Anxiety Associated With Increased Risk for Emergency Department Recidivism in Patients With Low-Risk Chest Pain

Anxiety contributes to the chest pain symptom complex in 30% to 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. The objective was to determine the prevalence of abnormal HADS-A scores in a cohort of low-risk chest pain patients and test the association of HADS-A score with subsequent healthcare utilization and symptom recurrence. In a single-center, prospective, observational cohort study of adult ED subjects with low-risk chest pain, the HADS-A was used to stratify participants into 2 groups: low anxiety (score <8) and high anxiety (score ≥8). At 45-day follow-up, chest pain recurrence was assessed by patient report, whereas ED utilization was assessed through chart review. Of the 167 subjects enrolled, 78 (47%) were stratified to high anxiety. The relative risk for high anxiety being associated with at least one 30-day ED return visit was 2.6 (95% confidence interval 1.4 to 4.7) and this relative risk increased to 9.1 (95% confidence interval 2.18 to 38.6) for 2 or more ED return visits. Occasional chest pain recurrence was reported by more subjects in the high anxiety group, 68% vs 47% (p = 0.029). In conclusion, 47% of low-risk chest pain cohort had abnormal levels of anxiety. These patients were more likely to have occasional recurrence of their chest pain and had an increased risk multiple ED return visits

Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care

Objectives To measure the effectiveness and cost effectiveness of providing care in a chest pain observation unit compared with routine care for patients with acute, undifferentiated chest pain. Design Cluster randomised controlled trial, with 442 days randomised to the chest pain observation unit or routine care, and cost effectiveness analysis from a health service costing perspective. Setting The emergency department at the Northern General Hospital, Sheffield, United Kingdom. Participants 972 patients with acute, undifferentiated chest pain (479 attending on days when care was delivered in the chest pain observation unit, 493 on days of routine care) followed up until six months after initial attendance. Main outcome measures The proportion of participants admitted to hospital, the proportion with acute coronary syndrome sent home inappropriately, major adverse cardiac events over six months, health utility, hospital reattendance and readmission, and costs per patient to the health service. Results Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% (difference 17%, odds ratio 0.50, 95% confidence interval 0.39 to 0.65, P < 0.001) and the proportion discharged with acute coronary syndrome from 14% to 6% (8%, –7% to 23%, P = 0.264). Rates of cardiac event were unchanged. Care in the chest pain observation unit was associated with improved health utility during follow up (0.0137 quality adjusted life years gained, 95% confidence interval 0.0030 to 0.0254, P = 0.022) and a saving of £78 per patient (–£56 to £210, P = 0.252). Conclusions Care in a chest pain observation unit can improve outcomes and may reduce costs to the health service. It seems to be more effective and more cost effective than routine care

A clinical practice audit of management and outcomes of patients presenting with chest pain to the Medical Admissions Unit

Acute central chest pain accounts for a significant proportion of emergency medical admissions. If chest pain evaluation is systematic & risk-based, it may prevent unnecessary admissions. This audit aims to observe various aspects of management of patients admitted with chest pain; areas needing review are identified and improvements on current practice are considered. The study observed the current practices in 292 admissions for chest pain to the Medical Admissions Unit over a 3 month period. The relative frequency of risk factors and utilisation of resources were observed. Ninety-one patients (31.2%) that were admitted with chest pain had a diagnostic ECG or raised cardiac enzymes. Twenty-one patients (7.2%) had an urgent exercise stress test (EST) whilst 27 patients (9.2%) had an urgent coronary angiogram. In all, 16 patients (5.5 %) were readmitted with a cardiac event and 8 patients (2.7%) died within 3 months. The presence of age >65, diabetes or hypertension were associated with a high rate of adverse events (13.9%, 16.4%, and 11.6% respectively).peer-reviewe

Information sheets for patients with acute chest pain: randomised controlled trial

Objectives: To determine whether providing an information sheet to patients with acute chest pain reduces anxiety, improves health related quality of life, improves satisfaction with care, or alters subsequent symptoms or actions. Design: Single centre, non-blinded, randomised controlled trial. Setting: Chest pain unit of an emergency department. Participants: 700 consecutive patients with acute chest pain and no clear diagnosis at initial presentation. Interventions: After a diagnostic assessment patients were randomised to receive either standard verbal advice or verbal advice followed by an information sheet. Main outcome measures: The primary outcome was anxiety (hospital anxiety and depression scale). Secondary outcomes were depression (hospital anxiety and depression scale), health related quality of life (SF-36), patient satisfaction, presentation with further chest pain within one month, lifestyle change (smoking cessation, diet, exercise), further information sought from other sources, and planned healthcare seeeking behaviour in response to further pain. Results 494 of 700 (70.6%) patients responded. Compared with those receiving standard verbal advice those receiving advice and an information sheet had lower mean hospital anxiety and depression scale scores for anxiety (7.61v8.63, difference 1.02, 95% confidence interval 0.20 to 1.84) and depression (4.14 v 5.28, difference 1.14, 0.41 to 1.86) and higher scores for mental health and perception of general health on the SF-36. The information sheet had no significant effect on satisfaction with care, subsequent symptoms, lifestyle change, information seeking, or planned actions in the event of further pain. Conclusions: Provision of an information sheet to patients with acute chest pain can reduce anxiety and depression and improve mental health and perception of general health but does not alter satisfaction with care or other outcomes. Trial registration Current Controlled Trials ISRCTN85248020

