Psychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit

doi:10.1067/mem.2001.118010

Annals of Emergency Medicine

Volume 38, Issue 4, October 2001, Pages 369-376

Presented at the British Association for Accident and Emergency Medicine annual meeting, Bournemouth, United Kingdom, April 2001.

https://doi.org/10.1067/mem.2001.118010 Get rights and content

Abstract

Study Objectives: We sought to measure psychologic morbidity and health-related quality of life among patients attending the hospital with acute chest pain both at presentation and 1 month after rigorous assessment for cardiac disease. Methods: Consecutive patients undergoing assessment on the chest pain observation unit of a large, urban emergency department were asked to complete 3 questionnaires: the Short Form-36 Health Survey (SF-36), the Euroqol Health Utility Questionnaire, and the Hospital Anxiety and Depression Scale. The same questionnaires were mailed 1 month later, along with a questionnaire documenting subsequent pain and reassurance. Results: At enrollment (n=166), 32 (19%) participants (95% confidence interval [CI] 15% to 26%) were experiencing moderate levels of anxiety, and 21 (13%, 95% CI 8% to 19%) were experiencing moderate levels of depression. Health utility and all SF-36 dimensions of quality of life were substantially below age-adjusted normal values. One month after assessment (n=110), only the Pain dimension score of SF-36 had significantly improved. Most scores were unchanged, and the Physical Role and Mental Health dimension scores of SF-36 had significantly deteriorated. Seventy (64%) patients (95% CI 54% to 72%) had further pain after discharge. Despite these findings, 98 (86%) patients (95% CI 78% to 91%) responded that their assessment was “completely reassuring” or “quite reassuring.” Conclusion: Patients with acute, undifferentiated chest pain have substantial psychologic morbidity and impairment of quality of life. Although patients respond that they are reassured by chest pain observation unit assessment, anxiety and depression remain prevalent and quality of life remains impaired 1 month after assessment. [Goodacre S, Mason S, Arnold J, Angelini K. Psychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit. Ann Emerg Med. October 2001;38:369-376.]

Introduction

Chest pain is a common cause for presentation at the emergency department.¹ Management is principally aimed at identifying patients with potentially life-threatening illness, such as acute myocardial infarction, rather than establishing a definitive diagnosis in all cases. Hence, a substantial proportion of patients have no clear diagnosis after their initial assessment.

The chest pain observation unit (CPOU) is a recent development in the assessment of acute chest pain.² Patients whose chest pain is undiagnosed by clinical assessment, ECG, or chest radiography undergo a period of intensive observation and investigation, culminating in provocative cardiac testing when appropriate. Those patients with no evidence of serious physical illness may be discharged home.

The effectiveness of this assessment in terms of detecting cardiac disease is now well established.³ Follow-up of patients assessed on a CPOU has shown that missed cardiac pathology is rare.1, 3 However, most patients assessed on a CPOU will not have cardiac disease. Evaluation of CPOU care to date has therefore focused on outcomes that are not directly relevant to most patients receiving CPOU care.

Psychologic disturbance is common among patients with chest pain.4, 5 The relationship between psychologic illness and chest pain with normal coronary arteries is well established in the cardiology outpatient setting, with panic disorder being present in 30% or more of patients with chest pain but without significant coronary artery disease.4, 5 Studies of patients presenting to the ED with acute chest pain6, 7, 8 have demonstrated a prevalence of 20% to 25% for panic disorder and a similar prevalence for depression. Admitted patients (thereby a selected group) typically have persistent chest pain and psychiatric problems after discharge,9, 10, 11 which may last for many years and appear to worsen after assessment.⁹ It is unclear whether important psychologic symptoms persist after evaluation and discharge of unselected patients with acute chest pain or what effect these psychologic symptoms have on quality of life.

Clinicians may be aware of anxiety in their patients, but they may ascribe it to concern regarding an acute cardiac problem and may assume that anxiety will subside with thorough physical evaluation and reassurance. We suspect this assumption may be widespread among clinicians. Certainly, psychologic outcomes and quality of life are rarely measured in the CPOU literature, suggesting they are not considered to be important. Yet there is little evidence to support any assumption that anxiety will resolve and quality of life will improve with thorough diagnostic assessment.

Before the advent of CPOU care, Sox et al¹² randomized 176 patients thought clinically to have nonspecific chest pain to have either routine ECG and creatinine kinase measurement or no diagnostic testing. Short-term disability was decreased and satisfaction with care was increased in the tested group, but there was no difference in anxiety about serious disease. The evaluation of nonspecific chest pain and the techniques available for measuring anxiety and quality of life have advanced considerably since this study was published. CPOU assessment increases diagnostic certainty,¹³ which might allow the clinician to give more definite reassurance. This has been linked to improved patient satisfaction after CPOU assessment.¹⁴ However, we are not aware of any study that has evaluated psychologic symptoms or quality of life after CPOU care.

