1. R.E. van de Kraats, resident in psychiatry
H. Barends, resident in emergency medicine
JG Lijmer, consultant psychiatry (presenting)
Panic Symptoms in Patients with Non-Cardiac
Chest Pain or Palpitations in the Emergency
Department: A Blind Spot in the Emergency
Department
3. APM 2014
Disclosure: Jeroen Lijmer, MD
With respect to the following presentation, there
has been no relevant (direct or indirect) financial
relationship between the party listed above (and/or
spouse/partner) and any for-profit company in the
past 24 months which could be considered a
conflict of interest.
4. Background
⢠50â90% of patients presenting with chest pain are
diagnosed with non-cardiac chest pain (1,2)
⢠More than half of these patients continue to report chest
pain and remain concerned about having a serious heart
disease (3,4)
⢠This results in high medical care utilization
1. Wulsin LR et al. Int J Psychiatry Med 1991
2. Yingling KW et al. J Gen Inter Med 1993
3. Chambers J
5. Prevalence of panic disorder in ER
⢠Previous studies in this population showed high
prevalence rates of panic disorders (up to 44 %) 2,6,7,8
Study n Panic disorder
Yingling 1993 229 40 (18%)
Kuijpers 2003 134 49 (36%)
White 2008 229 50 (22%)
Foldes-Busque 2011 771 339 (44%)
6. Research question
⢠Aim of this study was to report the frequency of panic
disorder as diagnosed by emergency physicians in
patients with non-cardiac chest pain
7. Methods
⢠Retrospective consecutive cohort study
⢠January 2013 until April 2013
⢠Patients presenting with chest pain and palpitations at
the emergency department of a large city-center
teaching hospital in Amsterdam, The Netherlands
⢠Extraction of the final diagnosis by the emergency
physician was reviewed by two independent researchers
and categorized
10. Results
⢠530 patients visited our ED with chest pain or
palpitations
⢠367 (69%) suffered from non-cardiac chest complaints
⢠In only 24 patients (7%) a psychological cause was
described
⢠2 patients visited the emergency department more than
50 times.
11. Conclusions
ďˇ We found a low rate of anxiety related diagnoses by
emergency physicians in patients with NCCP compared
to previous studies using structured interviews
⢠Interventions are needed to improve the detection of
psychiatric symptoms in the emergency room
⢠Underdiagnosis can lead to high medical care utilization
13. References
1. Wulsin LR, Arnold LM, Hillard JR. Axis I disorders in ER patients with atypical chest pain. Int J
Psychiatry Med 1991; 21 (1): 37-46
2. Yingling KW, Wulsin LR, Arnold LM, Rouan GW. Estimated prevalences of panic disorder and
depression among consecutive patients seen in an emergency department with acute chest pain.
J Gen Inter Med 1993; 8:231-235
3. Kisely SR, Campbell LA, Yelland MJ, Paydar A. Psychological interventions for symptomatic
management of non-specific chest pain in patients with normal coronary anatomy (review).
Cochrane Coll 2013; 6:CD004101
4. Potts SG, Bass CM. Psychological comorbidity in patients with chest pain and normal or near-
normal coronary arteries: a long term follow-up study. Psychol. Med 1995;25:339-347
5. Chambers J, Bass. Chest pain with normal coronary anatomy: a review of natural history and
6. Kuijpers PM, Honig A, Griez EJ, Braat SH, Wellens HJ. Panic disorder, chest pain and
palpitations: a pilot study of a Dutch First Heart Aid. Ned Tijdschr Geneeskd 2000 15;144(16):745
7. White KS, Raffa SD, Jakle KR, et al. Morbidity of DSM-IV axis I disorders in patients with
noncardiac chest pain: psychiatric morbidity linkedwith increased pain and health care utilization.
J Consult Clin Psychol 2008;76:422â430.
8. Foldes-Busque G, Marchand A, Chauny JM, Poitras J, Diodati J, Denis I et al. Unexplained chest
pain in the ED: could it be panic?. Am J Emerg Med 2011; 29(7): 743-751