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

Emergency Department Physician Attitudes, Practices, and Needs Assessment for the Management of Patients with Chest Pain Secondary to Anxiety and Panic

poster abstractBackground Chest pain is a common medical complaint, accounting for 7 million annual visits to US Emergency Departments (EDs) [1]. Most research and clinical resources are focused on the management of the life-threatening acute coronary syndrome (ACS); however, about 80% of all patients presenting to EDs with chest pain do not have a cardiopulmonary emergency [2-4]. Non-ACS chest pain can be caused by anxiety or a panic disorder, and such etiologies remain undiagnosed in almost 90% of cases, and frequently have worse outcomes [5-9]. Objective and Methods The study objective was to assess ED physician’s attitudes, practices, and needs in managing chest pain related to anxiety and panic. A REDCap survey of 15 Likert-style questions was constructed using expert consensus to ensure content validity then administered to all faculty and resident physicians in the IU Department of Emergency Medicine (113 individuals, 65.5% response-rate). Results ED providers believe a significant proportion (31.5%) of patients with chest pain at low risk for ACS are due to panic/anxiety. Providers give such patients instructions on how to manage their panic/anxiety only 34.8% of the time, while even fewer (19.0%) make a diagnosis of anxiety or panic disorder in their documentation. Most providers (77.0%) would welcome a narrative to aid in discussing anxiety/panic as a cause of chest pain and nearly all (85.1%) would find it helpful to have specific clinic information available to aid in follow-up. Conclusions A significant number of ED patients with chest pain are likely due to anxiety, and a majority of physicians report not having the resources necessary to manage these patients. Further work to develop relevant resources would aim to improve provider confidence in treating these patients, and would hope to improve management of anxiety or panic as a cause of chest pain in the ED

Emergency Department Cardiopulmonary Evaluation of Low-Risk Chest Pain Patients with Self-Reported Stress and Anxiety

Background Chest pain is a high-risk emergency department (ED) chief complaint; the majority of clinical resources are directed toward detecting and treating cardiopulmonary emergencies. However, at follow-up, 80%–95% of these patients have only a symptom-based diagnosis; a large number have undiagnosed anxiety disorders. Objective Our aim was to measure the frequency of self-identified stress or anxiety among chest pain patients, and compare their pretest probabilities, care processes, and outcomes. Methods Patients were divided into two groups: explicitly self-reported anxiety and stress or not at 90-day follow-up, then compared on several variables: ultralow (<2.5%) pretest probability, outcome rates for acute coronary syndrome (ACS) and pulmonary embolism (PE), radiation exposure, total costs at 30 days, and 90-day recidivism. Results Eight hundred and forty-five patients were studied. Sixty-seven (8%) explicitly attributed their chest pain to “stress” or “anxiety”; their mean ACS pretest probability was 4% (95% confidence interval 2.9%–5.7%) and 49% (33/67) had ultralow pretest probability (0/33 with ACS or PE). None (0/67) were diagnosed with anxiety. Seven hundred and seventy-eight did not report stress or anxiety and, of these, 52% (403/778) had ultralow ACS pretest probability. Only one patient (0.2%; 1/403) was diagnosed with ACS and one patient (0.4%; 1/268) was diagnosed with PE. Patients with self-reported anxiety had similar radiation exposure, associated costs, and nearly identical (25.4% vs. 25.7%) ED recidivism to patients without reported anxiety. Conclusions Without prompting, 8% of patients self-identified “stress” or “anxiety” as the etiology for their chest pain. Most had low pretest probability, were over-investigated for ACS and PE, and not investigated for anxiety syndromes

Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation

Objectives: To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system. Methods: We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression. Results: Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91–16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03–10.53), and non-white race (AOR, 3.53; 95% CI, 1.76–7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36–6.25). Conclusions: Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations

Medical therapies for motor symptoms in Parkinson’s Disease

Parkinson’s Disease is the second most common neurodegenerative disorder in the aging population. It is associated with progressive loss of nigrostriatal dopaminergic neurons. Parkinsonism is a clinical syndrome that consists of motor and non-motor symptoms. It has been well described that many if not all of these deficits are associated with abnormalities related to the neurotransmitter Dopamine. This review is intended for primary care physicians who often establish the diagnosis and initiate Parkinson’s treatments. One challenge faced by the primary care physician is to decide the appropriate medication and starting dose. Often medications are used at very low doses or incorrect dosing schedules This review aims to summarize these medications, their potential side effects and the rationale for medication choices

