Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department

Bodily sensations and quality of life in adolescents with non-cardiac chest pain: a comparative study for the undetermined part of a frequent health problem

BACKGROUND

Chest pain in adolescents represents a considerable burden for health services and is rarely associated with cardiac disease. Since chest pain could be related to psychosocial factors there is a need for exploring the relationships among stressful situations, drug consumption, suicidal behaviors, accompanying bodily symptoms and health-related quality of life in adolescents with non-cardiac chest pain.

METHODS

In this study, we assessed these determinants in 108 adolescents with non-cardiac chest pain (NCCP) and a control group of 77 patients using a structured interview applied to the patients presented to the cardiology outpatient clinics of Tepecik Training and Research Hospital, İzmir, Türkiye, between 30 October 2018 and 30 June 2019. After the interview, the adolescents were given a self-administered pediatric quality of life inventory and the body sensations questionnaire for assessing aspects of fear.

RESULTS

Adolescents with NCCP expressed more panic associated bodily symptoms and reported worse subjective physical, academic, and emotional functioning in addition to more suicidal ideation.

CONCLUSIONS

NCCP could be accepted as a warning sign of an underlying psychosocial problem and requires a more interdisciplinary collaborative care by pediatricians, psychologists, and psychiatrists.

Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study

Background/Aims

Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population.

Methods

Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed.

Results

Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis.

Conclusions

The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.

Patients with depression symptoms are more likely to experience improvements of internet-based cognitive behavioral therapy: a secondary analysis of effect modifiers in patients with non-cardiac chest pain in a randomized controlled trial

BACKGROUND

Non-cardiac chest pain is common and associated with increased anxiety and reduced health-related quality of life. Randomized controlled trials on psychological interventions for patients with non-cardiac chest pain have reported mixed results. Patients with non-cardiac chest pain are a heterogeneous group. Identifying sub-groups that could potentially benefit more (or less) from an intervention would be valuable knowledge. We have conducted a randomized controlled trial where internet-based cognitive behavioural therapy (iCBT) had effect on reducing cardiac anxiety and increasing health-related quality of life at 12-month follow-up. The aim of the present study was to explore potential effect modifiers of iCBT in patients with non-cardiac chest pain on cardiac anxiety and/or health related quality of life at 12-month follow-up.

METHODS

We analysed data from our randomized, controlled trial where 161 patients with non-cardiac chest pain were included and randomized to either iCBT or a treatment as usual (control). Cardiac anxiety measured by the Cardiac Anxiety Questionnaire and health-related quality of life measured by the EuroQol Visual Analog Scale at 12 month follow-up were the primary outcomes. Four potential baseline characteristics where identified as potential effect modifiers by a theory-based approach: (1) depression measured by the Patient Health Questionnaire; (2) anxiety measured by the Body Sensations Questionnaire; (3) prior healthcare contacts measured by a self-developed question; and (4) chest pain frequency measured by a self-developed question. Each potential effect modifier was analysed in a linear regression model where cardiac anxiety and EQ-VAS scores at 12-month follow-up, separately, were used as dependent variables. The potential differential treatment effect for each effect modifier was assessed by the interaction term: effect modifier x treatment group.

RESULTS

Depression symptoms at baseline predicted a differential treatment effect at 12-month follow-up on health-related quality of life in favor of the iCBT group (regression coefficient of the interaction term: -1.85 (CI -3.28 to -0.41), p = 0.01), but not on cardiac anxiety at 12-month follow-up. Fear of bodily symptoms, chest pain frequency and prior health care contacts at baseline did not predict a treatment effect on either health-related quality of life or cardiac anxiety.

CONCLUSIONS

Depression symptoms at baseline predicted a positive treatment effect of iCBT on health-related quality of life in patients suffering from non-cardiac chest pain. This indicates that it is important to identify patients with non-cardiac chest pain and co-occurring depression symptoms given that they are particularly likely to benefit from iCBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03096925 .

The association between socioeconomic status and health-related quality of life among young and middle-aged maintenance hemodialysis patients: multiple mediation modeling

Objective

To explore the relationship between socioeconomic status (SES), illness perception, social functioning, and health-related quality of life (HRQoL) of young and middle-aged maintenance hemodialysis (MHD) patients and the internal mechanism of action.

Design

A multicenter cross-sectional study.

