease: A Feasibility Study

Implementing cognitive-behavioral therapy (CBT), the first-line psychological treatment for panic disorder (PD), may be challenging in patients with comorbid coronary artery disease (CAD).This study aimed at assessing the feasibility and acceptability of a CBT for PD protocol that was adapted to patients suffering from comorbid CAD. It also aimed at evaluating the efficacy of the intervention to reduce PD symptomatology and psychological distress and improve quality of life. This was a single-case experimental design with pre-treatment, post-treatment and 6-month follow-up measures. Patients with PD and stable CAD received 14 to 17 individual, 1-h sessions of an adapted CBT for PD protocol. They completed interviews and questionnaires at pre-treatment, post-treatment and at a 6-month follow-up assessing intervention acceptability, PD symptomatology, psychological distress and quality of life. A total of 6 patients out of 7 completed the intervention and 6-month follow-up, indicating satisfactory feasibility. Acceptability was high (medians of ≥ 8.5 out of 9 and ≥ 80%) both at pre and post treatment. Remission rate was of 83% at post-treatment and 6-month follow-up. The intervention appeared to have positive effects on comorbid anxiety and depression symptoms and quality of life. The intervention appeared feasible and acceptable in patients with comorbid CAD. The effects of the adapted CBT protocol on PD symptoms, psychological distress and quality of life are promising and were maintained at the 6-month follow-up. Further studies should aim at replicating the present results in randomized-controlled trials

Palpitations: Evaluation and management by primary care practitioners

Palpitations are a common, non-specific presenting complaint in primary healthcare and emergency departments. Palpitations are mostly a symptom of benign underlying disease but a sign of life-threatening conditions. Importantly, palpitations are a symptom and not a diagnosis, and cardiac causes are the most concerning aetiology. Clinicians should seek to identify the underlying cause. History and physical examination are important in the assessment of patients with palpitations, and the use of a 12-lead electrographic (ECG) monitor on presentation is the gold standard of diagnosis. If the aetiology cannot be determined, an ambulatory Holter 24–48-h monitor can be used. Treatment and follow-up of patients presenting with palpitations as the main complaint will depend on the aetiology and investigation findings. Patients with palpitations accompanied by dizziness, excessive fatigue, or chest pains should receive adequate acute care aiming to stabilise their condition before referring to a higher level of care.

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study

Background

Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress.

Design/Method

This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files.

Discussion

This study will provide essential information on the prevalence and incidence of anxiety disorders in patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions.

Reliability, validity and cut-off score of the Chinese version of the panic disorder severity scale self-report form in patients with panic disorder

BACKGROUND

Panic disorder (PD) is often undiagnosed, misdiagnosed, or untreated in non-psychiatric clinical settings. Therefore, a cost-effective, accurate and easy-to-administer instrument for PD assessment is still needed. For that reason, the self-report version of the Panic Disorder Severity Scale (PDSS-SR) has been developed and suggested to be a reliable and useful tool in clinical and research settings. The current study aims to evaluate the reliability and validity of the Chinese version of the PDSS-SR and determine the cut-off score of the PDSS-SR.

METHODS

A total of 133 patients with PD in Shanghai were assessed by the PDSS-SR, PDSS and Hamilton Anxiety Rating Scale (HAMA). Moreover, 117 patients with non-PD anxiety and 51 healthy subjects also completed the PDSS-SR to construct a receiver operating characteristic (ROC) curve with the scores of PD patients.

RESULTS

The internal consistency (Cronbach's α) of the PDSS-SR was 0.72-0.80, and the interrater correlation coefficient was 0.78. The results of principal component analysis and varimax rotation indicated that the PDSS-SR had a two-factor structure, with all seven items having salient loadings. The cut-off score was 4, which was associated with high sensitivity (96.03%) and specificity (61.31%).

CONCLUSIONS

The findings demonstrate that these items and the total score of the PDSS-SR have acceptable reliability and validity in patients with PD and that the PDSS-SR can be used by general doctors for clinical screening in China.

