Low-risk chest pain in the ED: treat the patient, not the complaint

Patients presenting with chest pain associated with normal EKGs, negative cardiac enzymes, and few cardiac risk factors are designated “low-risk,” and can often be safely to discharge from the emergency department (ED) for early patient follow-up if no emergent conditions are found. ED care for low-risk chest pain is common: United States EDs annually see over 8 million visits for chest pain or related symptoms. Since chest pain is a high-risk complaint (i.e., imminent threat to life), a large amount of resources is allocated to detect and treat cardiopulmonary disease. Missed myocardial ischemia is clinically important concern: failure to detect it leads to a risk-adjusted mortality ratio that nearly doubles that of patients hospitalized for the same condition. An earlier Urgent Matters post by Dr. Evan Kuhl discussed the concept of shared decision making in patients with low-risk chest pain, which describes a way that providers can communicate risk with patients and deliver care in accordance with their values.

After ensuring no serious medical problems are present, the question for ED physicians and patients is: “What is the actual cause for the symptoms and how should they be treated?” Prior studies have shown that up to 55% of patients with non-cardiopulmonary chest pain may be suffering from anxiety or panic disorders, which remain undiagnosed in almost 90% of cases (Foldes-Busque et al & Eken et al). A study by Musey Jr. et al in press in The Journal of Emergency Medicine examines for self-reported stress/anxiety in low-risk chest pain patients. Dr. Musey Jr.’s study is a secondary analysis of prospective outcomes from four centers including 851 participants presenting to the ED with chief complaints of chest pain and or shortness of breath. Participants were divided into two groups (1) explicitly self-reported anxiety/stress (2) no explicitly self-reported anxiety/stress at 90-day follow-up. These groups were compared on several metrics including pretest probability (PTP), outcome rates for ACS and pulmonary embolism (PE), radiation exposure, and 90-day recidivism. When asked “What do you think caused your chest pain?” sixty-seven (8%) patients responded explicitly that their chest pain was caused by mental “stress” or “anxiety.” From this group, the mean ACS PTP was 4% (95% [CI] 2.9-5.7%), with 49% (33/67) having an ultralow (<2.5%) ACS PTP. The mean PE PTP was 5% (95% [CI] 3.6-5.7%) with 46% (31/67) having an ultralow PE PTP. The study found that none of the 67 patients had ACS or PE, and their radiation exposure, costs associated with care, and recidivism rates were similar to patients who did not volunteer anxiety as the cause of their chest pain.

 

Additionally, none of the patients with self-perceived anxiety were treated for anxiety or received a diagnosis of anxiety.

 

From the entire cohort, only two patients were given an ICD-9 diagnosis of anxiety. Musey Jr. et al.’s findings may indicate a missed opportunity to detect a treatable condition in patients who seldom receive an actionable diagnosis as opposed to descriptive “chest pain.”

 

“Detection and treatment of anxiety and panic syndromes may help forestall development of chronic chest pain and recurrent desire for medical reassurance, despite negative cardiac evaluations.”

 

Ultimately, we need to focus on treating not only the serious but also the non-serious symptoms for ED patients. This is especially true in chest pain given the recent literature on the topic.


Ameer Khalek is a MPH Candidate of the GWU Milken Institute School of Public Health