Methods

An aggregate of 332 young and middle-aged MHD patients were enrolled from hemodialysis centers in four general hospitals in Guangzhou, Guangdong, China, from June to December 2022. The questionnaires used included one for general demographic data, the Brief Illness Perception Questionnaire (BIPQ), Social Dysfunction Screening Scale (SDSS), and the 12-item Short Form Health Survey (SF-12).

Results

Both SES and HRQoL were negatively correlated with illness perception and social functioning, respectively. SES was positively correlated with HRQoL. Illness perception was positively correlated with social functioning. The indirect effects of illness perception and social functioning on the relationship between SES and HRQoL were 0.33 and 0.31, making up 41.06% and 38.91% of the sum. The chain indirect effect of illness perception and social functioning was 0.10, making up 12.59% of the total effect, while gender did not play a moderating role.

Conclusion

Illness perception and social functioning may independently and accumulatively mediate the association between SES and HRQoL. Nurses should consider developing individual intervention program for young and middle-aged MHD patients with low SES, focusing on establishing targeted counseling and health education strategies corresponding to illness perception and social functioning to help patients improve their HRQoL.

Depression and anxiety mediate the relationship between illness representations and perceived distress in patients with chronic pain

Illness representations explain the individual's perception and processing of health-related information. In a chronic condition such as persistent pain, illness representations might influence treatment adherence and outcome. This study aims to exploratively identify illness representations of patients with chronic pain and their association to mental disorders and subjective distress. 95 participants admitted to an inpatient university clinic were included. Validated instruments were used to assess illness representations (IPQ-R), mental health disorders (PHQ-D), and subjective distress (PSQ). Sociodemographic data and scores for the instruments were first inspected descriptively. Correlation, regression, and mediator analyses were conducted. Analyses indicated that the distributions of the IPQ-R range toward higher values. In regard to mental disorders (PHQ-D) and subjective distress (PSQ), we found several significant correlations with subscales of the IPQ-R. A regression analysis showed the IPQ-R subscales personal control, emotional representation and sex (males) to be significant predictors of subjective distress measured with the PSQ (F(11,86) = 11.55, p < .001, adjusted R2 = 0.545). Depression, anxiety, and stress syndromes (PHQ-D) significantly mediated the positive association between emotional representations (IPQ-R, predictor) and subjective distress (PSQ, outcome) with a total effect of c = .005, 95% CI [.005; .129]. Illness representations play a significant role in evaluating patients' subjective distress and mental health. It is advised to incorporate illness representations into standard protocols for psychological interventions to comprehend their influence on targeted therapeutic strategies, particularly those tailored for pain management.

Non-Cardiac Chest Pain as a Persistent Physical Symptom: Psychological Distress and Workability

Non-Cardiac Chest Pain (NCCP) is persistent chest pain in the absence of identifiable cardiac pathology. Some NCCP cases meet criteria for Persistent Physical Symptoms (PPS), where the symptoms are both persistent and distressing/disabling. This study aimed to identify patients that might need specialist treatment for PPS by examining cases of NCCP that meet PPS criteria. We analysed data from 285 chest pain patients that had received an NCCP diagnosis after attending an emergency cardiac department. We compared NCCP patients who did and did not meet the additional criteria for heart-related PPS and hypothesised that the groups would differ in terms of psychological variables and workability. We determined that NCCP patients who meet PPS criteria were more likely than other NCCP patients to be inactive or unable to work, reported more general anxiety and anxiety about their health, were more depressed, ruminated more, and, importantly, had a higher number of other PPS. A high proportion of NCCP patients meet PPS criteria, and they are similar to other PPS patients in terms of comorbidity and disability. This highlights the importance of focusing psychological interventions for this subgroup on the interplay between the range of physical and psychological symptoms present.

Diagnostic Value of Bone SPECT/CT Using 99mTc-Methylene Diphosphonate in Patients with Unspecified Chest Wall Pain

PURPOSE

We investigated the diagnostic performance of single photon emission computed tomography (SPECT)/computed tomography (CT) as a combination of functional and anatomic imaging, in patients with unspecified chest wall pain.

METHODS

Fifty-two patients with unspecified chest wall pain and no history of recent major traumatic events or cardiac disease were included. The number and location of radioactive chest wall lesions were evaluated on both planar images and SPECT/CT. The clinical diagnosis was made based on all of the clinical and imaging data and follow-up information.