Hypothetical interventions on emergency ambulance and prehospital acetylsalicylic acid administration in myocardial infarction patients presenting without chest pain

BACKGROUND: Myocardial infarction (MI) patients presenting without chest pain are a diagnostic challenge. They receive suboptimal prehospital management and have high mortality. To elucidate potential benefits of improved management, we analysed expected outcome among non-chest pain MI patients if hypothetically they (1) received emergency ambulances/acetylsalicylic acid (ASA) as often as observed for chest pain patients, and (2) all received emergency ambulance/ASA. METHODS: We sampled calls to emergency and non-emergency medical services for patients hospitalized with MI within 24 h and categorized calls as chest pain/non-chest pain. Outcomes were 30-day mortality and a 1-year combined outcome of re-infarction, heart failure admission, and mortality. Targeted minimum loss-based estimation was used for all statistical analyses. RESULTS: Among 5418 calls regarding MI patients, 24% (1309) were recorded with non-chest pain. In total, 90% (3689/4109) of chest pain and 40% (525/1309) of non-chest pain patients received an emergency ambulance, and 73% (2668/3632) and 37% (192/518) of chest pain and non-chest pain patients received prehospital ASA. Providing ambulances to all non-chest pain patients was not associated with improved survival. Prehospital administration of ASA to all emergency ambulance transports of non-chest pain MI patients was expected to reduce 30-day mortality by 5.3% (CI 95%: [1.7%;9%]) from 12.8% to 7.4%. No significant reduction was found for the 1-year combined outcome (2.6% CI 95% [− 2.9%;8.1%]). In comparison, the observed 30-day mortality was 3% among ambulance-transported chest pain MI patients. CONCLUSIONS: Our study found large differences in the prehospital management of MI patients with and without chest pain. Improved prehospital ASA administration to non-chest pain MI patients could possibly reduce 30-day mortality, but long-term effects appear limited. Non-chest pain MI patients are difficult to identify prehospital and possible unintended effects of ASA might outweigh the potential benefits of improving the prehospital management. Future research should investigate ways to improve the prehospital recognition of MI in the absence of chest pain. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12872-022-03000-1

Chest pain caused by multiple exostoses of the ribs: A case report and a review of literature

Abstract The aim of this paper is to report an exceptional case of multiple internal exostoses of the ribs in a young patient affected by multiple hereditary exostoses (MHE) coming to our observation for chest pain as the only symptom of an intra-thoracic localization. A 16 years old patient with familiar history of MHE came to our observation complaining a left-sided chest pain. This pain had increased in the last months with no correlation to a traumatic event. The computed tomography (CT) scan revealed the presence of three exostoses located on the left third, fourth and sixth ribs, all protruding into the thoracic cavity, directly in contact with visceral pleura. Moreover, the apex of the one located on the sixth rib revealed to be only 12 mm away from pericardium. Patient underwent video-assisted thoracoscopy with an additional 4-cm mini toracotomy approach. At the last 1-year followup, patient was very satisfied and no signs of recurrence or major complication had occured. In conclusion, chest pain could be the only symptom of an intra-thoracic exostoses localization, possibly leading to serious complications. Thoracic localization in MHE must be suspected when patients complain chest pain. A chest CT scan is indicated to confirm exostoses and to clarify relationship with surrounding structures. Video-assisted thoracoscopic surgery can be considered a valuable option for exostoses removal, alone or in addiction to a mini-thoracotomy approach, in order to reduce thoracotomy morbidity

Cardiovascular Disorders in Adolescents with Chest Pain

Objective: To detect cardiovascular abnormalities in adolescents with chest pain.     Methods: In this cross sectional study, the subjects were 25 adolescents with chest pain who came to the Cardiac Center of Dr. Hasan Sadikin General Hospital, Bandung during the period of January 2008 to January 2011. The presence of established cardiovascular disorders were based on history, physical examination, electrocardiography and echocardiography    Results: It was found that 13/25 adolescents with chest pain had cardiovascular abnormalities. Of the 25 teens that came with chest pain, most of which showed normal electrocardiographic results, only 9/25 of those with dysrhythmias experienced sinus tachycardia and 8 had a first degree AV block. Echocardiography examination showed only four patients with abnormal cardiac anatomy.  No correlation between nutritional status and chest pain, and cardiovascular abnormalities and chest pain (p = 0.206 and p = 0.632, respectively). There was a positive correlation between sex and cardiovascular abnormalities in adolescents with chest pain (p = 0.007).Chest pain is a prevalent problem that is usually benign and that it frequently signals underlying cardiac disease.Conclusions: Cardiovascular abnormalities in adolescents with symptoms of chest pain are found in some cases. There is no correlation between female and male adolescents with chest pain  and  cardiovascular abnormalities.Keywords: Adolescents, cardiovascular, chest painDOI: 10.15850/ijihs.v2n1.28

Symptoms Of Depression Are Linked To Subsequent Recurrent Chest Pain In Patients Admitted To An Emergency Department Chest Pain Unit.

