28 Comorbid Psychological Factors in Emergency Department Patients With Low Risk Chest Pain Associated With Anxiety

Abstract

Anxiety is thought to be a significant contributor to chest pain symptoms in approximately 40% of patients with low risk chest pain seen in the emergency department (ED). The validated Hospital Anxiety Depression Scale - Anxiety subscale (HADS-A) has been used as an anxiety screening tool in this population. These patients have been shown to have persistent anxiety symptoms at follow-up and significantly higher ED utilization. The objective of this study was to determine the prevalence of abnormal anxiety levels in a cohort of low-risk chest pain patients and characterize their comorbid psychological contributors. We hypothesized that those with abnormal anxiety scores would have worse concomitant depression, optimism and pain catastrophizing scores in addition to experiencing more life trauma. This was a pre-planned secondary analysis of a single-center, prospective observational cohort study of ED subjects with low risk chest pain. Eligible subjects between 18 and 70 years old with no history of acute coronary syndrome (ACS) and a physician-reported HEART score < 4, were enrolled. The HADS-A was used to stratify participants into 2 groups: Low Anxiety (score<8) and High Anxiety (score≥8). Outcomes assessed included concomitant depression via the Hospital Anxiety Depression Scale - Depression subscale (HADS-D), previous trauma (Traumatic Life Events Questionnaire), optimism (Life Optimism Test-Revised), and pain catastrophizing (Pain Catastrophizing Scale). These groups were analyzed and compared using t-tests for continuous data and chi-square for proportional/categorical data. Of 442 screened subjects, 304 met enrollment criteria and 163 (36.8%) gave informed consent. Seventy-six (47%) were stratified into the High Anxiety group with a score≥8. There were no differences in baseline demographics between groups. Overall, there was a moderate positive correlation between HADS-A and HADS-D scores with a Pearson’s R of 0.519. Thirty percent of all subjects had abnormal depression scores ≥8 on the HADS-D and 35 subjects (45%) had both abnormal anxiety as well as depression. Mean depression scores were significantly different between the low anxiety and high anxiety groups (3.64, 95% CI 2.17 to 5.10). Traumatic experiences of assault with a weapon (p=0.000), physical assault (p=0.012), sexual assault (p=0.046), witnessing fire (p=0.034), natural disaster (p=0.035) were all associated with abnormal levels of anxiety. However, only sexual assault (p=0.030) and other unwanted sexual encounters (p=0.040) were associated with abnormal levels of depression. Optimism was negatively correlated with both anxiety (R=-0.489) and depression (R=-0.504). Additionally, optimism was significantly lower for subjects with either abnormal anxiety (mean difference of 3.86, 95% CI 2.46 to 5.26) or abnormal depression (mean difference 4.32, 95% CI 2.80 to 5.83). Pain catastrophizing was also significantly higher in subjects with either abnormal anxiety or depression (p=0.000). The prevalence of abnormal levels of anxiety in our low risk chest pain cohort was 47%. These patients were more likely to have concurrent symptoms of depression, multiple traumatic exposures, a less optimistic outlook, and a pain catastrophizing phenotype. These data indicate there may be an opportunity to address these problems in many low risk chest pain patients as a best practice.