RESULTS

Chest wall diseases were diagnosed in 42 patients (80.8 %). SPECT/CT showed abnormal findings in 35 (67.3 %) patients with positive predictive value (PPV) of 97.1 %. SPECT/CT revealed 56 % more lesions than planar bone scan (P = 0.002) and most of the abnormal radioactive lesions (94.6 %) showed combined morphological changes on the matched CT component. When comparing between age subgroups (< 60 y vs. ≥ 60 y), the prevalence of chest wall disease and diagnosis rate of fracture was significantly higher in the older age group. On SPECT/CT, the older age group showed higher frequency of having abnormal finding (95.8 % vs. 42.9 %, P < 0.001) and significantly more lesions were detected (a total of 189 vs. 32, P = 0.003).

CONCLUSION

SPECT/CT showed good diagnostic performance and proved to have higher sensitivity, detecting 56 % more lesions than planar bone scan. A negative result could be helpful for excluding pathologic chest wall disease. SPECT/CT might be recommended for integration in to the diagnostic workup in patients with unspecified chest wall pain, especially in patients ≥ 60 y of age, considering the high disease prevalence and the high frequency of positive results.

The associations between psychological distress and health-related quality of life in patients with non-cardiac chest pain

Background

Recurrent chest pain episodes with no clear explanation may affect patients’ psychological wellbeing and health-related quality of life (HRQoL) negatively. Despite the fact that a significant amount of patients with non-cardiac chest pain (NCCP) might have a history of Cardiac Disease (CD), there is today a lack of knowledge on how CD influences the association between psychological wellbeing and HRQoL in patients with NCCP. Therefore, the aim of this study is to describe HRQoL in patients with NCCP, with or without history of CD, and to explore the association between HRQoL and cardiac anxiety, depressive symptoms, fear of body sensations and somatization.

Methods

Five hundred fifty-two patients discharged with NCCP from four hospitals in Southeast Sweden completed the EQ-5D, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9, Body Sensations Questionnaire, and Patient Health Questionnaire-15.

Results

Fifty precent reported at least moderate problems regarding pain/discomfort and 25% reported at least moderate problems in the HRQoL dimensions mobility, usual activities, and anxiety/depression. Patients with NCCP and history of CD reported significantly lower HRQoL (p ≤ 0.05) compared to patients with NCCP without CD. In the total study population, cardiac anxiety, depressive symptoms, and somatization had weak significant negative associations (beta = 0.187–0.284, p < 0.001) with HRQoL. In patients with history of CD, the association between depressive symptoms and HRQoL was moderate (beta = − 0.339, p < 0.001), compared to weak association in patients without CD (beta = − 0.193, p < 0.001). On the other hand, the association between cardiac anxiety and HRQoL was weak in both patients with history of CD (beta = − 0.156, p = 0.05), and in those without (beta = − 0.229, p < 0.001).

Conclusions

Patients with NCCP, in particular those with history of CD, reported low levels of HRQoL, which was associated with psychological distress. This should be considered when developing psychological interventions aiming to improve HRQoL in patients with NCCP.

Psychological and psychopathological sequelae in cardiovascular acute disease

The burden of mental illness is profound and growing. Each year, almost one in three adults in the non-institutionalized community has a diagnosable mental or addictive disorder, and this figure climbs to approximately 40% among emergency departments patients. We described the principal cardiovascular acute disease and their emotional and behavioral consequences where psychological intervention could improve the care pathway and clinical outcome. Peer-reviewed articles from Medline, Psycinfo, Web of Science, Scopus, and Cochrane library, about psychological and psychopathological sequelae in cardiovascular acute disease were searched. The psychological and psychopathological sequelae associated to stroke include emotional and behavioral changes and cognitive impairment. Fear, symptoms of depression, anxiety or specific post-traumatic symptoms like intrusions, hyper-arousal and/or cognitive avoidance are common in people suffering of cardiovascular acute disease treated at emergency departments. In emergency departments, health personnel must recognize psychological and psychopathological sequelae in cardiovascular acute disease in order to develop effective interventions for these patients. Identify factors that are associated with both psychological distress and physical distress and promote interventions aimed at reducing psychological distress and improving psychological health empowerment is an important element to consider in order to offer the best care to vulnerable population as that suffering of cardiovascular acute disease.

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.

Chest Pain: If It Is Not the Heart, What Is It?