Clinical Approach to Patients with Palpitations

Palpitations are among the most common symptoms that prompt patients to consult a physician. In the diagnostic workup of patients with palpitations, the initial evaluation involves history, physical examination, and 12-lead electrocardiogram. These investigations yield a prognostic stratification of the patients, and a definitive suspected diagnosis of the cause of symptoms in a good proportion of cases. When the initial evaluation results are negative and the patient is suffering from heart disease, or if the palpitations are frequent or poorly tolerated and with a high probability of an arrhythmic origin, ambulatory electrocardiogram monitoring and/or electrophysiological study should be undertaken.

Anxiety sensitivity in smokers with indicators of cardiovascular disease

There is growing recognition of the importance of understanding the nature of the associations between anxiety and cardiovascular disease (CVD), although limited research has examined mechanisms that may explain the anxiety-CVD link. Anxiety sensitivity (fear of anxiety-relevant somatic sensations) is a cognitive-affective risk factor implicated in the development of anxiety psychopathology and various behavioral risk factors for CVD, although has not been examined among individuals with CVD. Adult daily smokers (n = 619; 50.9% female; M_age = 44.0, SD = 13.67) completed an online survey that included the Anxiety Sensitivity Index-3 (ASI-3) and the Patient Health Questionnaire (PHQ). The presence of CVD was assessed via the presence of ≥1 of the following: heart attack, heart murmur, positive stress test, heart valve abnormality, angina, and heart failure. Smokers with CVD indicators (n = 66, 10.7%) had significantly higher scores on the ASI-3 (M = 33.5, SD = 22.15), relative to smokers without CVD (M = 22.0, SD = 17.92; Cohen's d = .57). Those with CVD were significantly more likely to have moderate or high anxiety sensitivity (66.7%) relative to those without CVD (49.4%). Physical and social concerns about the meaning of somatic sensations were common among smokers with CVD.

Investigation of anxiety levels of patients with chest pain admitted to emergency department

Introduction

We aimed to investigate the demographical features, anxiety levels and clinical findings of the patients admitted to our Emergency department (ED) due to chest pain.

Methods

Patients with chest pain older than 18 years were included into the study. Demographical features such as age, sex and education level, initial diagnosis in the ED, whether they were hospitalized or coronary intervention performed, were recorded. To determine the anxiety levels of the patients, State-trait Anxiety Inventory (STAI) was performed.

Results

Two-hundred and eight adult patients with chest pain were included into the study. We could not determine a relationship between STAI levels of patients according to demographical findings, however, STAI scores tended to decrease by age. Considering the education levels of the patients, it was determined that STAI scores of university graduates were higher than others. The STAI scores of patients discharged from the ED were higher than those hospitalized. When patients were compared according to whether coronary intervention (CI) was performed or not, it was determined that patients who did not require CI had higher STAI scores. When coronary lesion localization of the patients hospitalized was investigated, any relationship could not be determined.

Conclusion

In this study, we determined that anxiety levels of the patients with chest pain do not correlate with the severity of the disease. Higher anxiety levels of patients discharged from ED when compared to those with ACS is a challenging problem for both ED physicians and cardiologists.

Is there cardiac risk in panic disorder? An updated systematic review

BACKGROUND

The recognized relationship between panic disorder (PD) and cardiac disorders (CDs) is not unequivocal. We reviewed the association between PD and coronary artery disease (CAD), arrhythmias, cardiomyopathies, and sudden cardiac death.

METHODS

We undertook an updated systematic review, according to PRISMA guidelines. Relevant studies dating from January 1, 2000, to December 31, 2014, were identified using the PubMed database and a review of bibliographies. The psychiatric and cardiac diagnostic methodology used in each study was then to very selective inclusion criteria.

RESULTS

Of 3044 studies, 14 on CAD, 2 on cardiomyopathies, and 1 on arrhythmias were included. Overall, the studies supported a panic-CAD association. Furthermore, in some of the studies finding no association between current full-blown PD and CAD, a broader susceptibility to panic, manifesting as past PD, current agoraphobia, or subthreshold panic symptoms, appeared to be relevant to the development of CAD. Preliminary data indicated associations between panic, arrhythmias, and cardiomyopathies.

LIMITATIONS

The studies were largely cross-sectional and conducted in cardiological settings. Only a few included blind settings. The clinical conditions of patients with CDs and the qualifications of raters of psychiatric diagnoses were highly heterogeneous. CDs other than CAD had been insufficiently investigated.

