This study examined the frequency of panic disorder diagnoses in patients presenting to the emergency department with non-cardiac chest pain or palpitations. The researchers conducted a retrospective review of 530 patients who visited the emergency department over a 4 month period. They found that while previous studies using structured interviews found panic disorder rates as high as 44%, emergency physicians in this study only diagnosed anxiety or panic disorder in 7% of the 367 patients who were found to have non-cardiac chest symptoms. The low rate of psychiatric diagnoses could lead to overutilization of medical services. Improved training may help emergency physicians better identify panic and other psychiatric symptoms.

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

2. Introduction

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
• 50–90% 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

8. Results
31%
8%
12%8%
33%
4% 2% 2%
Pa ents with chest symptoms, Jan‐March 2013, n=530
Cardiac
Pulmonar
y
Musculos
keletal
Gastro
intes nal

9. Results
11%
17%
12%
47%
7%
2% 4%
Non‐cardiac chest symptoms, n=367
Pulmonary
Musculoskeletal
Gastro intestinal
Atypical
Anxiety related
Drug related
Other

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
 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

12. Discussion
• If Tony would have come to our ED…
• Further research
• Questions?

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;76:422–430.
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