Noncardiac chest pain is an angina-type discomfort without indication of ischemia. Diagnosis can be difficult because of its heterogeneous nature. Classification varies by specialty; gastroenterology uses the terminology gastroesophageal reflux disease related versus non-gastroesophageal reflux disease related. Other disciplines recognize noncardiac chest pain etiologies as having gastrointestinal, musculoskeletal, psychiatric, or pulmonary/other as underlying etiologies. Diagnostics yield a specific cause for effective treatment, which is aimed at the underlying etiology, but it is not always possible. Some patients with noncardiac chest pain have comorbidities and ongoing pain that lead to decreased quality of life and continued health care use.

Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain

Background

Approximately 80% of patients presenting to emergency departments (ED) with chest pain do not have any true cardiopulmonary emergency such as acute coronary syndrome (ACS). However, psychological contributors such as anxiety are thought to be present in up to 58%, but often remain undiagnosed leading to chronic chest pain and ED recidivism.

Methods

To evaluate ED provider beliefs and their usual practices regarding the approach and disposition of patients with low risk chest pain associated with anxiety, we constructed a 22-item survey using a modified Delphi technique. The survey was administered to a convenience sample of ED providers attending the 2016 American College of Emergency Physicians Scientific Assembly in Las Vegas.

Results

Surveys were completed by 409 emergency medicine providers from 46 states and 7 countries with a wide range of years of experience and primary practice environment (academic versus community centers). Respondents estimated that 30% of patients presenting to the ED with chest pain thought to be low risk for ACS have anxiety or panic as the primary cause but they directly communicate this belief to only 42% of these patients and provide discharge instructions to 48%. Only 39% of respondents reported adequate hospital resources to ensure follow-up. Community-based providers reported more adequate follow-up for these patients than their academic center colleagues (46% vs. 34%; p = 0.015). Most providers (82%) indicated that they wanted to have referral resources available to a specific clinic for further outpatient evaluation.

Conclusion

Emergency Department providers believe approximately 30% of patients seeking emergency care for chest pain at low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety. This highlights an opportunity for patient centered communication.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0161-x) contains supplementary material, which is available to authorized users.

The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study

BACKGROUND

Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.

METHODS

This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.

RESULTS

The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.

CONCLUSIONS

There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).

Evaluation of the Effectiveness of a Phone Based Care Coordination Pilot on Hospital Utilisation and Costs for Patients With Chest Pain

BACKGROUND

A small percentage of the population represents a disproportionate number of attendances at emergency departments (ED). "Frequent presenters" to ED with chest pain do not always fit into established pathways for acute myocardial events. With accelerated "rule out" protocols, patients are often discharged from the ED after short lengths of stay. This research will evaluate the effectiveness of a phone based care-coordination pilot designed to meet the needs of patients attending ED with cardiac and non-cardiac chest pain.

METHODS

A longitudinal, single-arm interventional study with retrospectively recruited control group. Ninety-five patients were enrolled as the intervention group; 97 patients were retrospectively identified as controls. These patients had re-presented with chest pain within 6 months of a cardiac event, or attended hospital within 12 months two or more times with chest pain and/or complex needs. Intervention group patients were holistically assessed then phone-coached to support self-management of chest pain over 6 months. Following descriptive and univariate analysis, multivariate analysis was conducted to adjust for noted differences between the intervention and control groups.

RESULTS

Thirty-day representation to ED was significantly less for the intervention group (14.1%) compared to controls (27.7%). After adjusting for baseline differences, intervention patients were more than two-fold less likely to re-present compared to controls (OR=0.42, 95%CI: 0.19-0.96). After adjustment for baseline differences, the savings in subsequent inpatient costs was $1588 per person, as a result of intervention, patients were less likely to have inpatient readmissions (16.3%) compared to controls (20.2%), although this was not statistically significant (p=0.588).

CONCLUSION

A phone based care-coordination pilot with targeted interventions has the potential to reduce ED presentations and hospital readmissions among patients representing with chest pain.

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

BACKGROUND

Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers.

METHODS

We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP.

RESULTS

We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions.

CONCLUSIONS

Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

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.

