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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.
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      References

        • Rui P
        • Kang K
        National Hospital Ambulatory Medical Care Survey: 2015 Emergency Department Summary Tables: CDC.
        US Centers for Disease Control and Prevention, 2015: 34
        • Musey Jr, PI
        • Kline JA
        Do gender and race make a difference in acute coronary syndrome pretest probabilities in the emergency department?.
        Acad Emerg Med. 2016; 24: 142-151
        • Kline JA
        • Jones AE
        • Shapiro NI
        • Hernandez J
        • Hogg MM
        • Troyer J
        • Nelson RD
        Multicenter, randomized trial of quantitative pretest probability to reduce unnecessary medical radiation exposure in emergency department patients with chest pain and dyspnea.
        Circ Cardiovasc Imaging. 2014; 7: 66-73
        • Kline JA
        • Shapiro NI
        • Jones AE
        • Hernandez J
        • Hogg MM
        • Troyer J
        • Nelson RD
        Outcomes and radiation exposure of emergency department patients with chest pain and shortness of breath and ultralow pretest probability: a multicenter study.
        Ann Emerg Med. 2014; 63: 281-288
        • Webster R
        • Norman P
        • Goodacre S
        • Thompson AR
        • McEachan RRC
        Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department.
        Psychol Health. 2014; 29: 1265-1282
        • Foldes-Busque G
        • Marchand A
        • Chauny J-M
        • Poitras J
        • Diodati J
        • Denis I
        • Lessard M-J
        • Pelland M-E
        • Fleet R
        Unexplained chest pain in the ED: could it be panic?.
        Am J Emerg Med. 2011; 29: 743-751
        • Demiryoguran NS
        • Karcioglu O
        • Topacoglu H
        • Kiyan S
        • Ozbay D
        • Onur E
        • Korkmaz T
        • Demir OF
        Anxiety disorder in patients with non-specific chest pain in the emergency setting.
        Emerg Med J. 2006; 23: 99-102
        • Eken C
        • Oktay C
        • Bacanli A
        • Gulen B
        • Koparan C
        • Ugras SS
        • Cete Y
        Anxiety and depressive disorders in patients presenting with chest pain to the emergency department: a comparison between cardiac and non-cardiac origin.
        J Emerg Med. 2010; 39: 144-150
        • Aikens JE
        • Michael E
        • Levin T
        • Myers TC
        • Lowry E
        • McCracken LM
        Cardiac exposure history as a determinant of symptoms and emergency department utilization in noncardiac chest pain patients.
        J Behav Med. 1999; 22: 605-617
        • Webster R
        • Thompson AR
        • Norman P
        'Everything's fine, so why does it happen?' A qualitative investigation of patients' perceptions of noncardiac chest pain.
        J Clin Nurs. 2015; 24: 1936-1945
        • Khandaker GM
        • Zammit S
        • Lewis G
        • Jones PB
        Association between serum C-reactive protein and DSM-IV generalized anxiety disorder in adolescence: findings from the ALSPAC cohort.
        Neurobiol Stress. 2016; 4: 55-61
        • Roifman I
        • Beck PL
        • Anderson TJ
        • Eisenberg MJ
        • Genest J
        Chronic inflammatory diseases and cardiovascular risk: a systematic review.
        Can J Cardiol. 2011; 27: 174-182
        • Tona F
        • Serra R
        • Di Ascenzo L
        • Osto E
        • Scarda A
        • Fabris R
        • Montisci R
        • Famoso G
        • Tellatin S
        • Foletto M
        • Giovagnoni A
        • Iliceto S
        • Vettor R
        Systemic inflammation is related to coronary microvascular dysfunction in obese patients without obstructive coronary disease.
        Nutr Metab Cardiovasc Dis. 2014; 24: 447-453
        • Backus BE
        • Six AJ
        • Kelder JC
        • Bosschaert MA
        • Mast EG
        • Mosterd A
        • Veldkamp RF
        • Wardeh AJ
        • Tio R
        • Braam R
        • Monnink SH
        • van Tooren R
        • Mast TP
        • van den Akker F
        • Cramer MJ
        • Poldervaart JM
        • Hoes AW
        • Doevendans PA
        A prospective validation of the HEART score for chest pain patients at the emergency department.
