Psychological comorbidity in patients presenting to the emergency department with low-risk chest pain and anxiety

(Press-News.org) INDIANAPOLIS -- Chest pain ranks as the second most common reason for emergency department (ED) visits, making it a key concern for patients and doctors. However, 80 percent of these cases are considered low-risk and not related to heart disease, and for these patients, anxiety and panic disorders are frequent diagnoses.

A new study led by the Indiana University School of Medicine and Regenstrief Institute researchers shows that many patients who visit the ED with low-risk chest pain might benefit more from treatment for underlying psychological conditions than from extensive cardiac testing.

Anxiety is not only common among low-risk chest pain patients, but is often accompanied by other treatable comorbidities, including depression, somatization – the experience of psychological distress through physical symptoms – and post-traumatic stress disorder. By identifying and addressing these conditions, more targeted follow-up strategies can be developed to reduce repeat ED visits and unnecessary evaluations, improving patient outcomes and allowing health systems to focus resources where they matter most.

“Anxiety is a common fellow traveler with low-risk chest pain,” said corresponding author, IU School of Medicine and Regenstrief Research Scientist Kurt Kroenke, M.D. “It is a frequent issue in the emergency department. While many patients worry about their heart, in many cases the chest pain is not cardiac, which raises the important question of whether there is something else that can be treated.”

The research, part of the Patient-Centered Treatment of Anxiety after Low-Risk Chest Pain in the Emergency Room (PACER) trial, showed that more than 42 percent of patients had severe anxiety, defined by a score of 15 or higher on the Generalized Anxiety Disorder (GAD-7) scale, a standardized tool developed by Dr. Kroenke to assess the severity of anxiety symptoms. In addition, three-quarters of ED patients screened positive for panic disorder.

Evidence-based treatments for anxiety and comorbidities

Two effective approaches to reduce anxiety in patients with low-risk chest pain: Cognitive Behavioral Therapy (CBT) and prescription medications were identified in the study. These treatments can be used on their own or combined to create a more comprehensive care plan, helping to better manage symptoms and prevent unnecessary return visits to the ED.

Psychotropic medications such as antidepressants and anti-anxiety medicines remain important tools for managing anxiety disorders. When used appropriately, these medications can lessen both the intensity and frequency of symptoms and are often most effective when paired with psychological therapy.

“There are classes of medicines that are effective for anxiety, particularly when it’s chronic,” said Dr. Kroenke. “It’s no different than taking a medicine for high blood pressure – if someone has high blood pressure, we have medicines that lower it. Similarly, if someone has high anxiety, we have medicines that can effectively reduce it.”

The other effective approach is CBT, which helps individuals recognize and reframe thought patterns, manage panic symptoms and reduce fear associated with chest discomfort. Research shows that even brief courses of this behavioral therapy can significantly improve anxiety and quality of life. The PACER trial compared standard therapist-administered CBT to peer-supported internet-based CBT in patients with LRCP and anxiety.

“Emergency physicians often reassure patients that their chest pain isn’t caused by the heart, but reassurance alone is not enough. Connecting patients with proven therapies like cognitive-behavioral therapy and medications can change the trajectory of their care and improve long-term outcomes,” said IU School of Medicine and Regenstrief Researcher Paul Musey, M.D., M.S.

This research was supported by Patient-Centered Outcomes Research Institute (CER2019C3-17869).

“Psychological Comorbidity in Patients Presenting to the Emergency Department With Low-Risk Chest Pain and Anxiety,” is published in Academic Emergency Medicine.

Authors and their affiliations, as listed in the publication are:

Linh Dang1, Kurt Kroenke2, Jill Connors3, Timothy E Stump4, Patrick O Monahan4, Yelena Chernyak5, Emily Holmes5, Colin Hoffman4, Kevin Prather6, Paul I Musey6

Affiliations

1Indiana University School of Medicine, Indianapolis, Indiana, USA.

2Department of Medicine, Indiana University School of Medicine and Regenstrief Institute, Indianapolis, Indiana, USA.

3Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.

4Department of Biostatistics and Health Data Sciences, Indiana University School of Medicine, Indianapolis, Indiana, USA.

5Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA.

6Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Kurt Kroenke, M.D.
In addition to his role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Kurt Kroenke M.D., is an IU Indianapolis Chancellor’s Professor and a professor of medicine at Indiana University School of Medicine. 

Paul I. Musey Jr., M.D., M.S.
In addition to his role as a research scientist with the William M. Tierney Center for Health Services Research at Regenstrief Institute, Paul Musey Jr., M.D., M.S., is the Eskenazi Health Foundation Chair and Scholar of Emergency Medicine and associate professor and vice chair of research for the Indiana University School of Medicine Department of Emergency Medicine. He also is medical director, IU Health Enterprise Clinical Research Operations (ECRO).

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