We therefore need to know more about patient-centered outcomes in CPOU care. We need to know the prevalence of psychologic disturbance in the CPOU population and whether any such disturbance persists after thorough physical evaluation. We also need to know whether chest pain is associated with impaired quality of life and whether chest pain and impaired quality of life persist after discharge. If so, future evaluation of CPOU services will need to consider the effect of intervention on those with noncardiac, as well as cardiac, chest pain and measure a wider range of outcomes than cardiac events and mortality.

This study aims to quantify psychologic morbidity and health-related quality of life in a group of patients investigated for acute, undifferentiated chest pain, both before and after intensive cardiac investigation.

Section snippets

Materials and methods

Our urban teaching hospital ED sees approximately 75,000 new patients per year, of whom approximately 4% have chest pain. Patients presenting with chest pain between 9 AM and 9 PM with a low (approximately 5%) but not negligible risk of myocardial infarction are examined in the CPOU. Approximately 25% of patients with chest pain are suitable for CPOU care: 18% present between 9 AM and 9 PM and are assessed on CPOU, and 7% present after hours. Those with diagnostic ECG changes (approximately 10%

Results

Two hundred fifty patients were referred from the ED to the CPOU between October 18, 1999, and April 18, 2000. One hundred sixty-eight (67.2%) were enrolled in the study. Unfortunately, the reasons for exclusion were not accurately recorded, and therefore, proportions for each exclusion criterion cannot be reported. All 168 patients were sent a follow-up questionnaire, and 119 (70.8%) completed follow-up. The characteristics and final diagnoses of those who were enrolled and those who completed

Discussion

This study confirms the high prevalence of psychologic morbidity previously reported in patients presenting with acute chest pain.6, 7, 8 Our estimates for the prevalence of anxiety and depression at presentation (19% and 13%, respectively) are slightly lower than previously reported estimates6, 7, 8 for panic disorder and depression (both 20% to 25%) but still indicate considerable morbidity. The prevalence of anxiety and depression are essentially unchanged 1 month after CPOU evaluation.

Acknowledgements

Author contributions: The study was conceived by SG and designed by SG and SM. Recruitment and data collection were undertaken by JA and KA. Data analysis was undertaken by SG and SM. SG drafted the manuscript and all authors contributed to revision. SG takes responsibility for the paper as a whole.