CONCLUSIONS

Our review supported a relationship between PD and CDs. Given the available findings and the involvement of the cardiorespiratory system in the pathophysiology of PD, an in-depth investigation into the panic-CDs association is highly recommended. This should contribute to improved treatment and prevention of cardiac events and/or mortality, linked to PD.

Increased arterial stiffness parameters in panic disorder patients in long term treatment period

BACKGROUND

The relationship between mental stress and cardiovascular disease has been shown in several studies. Panic disorder (PD) is also associated with cardiovascular disease due to increased risk of myocardial infarction. The aim of this study is to evaluate the association between arterial stiffness parameters and depression/anxiety scores in patients with PD.

METHODS

The study population consisted of 25 patients with PD and 25 age-sex-matched healthy controls. Depression and anxiety levels were evaluated by Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), respectively. Determination of arterial stiffness parameters was conducted using a Mobil-O-Graph arteriograph system that detected signals from the brachial artery.

RESULTS

While baseline characteristics were similar between two groups, BDI and BAI scores were significantly higher in patients with PD (p < 0.005). The pulse wave velocity (PWV) and Augmentation Index (AIx) were also significantly higher in patients with PD (p = 0.001, p = 0.006). There was a moderate correlation between PWV and AIx with BAI scores (r = 0.442, p = 0.001, r = 0.441, p = 0.001). AIx was also positively correlated with BDI scores (r = 0.415, p = 0.03).

CONCLUSION

We demonstrated a significant relationship between arterial stiffness parameters and anxiety/depression scores in patients with PD who receive antidepressant treatment.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem which sometimes leads to excess use of medical care. Although many studies have examined the causes of pain in these patients, few clinical trials have evaluated treatment. This is an update of a Cochrane review originally published in 2005 and last updated in 2010. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To assess the effects of psychological interventions for chest pain, quality of life and psychological parameters in people with non-specific chest pain.

SEARCH METHODS

We searched the Cochrane Library (CENTRAL, Issue 4 of 12, 2014 and DARE Issue 2 of 4, 2014), MEDLINE (OVID, 1966 to April week 4 2014), EMBASE (OVID, 1980 to week 18 2014), CINAHL (EBSCO, 1982 to April 2014), PsycINFO (OVID, 1887 to April week 5 2014) and BIOSIS Previews (Web of Knowledge, 1969 to 2 May 2014). We also searched citation lists and contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed quality of studies. We contacted trial authors for further information about the included RCTs.

MAIN RESULTS

We included two new papers, one of which was an update of a previously included study. Therefore, a total of 17 RCTs with 1006 randomised participants met the inclusion criteria, with the one new study contributing an additional 113 participants. There was a significant reduction in reports of chest pain in the first three months following the intervention: random-effects relative risk = 0.70 (95% CI 0.53 to 0.92). This was maintained from three to nine months afterwards: relative risk 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain-free days up to three months following the intervention: mean difference (MD) 3.00 (95% CI 0.23 to 5.77). This was associated with reduced chest pain frequency (random-effects MD -2.26, 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects MD -0.81, 95% CI -2.35 to 0.74). There was no effect on severity (random-effects MD -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Due to the nature of the main interventions of interest, it was impossible to blind the therapists as to whether the participant was in the intervention or control arm. In addition, in three studies the blinding of participants was expressly forbidden by the local ethics committee because of issues in obtaining fully informed consent . For this reason, all studies had a high risk of performance bias. In addition, three studies were thought to have a high risk of outcome bias. In general, there was a low risk of bias in the other domains. However, there was high heterogeneity and caution is required in interpreting these results. The wide variability in secondary outcome measures made it difficult to integrate findings from studies.

AUTHORS' CONCLUSIONS

This Cochrane review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. However, these conclusions are limited by high heterogeneity in many of the results and low numbers of participants in individual studies. The evidence for other brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

The diagnostic significance of NT-proBNP and troponin I in emergency department patients presenting with palpitations

OBJECTIVE

This prospective study investigated the diagnostic significance of the N-terminal pro-brain natriuretic (NT-proBNP) and troponin I peptides in emergency department patients presenting with palpitations.