        Int J Cardiol. 2013; 168: 2153-2158
        • Kuijpers PM
        • Denollet J
        • Lousberg R
        • Wellens HJ
        • Crijns H
        • Honig A
        Validity of the hospital anxiety and depression scale for use with patients with noncardiac chest pain.
        Psychosomatics. 2003; 44: 329-335
        • Bjelland I
        • Dahl AA
        • Haug TT
        • Neckelmann D
        The validity of the hospital anxiety and depression scale. An updated literature review.
        J Psychosom Res. 2002; 52: 69-77
        • Musey Jr, PI
        • Lee JA
        • Hall CL
        • Kline JA
        Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain.
        BMC Emerg Med. 2018; 18: 10-17
        • Kachintorn U
        How do we define non-cardiac chest pain.
        J Gastroenterol Hepatol. 2005; 20: S2-S5
        • Kisely SR
        • Campbell LA
        • Yelland MJ
        • Paydar A
        Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy.
        Cochrane Database Syst Rev. 2012; 6CD004101
        • Al-Ani M
        • Winchester DE
        Prevalence and overlap of noncardiac conditions in the evaluation of low-risk acute chest pain patients.
        Crit Pathw Cardiol. 2015; 14: 97-102
        • Webster R
        • Norman P
        • Goodacre S
        • Thompson A
        The prevalence and correlates of psychological outcomes in patients with acute non-cardiac chest pain: a systematic review.
        Emerg Med J. 2012; 29: 267-273
        • Musey Jr, PI
        • Kline JA
        Emergency department cardiopulmonary evaluation of low-risk chest pain patients with self-reported stress and anxiety.
        J Emerg Med. 2017; 52: 273-279
        • Lees-Haley PR
        • Dunn JT
        The ability of naive subjects to report symptoms of mild brain injury, post-traumatic stress disorder, major depression, and generalized anxiety disorder.
        J Clin Psychol. 1994; 50: 252-256
        • Van Ameringen M
        • Mancini C
        • Simpson W
        • Patterson B
        Potential use of Internet-based screening for anxiety disorders: a pilot study.
        Depress Anxiety. 2010; 27: 1006-1010
        • Hadlandsmyth K
        • Rosenbaum DL
        • Craft JM
        • Gervino EV
        • White KS
        Health care utilisation in patients with non-cardiac chest pain: a longitudinal analysis of chest pain, anxiety and interoceptive fear.
        Psychol Health. 2013; 28: 849-861
        • Aikens JE
        • Zvolensky MJ
        • Eifert GH
        Differential fear of cardiopulmonary sensations in emergency room noncardiac chest pain patients.
        J Behav Med. 2001; 24: 155-167
        • White KS
        • Craft JM
        • Gervino EV
        Anxiety and hypervigilance to cardiopulmonary sensations in non-cardiac chest pain patients with and without psychiatric disorders.
        Behav Res Ther. 2010; 48: 394-401
        • Meli L
        • Alcantara C
        • Sumner JA
        • Swan B
        • Chang BP
        • Edmondson D
        Enduring somatic threat perceptions and post-traumatic stress disorder symptoms in survivors of cardiac events.
        J Health Psychol. 2017; 22: 1-11
        • White KS
        • Raffa SD
        • Jakle KR
        • Stoddard JA
        • Barlow DH
        • Brown TA
        • Covino NA
        • Ullman E
        • Gervino EV
        Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: psychiatric morbidity linked with increased pain and health care utilization.
        J Consult Clin Psychol. 2008; 76: 422-430
        • Dumville JC
        • MacPherson H
        • Griffith K
        • Miles JN
        • Lewin RJ
        Non-cardiac chest pain: a retrospective cohort study of patients who attended a rapid access chest pain clinic.
        Fam Pract. 2007; 24: 152-157