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In this cross-sectional study, all consecutive adult patients admitted to the community hospital-based ED in the study period were enrolled prospectively. HAD-A items were responded by the patients themselves. Demographic characteristics, history, and clinical findings were analyzed.
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A small percentage of the population represents a disproportionate number of attendances at emergency departments (ED). “Frequent presenters” to ED with chest pain do not always fit into established pathways for acute myocardial events. With accelerated “rule out” protocols, patients are often discharged from the ED after short lengths of stay. This research will evaluate the effectiveness of a phone based care-coordination pilot designed to meet the needs of patients attending ED with cardiac and non-cardiac chest pain.
A longitudinal, single-arm interventional study with retrospectively recruited control group. Ninety-five patients were enrolled as the intervention group; 97 patients were retrospectively identified as controls. These patients had re-presented with chest pain within 6 months of a cardiac event, or attended hospital within 12 months two or more times with chest pain and/or complex needs. Intervention group patients were holistically assessed then phone-coached to support self-management of chest pain over 6 months. Following descriptive and univariate analysis, multivariate analysis was conducted to adjust for noted differences between the intervention and control groups.
Thirty-day representation to ED was significantly less for the intervention group (14.1%) compared to controls (27.7%). After adjusting for baseline differences, intervention patients were more than two-fold less likely to re-present compared to controls (OR = 0.42, 95%CI: 0.19–0.96). After adjustment for baseline differences, the savings in subsequent inpatient costs was $1588 per person, as a result of intervention, patients were less likely to have inpatient readmissions (16.3%) compared to controls (20.2%), although this was not statistically significant (p = 0.588).
A phone based care-coordination pilot with targeted interventions has the potential to reduce ED presentations and hospital readmissions among patients representing with chest pain.
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Second, we found high rates of psychological morbidity in chest pain patients presenting to the ED. The rates of depression and anxiety were higher than previously reported.5,8 Specifically, anxiety was highly prevalent in our chest pain population, whereas the prevalence of anxiety was only slightly higher than depression in prior reports.8
Only a small fraction of acute chest pain in the emergency department (ED) is due to obstructive coronary artery disease (CAD). ED chest pain remains associated with high rates of recidivism, often in the presence of nonobstructive CAD. Psychological states such as depression, anxiety, and elevation of perceived stress may account for this finding. The objective of the study was to determine whether psychological states predict recurrent chest pain (RCP).
We conducted a prospective cohort study of low– to moderate–cardiac risk ED patients admitted to the Yale Chest Pain Center with acute chest pain. Depression, anxiety, and perceived stress were assessed in each patient using multistudy-validated screening scales: Patient Health Questionnaire (PHQ8), Clinical Anxiety Scale (CAS), and Perceived Stress Scale (PSS), respectively. All patients ruled out for infarction underwent appropriate cardiac stress testing. Primary outcome was RCP at 30 days evaluated by phone follow-up and medical record. The relationship between each psychological scale and RCP was evaluated using ordinal logistic regressions, controlling for known sociodemographic and cardiac risk factors. Depression (PHQ8 ≥ 10), anxiety (CAS ≥ 30), and perceived stress (PSS ≥ 15) were considered positive.
Between August 2013 and May 2015, 985 patients were screened at the Yale Chest Pain Center. Of 500 enrolled patients, 483 patients had complete data and 365 (76%) patients completed follow-up. Thirty-six percent (n = 131) had RCP within 1 month. On multivariable regression models, depression (odds ratio [OR] = 2.11, 95% CI 1.18-3.79) was a significant independent predictor of 30-day chest pain recurrence after adjustment, whereas PSS (OR = 0.96, 95% CI 0.60-1.53) and anxiety (OR = 1.59, 95% CI 0.80-3.20) were not. Similarly, there was a direct relationship between psychometric evaluation of depression (via PHQ8) and the frequency of chest pain.
Depression is independently associated with RCP regardless of significant cardiac ischemia on stress testing. Identification and targeted interventions may curtail recidivism with RCP.
Implicit affective evaluation of somatosensory sensations in patients with noncardiac chest pain
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Somatic symptoms are common in primary and secondary medical care with chest pain being one of the most frequently reported complaints (Kroenke & Price, 1993), often leading to negative affective reactions such as concerns and fear (Goodacre, Mason, Arnold, & Angelini, 2001).
Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit affective evaluations of somatosensory sensations, but this has never been studied empirically. The aim was therefore to assess implicit affective evaluations of somatosensory stimuli in NCCP using an experimental design.
A total of 34 patients with NCCP, 24 patients with cardiac chest pain, and 46 healthy controls, took part in the study. Participants completed a tactile modification of the Affect Misattribution Procedure (tAMP) and answered self-report measures on anxiety sensitivity, somatosensory amplification, and somatic symptom distress.
A 3 × 3-ANOVA revealed that most negative judgments were found in the aversive condition, but this effect was not specific to patients with NCCP. Anxiety sensitivity was positively associated with negative implicit evaluations of aversive tactile stimuli in the tAMP.
The task seemed to be too difficult for older participants. Also, future studies should apply clinically more relevant, e.g., heart related, stimuli that are more ecologically valid than the electrical stimulation of the finger used as a proxy for aversive somatosensory sensations here.
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We found that more than 25% of the total sample demonstrated depressive symptoms at both baseline and at follow-up. Other studies reported prevalence frequencies of depression in 20% to 50 % of patients with chest pain.7,23,38,39 This prevalence is much higher than in the general population, where the depression rate lies between 10% and 15%.40,41
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One hundred and thirty-one patients with noncardiac chest pain, 66 with acute myocardial infarction, and 70 with angina pectoris completed a depression screening questionnaire and the Montgomery Åsberg Depression Rating Scale. Healthcare utilization data were collected from a population-based, diagnosis-related database.
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^*: Author contributions are provided at the end of this article.

^**: Address for reprints: Steve Goodacre, MRCP, 87a Sydney Road, Sheffield, S6 3GG, United Kingdom; 0114 222 0842, fax 0114 222 0749;,E-mail [email protected].

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Original ContributionsPsychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit*,**

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Am J Cardiol

Ann Emerg Med

Am J Med

J Psychosom Res

Ann Emerg Med

Am Heart J

Am J Cardiol

Am J Med

Should we establish chest pain observation units in the United Kingdom? A systematic review and critical appraisal of the literature

J Accid Emerg Med

Chest pain and breathlessness: relationship to psychiatric illness

Am J Med

Panic disorder, chest pain and coronary artery disease: literature review

Can J Cardiol

Axis I disorders in ER patients with atypical chest pain

Int J Psychiatry Med

Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain

J Gen Intern Med

The course of psychiatric disorder associated with non-specific chest pain

J Psychosom Res

Five-year follow-up of young adults visiting an emergency unit because of atypical chest pain

J Intern Med

Original Contributions
Psychologic morbidity and health-related quality of life of patients assessed in a chest pain observation unit*,**