METHODS

Two groups of patients with palpitations but without documented supraventricular tachycardia were compared: a group with supraventricular tachycardia (n = 49) and a control group (n = 47). Both groups were diagnosed using electrophysiological studies during the study period. Blood samples were obtained from all of the patients to determine the NT-proBNP and troponin I levels within the first hour following arrival in the emergency department.

RESULT

The mean NT-proBNP levels were 207.74±197.11 in supraventricular tachyarrhythmia group and 39.99±32.83 pg/mL in control group (p<0.001). To predict supraventricular tachycardia, the optimum NT-proBNP threshold was 61.15 pg/mL, as defined by the receiver operating characteristic (ROC) curve, with a non-significant area under the ROC curve of 0.920 (95% CI, 0.86-0.97, p<0.001). The NT-proBNP cut-off for diagnosing supraventricular tachycardia had 81.6% sensitivity and 91.5% specificity. Supraventricular tachycardia was significantly more frequent in the patients with NT-proBNP levels ≥61.15 pg/mL (n = 44, 90.9%, p>0.001). The mean troponin I levels were 0.17±0.56 and 0.01±0.06 pg/mL for the patients with and without supraventricular tachycardia, respectively (p<0.05). Of the 96 patients, 21 (21.87%) had troponin I levels ≥0.01: 2 (4.25%) in the control group and 19 (38.77%) in the supraventricular tachycardia group (p<0.001).

CONCLUSION

Troponin I and, in particular, NT-proBNP peptide were helpful for differentiating supraventricular tachycardia from non- supraventricular tachycardia palpitations. Further randomized, large, multicenter trials are needed to define the benefit and diagnostic role of NT-proBNP and troponin I in the management algorithm of patients presenting with palpitations in emergency departments.

Increased pulse wave velocity in patients with panic disorder: independent vascular influence of panic disorder on arterial stiffness

OBJECTIVE

Acute and chronic mental stress and many psychiatric disorders have been accepted as a cause of cardiovascular disease. Panic disorder, a subtype of anxiety disorder, has been associated with increased risk of fatal myocardial infarction and sudden cardiac death in epidemiological studies. Carotid-femoral pulse wave velocity (CF-PWV) is currently the gold standard measurement of arterial stiffness. CF-PWV is a well-recognized predictor of an adverse cardiovascular outcome with higher predictive value than classical cardiovascular risk factors. The aim of our study is to measure PWV as the surrogate of arterial stiffness and vascular involvement in patients with panic disorder.

METHODS

Forty-two patients with PD, and 30 control participants were included in the study. Patients with hypertension, diabetes mellitus, or the history of any cardiovascular disease were excluded from study.

RESULTS

Baseline characteristics were not significantly different between the two groups, except carotid-femoral pulse wave velocity (PD vs. control; 7.51±2.02 vs. 6.24±1.09 m/s, p=0.001), heart rate, and smoking status. Additionally, CF-PWV positively correlated with age (r=0.250, p=0.034), heart rate (r=0.284, p=0.017), systolic and diastolic blood pressure (r=0.393, p=0.001 and r=0.286, p=0.015, respectively) significantly. However, only the presence of panic disorder was independently related to PWV (βeta: 0.317, p=0.011) in the multivariate analysis including age, heart rate, smoking status and blood pressure measurements.

CONCLUSION

Increased pulse wave velocity in patients with panic disorder may justify the associated risk as documented in previous studies, and may be useful in identifying the patients with higher risk of future cardiovascular complications.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To update the previously published systematic review.

SEARCH METHODS

We searched the Cochrane LIbrary (CENTRAL and DARE) (Issue 3 of 4 2011), MEDLINE (1966 to August Week 5, 2011), CINAHL (1982 to Sept 2011) EMBASE (1980 to Week 35 2011), PsycINFO (1887 to Sept Week 1, 2011), and Biological Abstracts (January 1980 to Sept 2011). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Six new RCTs were located and added to the existing trials, therefore, a total of 15 RCTs (803 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed-effect relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (random-effects mean difference = -2.26 95% CI -4.41 to -0.12) but there was no evidence of effect of treatment on chest pain frequency from three to twelve months (random-effects mean difference -0.81 95% CI -2.35, 0.74). There was no effect on severity (random-effects mean difference = -4.64 (95% CI -12.18 to 2.89) up to three months after the intervention. Overall there was generally a low risk of bias, however, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trials have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2008, Issue 4), MEDLINE (1966 to December 2008), CINAHL (1982 to December 2008) EMBASE (1980 to December 2008), PsycINFO (1887 to December 2008), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to December 2008). We also searched citation lists and approached authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Ten RCTs (484 participants) were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; mean difference = 2.81 (95% CI 1.28 to 4.34). This was associated with reduced chest pain frequency (mean difference = -1.73 (95% CI -2.21 to -1.26)) and severity (mean difference = -6.86 (95% CI -10.74 to -2.97)). However, there was high heterogeneity and caution is required in interpreting these results. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult to report on.