Depression masquerading as chest pain in a patient with Wolff Parkinson White syndrome

Wolff Parkinson White (WPW) syndrome is a condition in which there is an aberrant conduction pathway between the atria and ventricles, resulting in tachycardia. A 42-year-old patient, who was treated for WPW syndrome previously, presented with chronic somatic pain. With her cardiac condition in mind, she was thoroughly worked up for a recurrence of disease. As part of routine screening of all patients at our pain clinic, she was found to have severe depression as per the Patient Health Questionnaire–9 (PHQ–9) criteria. After ruling out sinister causes, she was treated for depression using oral Duloxetine and counselling. This led to resolution of symptoms, and improved her mood and functional capability. This case highlights the use of psychological screening tools and diligent examination in scenarios as confusing as the one presented here. Addressing the psychological aspects of pain and adopting a holistic approach are as important as treatment of the primary pathology.

The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain

Despite good physical prognosis, patients who receive a diagnosis of non-cardiac chest pain (NCCP) may experience persistent pain and distress. While cognitive-behavioural interventions have been found to be effective for this group, they are difficult to deliver in busy emergency department (ED) settings. Addressing the acceptability and relevance of self-help interventions is an important initial step in addressing this need. This study sought to examine the acceptability and relevance of an evidence-based self-help intervention for ED patients with persistent NCCP and anxiety. Patient (interviews: N = 11) and specialist chest pain nurse (focus group: N = 4) views on acceptability and feasibility were examined. Data were analysed using thematic analysis. Patients and nurses reported that there was a need for the intervention, as stress and anxiety are common among patients with NCCP, and provision of psychosocial support is currently lacking. Both patients and nurses reported that the intervention was relevant, acceptable, and potentially useful. Some changes to the intervention were suggested. Nurses reported that the intervention could be used within the existing staff resources available in an ED setting. This study represents an important first step towards developing a brief self-help intervention for ED patients with NCCP and anxiety. Further research should seek to determine the efficacy of the intervention in a pilot trial.

Psychological distress in medical patients seeking ED care for somatic reasons: results of a systematic literature review

OBJECTIVES

The aim of this systematic literature review is to investigate (A) currently used instruments for assessing psychological distress, (B) the prevalence of psychological distress in medical emergency department (ED) patients with acute somatic conditions and (C) empirical evidence on how predictors are associated with psychological distress.

METHODS

We conducted an electronic literature search using three databases to identify studies that used validated instruments for detection of psychological distress in adult patients presented to the ED with somatic (non-psychiatric) complaints. From a total of 1688 potential articles, 18 studies were selected for in-depth review.

RESULTS

A total of 13 instruments have been applied for assessment of distress including screening questionnaires and briefly structured clinical interviews. Using these instruments, the prevalence of psychological distress detected in medical ED patients was between 4% and 47%. Psychological distress in general and particularly depression and anxiety have been found to be associated with demographic factors (eg, female gender, middle age) and illness-related variables (eg, urgency of triage category). Some studies reported that coexisting psychological distress of medical patients identified in the ED was associated with physical and psychological health status after ED discharge. Importantly, during routine clinical care, only few patients with psychological distress were diagnosed by their treating physicians.

CONCLUSIONS

There is strong evidence that psychological distress is an important and prevalent cofactor in medically ill patients presenting to the ED with harmful associations with (subjective) health outcomes. To prove causality, future research should investigate whether screening and lowering psychological distress with specific interventions would result in better patient outcomes.

Chest pain syndromes are associated with high rates of recidivism and costs in young United States Veterans

Background

Recurrent chest pain is common in patients with and without coronary artery disease. The prevalence and burden of these symptoms on healthcare is unknown.

Objectives

To compare chest pain return visits (recidivism) in patients with unexplained chest pain (UCP) against reference group of patients with coronary artery disease (CAD) and estimate the annual cost of recurrent chest pain.

Methods

In a retrospective cohort study, a Veteran Affairs (VA) administrative and clinical database of Veterans who were deployed to or served in support of the wars in Iraq or Afghanistan was queried for first disease specific ICD-9 code to form two cohorts (UCP or CAD). Patients were followed between 09/2001-09/2010 for the first and cumulative return visits for UCP or cardiac pain (ACS or angina) to clinic, emergency department or admission; or for all-cause death. Time to return was analyzed using Cox regression and negative binomial models and adjusted for age, gender, race, marital status, and risk factors (hypertension, hyperlipidemia, diabetes, smoking and obesity). Direct total costs included inpatient, outpatient and fee basis (non-VA) costs.