SYMPTOMS OF DEPRESSION ARE LINKED TO SUBSEQUENT RECURRENT CHEST PAIN IN PATIENTS ADMITTED TO AN EMERGENCY DEPARTMENT CHEST PAIN UNIT. Summer A. Paradise, Matt Naftilan, James Dziura, Aini Jelani, Morgan Soffler and Basmah Safdar. Department of Emergency Medicine, Yale University, School of Medicine, New Haven, CT. Prior studies suggest a high prevalence of depression in patients with chest pain, but few US studies have examined depression and recurrent chest pain in the emergency room setting. This study sought to compare symptoms of depression, socio-demographic features, and clinical features between low-moderate-risk emergency room (ER) chest pain center (CPC) patients with and without recurrent chest pain at one-month following enrollment. This study was a prospective cohort study using convenience sample at a tertiary care hospital emergency room in a semi-urban setting. Patients were recruited from the chest pain center (CPC), and completed baseline surveys that assessed depression, anxiety, stress and chest pain. A one-month follow-up assessed the recurrence of chest pain. Univariate and multivariate statistical analyses were conducted. Between July 30th 2013 to January 31st 2015 a total of 850 patients were invited to participate in our study, 442 (52.0%) agreed to do so, of which 327 (74.0%) were included in the final analysis. An overall 29% had some evidence of depression, be it high symptom scores or current treatment for depression. In addition, using the PHQ-8, we identified forty-one (12.5%) new patients with depressive symptoms. More than two-thirds of enrolled patients had chest pain on at least one occasion following discharge from the hospital (n=115; 35.2%). Patients with recurrent chest pain tended to be slightly younger (51 versus 55 years of age; p= .001), more female (64.3%; p= .023) and less Caucasian (63.5% versus 70.3%; p= .154). In general, women had higher rates of recurrent/persistent chest pain (n=74/184; 40.2%) than men (n=41/143; 28.7%). The overall burden of depression was 37.4% of patients with recurrent/persistent chest pain, compared to 24.5% of patients without (p= .018). Regression analysis revealed that for each single point increase in PHQ-8 score, there is an 7.5% increase in the odds of having recurrent chest pain (model 5: OR=1.075; 95% CI=1.005, 1.149; p= .035). Gender also had a significant effect in the regression model, and the overall burden of depression was highest among women with recurrent/persistent chest pain (43.2%), and differed significantly from women without recurrent/persistent chest pain (26.4%), (p= .023). The prevalence of depression is high in ER patients with chest pain, and this is particularly relevant for women with baseline depression and recurrent chest pain at one-month follow-up

Role of Stellate ganglion block in post CABG sympathetically mediated chest pain

Acute chest pain is a common presentation in emergency. After clinical assessment undiagnosed chest pain can become a difficult problem. Sympathetically mediated chest pain is a rare presentation, as it is similar to that of secondary hyperalgesia in the intact skin surrounding an injury site. We are reporting a case of a 62 years old man who presented with atypical chest pain four months after coronary artery bypass grafting (CABG). On investigation no new change was noticed than previous evaluation. On chronic pain assessment he was having hyperalgesia to light touch in addition to the spontaneous chest pain. He was treated as a case of sympathetically mediated chest pain, pain modulators, analgesics and Stellate ganglion block. Patient responded dramatically to Stellate ganglion block and returned to work within two weeks time. This case illustrated the importance of early diagnosis of sympathetically mediated chest pain and role of Stellate ganglion block

Is there a need for a chest pain observation unit in St. Luke's Hospital and will it be cost effective?

Objectives: Studies from the USA suggest that using an A&E department based chest pain observation unit (CPOU) saves from $567 to$2030 per patient compared with hospital admission. In the UK cost effectiveness figures are lower at around £78 per patient. This study aims to review current practice for patients presenting with chest pain in St.Luke's Hospital (SLH), to determine the proportion of patients suitable for CPOU evaluation and consequently calculate any related cost effectiveness. Methods: 236 patients presenting with a primary complaint of chest pain to the A&E department at SLH between 1 st June and 12 th July 2003 were selected. The case histories of these patients were reviewed to ascertain how many of them would qualify for a CPOU management and specific data was collected. Results: Notes were retrieved for 217 patients. A total of 103 (47.5%) patients were suitable for a CPOU management. Mean length of in-hospital stay of these patients was 67.5 hours. Estimated mean cost saving per patient was LM220 and overall LM 19,800 per month. Conclusion: Potential exists for the setting up of CPOU care to reduce health service costs and improve health utility at St.Luke's Hospital.peer-reviewe