AUTHORS' CONCLUSIONS

This review suggests a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. Hypnotherapy is also a possible alternative. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

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.

Lack of a relationship between the pupillary light reflex response and state/trait anxiety in remitted patients with panic disorder

OBJECTIVE

Recently, some studies have indicated that pupillary function only correlates with state/trait anxiety in healthy subjects. In the present study, we examined whether or not there were relationships between the PLR functions and state/trait anxiety in remitted (the absence of panic attack (PA) symptoms for at least 6 months) PD patients compared to normal control (NC) subjects.

METHODS

Before and after audiovisual stimulation (AS) that induced mental stress through exposure to video images of high stress experiences, such as driving motor vehicles, the pupillary light reflex (PLR) was measured with an infrared pupillometer in 30 remitted PD patients and 30 age- and gender-matched NC subjects. In order to examine the relationships between the 8 PLR parameters (initial pupillary diameter in darkness, pupillary diameter at maximum constriction, constriction ratio, latency of the reflex, time to reach maximum constriction and time constant of redilation) and state/trait anxiety, we used the State-Trait Anxiety Inventory (STAI) and stepwise multiple regression analysis.

RESULTS

There was no significant group difference in the STAI-T score and STAI-S scores before and after AS. We confirmed the significant relationships between pupillary function and state/trait anxiety in NC subjects, but not in PD patients.

CONCLUSIONS

These findings suggest that in contrast to NCs, even remitted PD patients may have dysfunctional PLR regulation with mental loading, such as AS. Moreover, it is possible that the abnormalities of ANS exist extensively in PD, since almost all panic symptoms, including PA, are involved in cardiovascular symptoms, but not pupillary ones.

Panic symptoms at the interface of body and mind

Panic disorder is a common illness with significant impact on function and, at times, disabling consequences. Advances over recent years have yielded potential pathophysiologic mechanisms, including neurotransmitter systems and neural substrates. This article provides an overview of various models and hypotheses regarding the etiology of panic disorder. Because its symptoms overlap with the symptoms of various medical disorders, this discussion reviews the comorbidity of panic disorder with medical conditions, especially cardiac and respiratory disorders.

Psychosocial interventions for panic disorder after coronary artery bypass graft: a case study

It is increasingly recognized that patients with cardiovascular disease may also suffer from concurrent psychological problems. Many patients present to emergency services and cardiologists with a history of panic disorder. Because of the similarity of presenting symptoms, these patients are often undiagnosed and consequently have slower recovery times and are costly to the healthcare system. Panic disorder is a significant public health problem; however, it is a treatable condition. Healthcare providers should be aware of its occurrence in cardiovascular disease. This case study describes the use of psychosocial interventions, such as the cognitive behavior therapy, in the management of panic disorder after coronary artery bypass graft. A 64-year-old man was treated with 9 sessions of cognitive behavior therapy over a 5-month period. Baseline assessment showed significant distress and deficit in functioning. Following intervention, there was marked reduction in objective and subjective measurement of distress and overall improvement in functioning. Healthcare providers, particularly nurses, need to consider the integration of psychosocial interventions into areas of critical care to provide effective and holistic care. Preoperative screening would be helpful as well.

Dysfunctional baroreflex regulation of sympathetic nerve activity in remitted patients with panic disorder. A new methodological approach

BACKGROUND

Many researchers have studied the abnormalities of autonomic nervous system (ANS) such as decreased heart rate variability, which is a risk factor for sudden cardiac death, in patients with panic disorder (PD). However, no consistent abnormality has been uncovered to date. One of the reasons for this controversy may be due to the fact that most of these conventional studies have analyzed each physiological variable independent of other indices. We examined the ANS in PD patients using a new method which can more directly investigate the function of the baroreflex by examining the relation between the blood pressure (BP) and heart rate (HR).