Results

Of 749,036 patients, 20,521 had UCP and 5303 had CAD. UCP patients were young and had a lower burden of risk factors than CAD cohort (p < .01). Yet, these patients were likely to return earlier with any chest pain (adjusted Hazard Ratio [aHR] = 1.76; 95 % CI 1.65-1.88); or unexplained chest pain than CAD patients (aHR: 1.89; 95 % CI 1.77-2.01). UCP patients were also likely to return more frequently for any chest pain (aRate Ratio = 1.54; 95 % CI 1.43-1.64) or UCP than CAD patients (aRR =2.63; 95 % CI 2.43-2.87). Per 100 patients, the 1-year cumulative returns were 37 visits for reference group and 45 visits for UCP cohort. The annual costs for chest pain averaged $69,009 for CAD and $57,336 for UCP patients (log geometric mean ratio=1.25; 95 % CI 1.18-1.32).

Conclusion

Chest pain recidivism is common and costly even in patients without known CAD. We need evidence-based guidelines for these patients to minimize returns.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0287-9) contains supplementary material, which is available to authorized users.

'Everything's fine, so why does it happen?' A qualitative investigation of patients' perceptions of noncardiac chest pain

Aims and objectives

To examine patients' perceptions and experiences of noncardiac chest pain, within the framework of the common sense model.

Background

Patients with noncardiac chest pain have good physical prognosis, but frequently suffer prolonged pain and psychological distress. The common sense model may provide a good framework for examining outcomes in patients with noncardiac chest pain.

Design

Qualitative thematic analysis with semi‐structured interviews.

Methods

In 2010, participants recruited from an emergency department (N = 7) with persistent noncardiac chest pain and distress were interviewed using a semi‐structured schedule, and data were analysed using thematic analysis.

Results

Seven themes were identified; six of which mapped onto core dimensions of the common sense model (identity, cause, timeline, consequences, personal control, treatment control). Contrary to previous research on medically unexplained symptoms, most participants perceived psychological factors to play a causal role in their chest pain. Participants' perceptions largely mapped onto the common sense model, although there was a lack of coherence across dimensions, particularly with regard to cause.

Conclusion

Patients with noncardiac chest pain lack understanding with regard to their condition and may be accepting of psychological causes of their pain.

Relevance to clinical practice

Brief psychological interventions aimed at improving understanding of the causes of noncardiac chest pain and providing techniques for managing pain and stress may be useful for patients with noncardiac chest pain.

Cost-effectiveness of quantitative pretest probability intended to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea

OBJECTIVES

Quantitative pretest probability (qPTP) incorporated into a decision support tool with advice can reduce unnecessary diagnostic testing among patients with symptoms suggestive of acute coronary syndrome (ACS) and pulmonary embolism (PE), reducing 30-day costs without an increase in 90-day adverse outcomes. This study estimates long-term (beyond 90-day) costs and outcomes associated with qPTP. The authors hypothesized that qPTP reduces lifetime costs and improves outcomes in low-risk patients with symptoms suggestive of ACS and PE.

METHODS

This was a cost-effectiveness analysis of a multicenter, randomized controlled trial of adult emergency patients with dyspnea and chest pain, in which a clinician encountering a low-risk patient with symptoms suggestive of ACS or PE conducted either the intervention (qPTP for ACS and PE with advice) or the sham (no qPTP and no advice). Effect of the intervention over a patient's lifetime was assessed using a Markov microsimulation model. Short-term costs and outcomes were from the trial; long-term outcomes and costs were from the literature. Outcomes included lifetime transition to PE, ACS, and intracranial hemorrhage (ICH); mortality from cancer, ICH, PE, ACS, renal failure, and ischemic stroke; quality-adjusted life-years (QALYs); and total medical costs compared between simulated intervention and sham groups.

RESULTS

Markov microsimulation for a 40-year-old patient receiving qPTP found lifetime cost savings of $497 for women and $528 for men, associated with small gains in QALYs (2 and 6 days, respectively) and lower rates of cancer mortality in both sexes, but a reduction in ICH only in males. Sensitivity analysis for patients aged 60 years predicted that qPTP would continue to save costs and also reduce mortality from both ICH and cancer. Use of qPTP significantly reduced the lifetime probability of PE diagnosis, with lower probability of death from PE in both sexes aged 40 to 60 years. However, use of qPTP reduced the rate of ACS diagnosis and death from ACS at age 40, but increased the death rate from ACS at age 60 for both sexes.

CONCLUSIONS

Widespread use of a combined qPTP for both ACS and PE has the potential to decrease costs by reducing diagnostic testing, while improving most long-term outcomes in emergency patients with chest pain and dyspnea.