METHODS

During rest and audiovisual stimulation (AS) as mental stress such as being exposed to video imaginary of experiences such as driving motor vehicles, cardiovascular parameters, HR and BP were consecutively measured in 13 remitted PD patients and twenty aged and gender-matched normal controls (NC). In this study, to assess the cardiovascular ANS function (baroreflex) in PD we used the power spectrum analysis as usual and the mean of lag time (tau) between the Mayer wave components, which was closely related to sympathetic nerve activity of vasomotor, of HR and BP variability as a new trial.

RESULTS

The PD patients and NC did not differ with regard to the power spectrum analysis of the heart rate. We found that tau in the PD group was significantly shorter than that in the NC both before and after AS, especially before.

CONCLUSIONS

These findings suggest that remitted PD patients may have a dysfunctional baroreflex regulation of sympathetic nerve activity.

Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy

BACKGROUND

Recurrent chest pain in the absence of coronary artery disease is a common problem that sometimes leads to excess use of medical care. Although many studies examine the causes of pain in these patients, few clinical trails have evaluated treatment. The studies reviewed in this paper provide an insight into the effectiveness of psychological interventions for this group of patients.

OBJECTIVES

To investigate psychological treatments for non-specific chest pain (NSCP) with normal coronary anatomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2002, Issue 3), MEDLINE (1966 to 2002), CINAHL (1982 to 2002) EMBASE (1980 to 2002), PSYCH Info (1887 to 2002), the Database of Abstracts of Reviews of Effectiveness (DARE) and Biological Abstracts (January 1980 to 2002). We also searched citation lists and approached authors.

SELECTION CRITERIA

RCTs with standardised outcome methodology that tested any form of psychotherapy for chest pain with normal anatomy. Diagnoses included non-specific chest pain, atypical chest pain, syndrome X, or chest pain with normal coronary anatomy (as either inpatients or outpatients).

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data and assessed quality of studies. The authors contacted trial authors for further information about the RCTs included.

MAIN RESULTS

Eight studies involving 403 randomised participants were included. There was a significant reduction in reports of chest pain in the first three months following the intervention; fixed effects relative risk = 0.68 (95% CI 0.57 to 0.81). This was maintained from 3 to 9 months afterwards; relative risk = 0.58 (95% CI 0.45 to 0.76). There was also a significant increase in the number of chest pain free days up to three months following the intervention; the standardized mean difference = 0.85 (95% CI 0.38 to 1.31). However, there was high heterogeneity for this test. Wide variability in outcome measures made integration of studies for secondary outcome measures difficult.

AUTHORS' CONCLUSIONS

Review suggested a modest to moderate benefit for psychological interventions, particularly those using a cognitive-behavioural framework, which was largely restricted to the first three months after the intervention. The evidence for brief interventions was less clear. Further RCTs of psychological interventions for NSCP with follow-up periods of at least 12 months are needed.

Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain

Research suggests that anxiety sensitivity may be an important component in the negative response to pain sensations, especially those with cardiopulmonary origin. Furthermore, there is experimental evidence to suggest that such effects may be stronger in women than men. The primary aim of the current investigation was to determine the relative roles that anxiety sensitivity and gender have on the pain reports of patients referred to a hospital clinic with chest pain. A total of 78 female and 76 male adults were recruited on entry to a Rapid Access Medical Clinic. All patients had been referred with chest pain, and were administered a range of pain and anxiety measures prior to diagnosis. Results indicate that males were more likely to receive a diagnosis of cardiac chest pain, whereas females were more likely to receive a diagnosis of non-cardiac chest pain. Additionally, anxiety sensitivity was related to pain in women but not men. Finally, evidence was found for the mediating effect of negative interpretative bias on the relationship between anxiety sensitivity and pain. However, this mediating effect was only found in women. These results not only confirm that anxiety sensitivity is related to greater negative pain responses in women, but that this may be due to an increased tendency to negatively interpret sensations.

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.

Pupillary light reflex in panic disorder. A trial using audiovisual stimulation

BACKGROUND

Although many previous studies reported abnormalities of autonomic function in patients with panic disorder (PD), almost all targets in those studies primarily focused on cardiovascular autonomic functions. In the present study, we determined whether PD patients exhibited abnormalities in the pupillary autonomic nervous system (ANS).

METHODS

Before and after audiovisual stimulation (AS), which induced mental stress through exposure to video images of high stress experiences, such as driving motor vehicles, the pupillary light reflex (PLR) was measured by infrared pupillometer in 13 remitted PD patients and twenty age- and gender-matched normal controls (NC).

RESULTS

Before and after AS, there were no significant differences in initial pupillary diameters in dark conditions (D1), pupillary diameters at maximum constriction (D2) or constriction ratios (CR: (D1-D2)/D1) between PD and NC subjects. However, the CR ratio (CR before/CR after) was significantly higher in the PD group than in the NC.

CONCLUSIONS

These findings suggest that even remitted PD patients may have a dysfunctional PLR regulation with experimental stressors such as AS.

Autonomic Dysfunctions in Patients with Anxiety Throughout Therapy

Abstract Patterns of autonomic cardiovascular regulation were studied in patients with anxiety throughout the course of an intensive inpatient rehabilitation therapy at rest, and in response to an anxiety provocation, in order to measure reactivity changes. Patients had to meet the ICD-10 criteria: F40.0 (agoraphobia), F40.00 (agoraphobia without panic attacks), F40.01 (agoraphobia with panic attacks), or F41 (panic disorder). Thirty-eight patients (13 males, 25 females) were examined after recruitment (T1) and at the end of treatment (T2). Each laboratory session consisted of a resting baseline (5min) and two stress tests of 8min (presentation of word pairs with either neutral or with anxiety-related content). A continuous assessment of ECG, blood pressure, breathing pattern, and thoracic impedance allowed the calculation of heart rate variability (power spectra), baroreflex sensitivity, stroke volume, vascular compliance, and total peripheral resistance. In general, therapy had little impact on the parameters of autonomic cardiovascular regulation, neither on resting level nor on reactivity. Diminished baroreflex sensitivity values in our patients with anxiety were observed; in particular, 15% of the patients had values below 3ms/mmHg, which indicates an increased risk for cardiovascular mortality. Low baroreflex sensitivity in this group goes along with further changes within the cardiovascular system (higher heart rate, diminished heart rate variability, lower stroke volume, higher vascular compliance). This general effect describes altered sympathetic/parasympathetic balance and may be the consequence of illness-related changes in behavior. Our results suggest that a careful cardiovascular examination of patients with anxiety will detect patients with clinically significant cardiovascular alterations. This might lead to a more complex intervention in these patients including, for example, exercise training.

Correlates of therapeutic response in panic disorder presenting with palpitations: heart rate variability, sleep, and placebo effect

OBJECTIVE

To examine the correlates of therapeutic response of patients with panic disorder presenting with palpitations, we hypothesized that therapeutic response would correlate with heart rate variability (HRV) and sleep measures.

METHODS

After a 1-week placebo washout, 27 patients free of structural heart disease and not on cardioactive drugs were randomized in a double-blinded fashion to 4 weeks of treatment with clonazepam (a known antipanic agent) or placebo. We performed standard sleep measures and recorded HRV from 24-hour Holter acquisitions at baseline and end of study. We defined response to therapy as a 50% improvement in the Hamilton Anxiety Rating Scale (HARS) score, confirmed by questionnaires and reaction to sodium lactate infusion.

RESULTS

There were 12 responders and 15 nonresponders. Normalization of sleep pattern (including less stage 1 and rapid eye movement [REM] sleep) was observed in both drug and placebo responders (P = 0.011 and P = 0.05, respectively) and in placebo responders alone, compared with nonresponders (P = 0.006 and P = 0.013, respectively). Placebo responders were more likely to show less depression, but even after we controlled for depression, main sleep effects remained. None of the HRV measures correlated with response, but compared with placebo, clonazepam led to a decrease in all the time and frequency domain measures of HRV (all P < 0.05).

CONCLUSIONS

Central mechanisms are related to the therapeutic response of patients with panic disorder presenting with palpitations, but this does not directly correlate with HRV. Larger and longer studies may allow objective explanations of placebo response in panic disorder.