Characterizing the role of haloperidol for analgesia in the Emergency Department

The purpose of this study was to characterize emergency department (ED) physicians' beliefs and current practices regarding the use of haloperidol for the management of acute and acute on chronic pain. METHODS: A survey regarding haloperidol use was distributed by email to attending physicians, resident physicians, nurse practitioners, and physician assistants at emergency medicine departments in the Indiana University Health System and at St Joseph Mercy Ann Arbor. RESULTS: Of the 129 responses received, the majority (89.1%) of providers had used haloperidol for control of pain in the ED. The most common reason that respondents used haloperidol to treat pain was that they did not want to use an opioid or other agent (91.3%). The majority of providers (73.9%) believed that haloperidol was effective because there is a psychiatric component to pain, while over half of respondents (58.3%) chose haloperidol as they believed it to have analgesic properties. When haloperidol was used as a first line medication, providers felt that it was effective in controlling pain about 69.0% of the time without the need for further medication. The most common presentations for use were for unspecified abdominal pain, headache, and gastroparesis. CONCLUSION: ED providers reported using haloperidol most often as a second line treatment to manage both acute and acute on chronic pain. When haloperidol was used as a first line agent, providers claimed that additional medicines were not usually required. Haloperidol may provide an effective alternative to opioids in treatment of acute pain and acute exacerbations of chronic pain in the ED

Stressing Out About the Heart: A Narrative Review of the Role of Psychological Stress in Acute Cardiovascular Events

Objectives: Survivors of acute cardiovascular disease (CVD) events, such as acute coronary syndrome (ACS) and stroke, may experience significant psychological distress during and following the acute event. Long-term adverse effects may follow, including the development of posttraumatic stress disorder (PTSD), increased overall all-cause mortality, and recurrent cardiac events. The goal of this concepts paper is to describe and summarize the rates of adverse psychological outcomes, such as PTSD, following cardiovascular emergencies, to review how these psychological factors are associated with increased risk of future events and long-term health and to provide a theoretical framework for future work. Methods: A panel of two board-certified emergency physicians, one with a doctorate in experimental psychology, along with one PhD clinical psychologist with expertise in psychoneuroendocrinology were co-authors involved in the paper. Each author used various search strategies (e.g., PubMed, Psycinfo, Cochrane, and Google Scholar) for primary research and reviewed articles related to their section. The references were reviewed and evaluated for relevancy and included based on review by the lead authors RESULTS: A meta-analysis of 24 studies (N > 2,300) found the prevalence of ACS-induced PTSD at nearly 12%, while a meta-analysis of nine studies (N = 1,138) found that 25% of survivors of transient ischemic attack and stroke report PTSD symptoms. The presence of PTSD doubles 3-year risk of CVD/mortality risk in ACS survivors. Cardiac patients treated during periods of ED overcrowding, hallway care, and perceived poor clinician-patient communication appear at greater risk for subsequent PTSD. Conclusions: Psychological stress is often present in patients undergoing evaluation for acute CVD events. Understanding such associations provides a foundation to appreciate the potential contribution of psychological variables on acute and long-term cardiovascular recovery, while also stimulating future areas of research and discovery

Maternal Plasma and Breastmilk Viral Loads are Associated with HIV-1-Specific Cellular Immune Responses Among HIV-1-Exposed, Uninfected Infants in Kenya

Infants exposed to maternal HIV-1 provide an opportunity to assess correlates of HIV-1-specific interferon (IFN)-γ responses and may be informative in the development of HIV-1 vaccines. HIV-1-infected women with CD4 counts 200-500 cells/mm(3) were randomized to short-course zidovudine/nevirapine (ZDV/NVP) or highly active anti-retroviral therapy (HAART) between 2003 and 2005. Maternal plasma and breastmilk HIV-1 RNA and DNA were quantified during the first 6-12 months postpartum. HIV-1 gag peptide-stimulated enzyme-linked immunospot (ELISPOT) assays were conducted in HIV-1-exposed, uninfected infants (EU), and correlates were determined using regression and generalized estimating equations. Among 47 EU infants, 21 (45%) had ≥1 positive ELISPOT result during follow-up. Infants had a median response magnitude of 177 HIV-1-specific spot-forming units (SFU)/106 peripheral blood mononuclear cells (PBMC) [interquartile range (IQR)=117-287] directed against 2 (IQR = 1-3) gag peptide pools. The prevalence and magnitude of responses did not differ by maternal anti-retroviral (ARV) randomization arm. Maternal plasma HIV-1 RNA levels during pregnancy (P=0.009) and breastmilk HIV-1 DNA levels at 1 month (P=0.02) were associated with a higher magnitude of infant HIV-1-specific ELISPOT responses at 1 month postpartum. During follow-up, concurrent breastmilk HIV-1 RNA and DNA (cell-free virus and cell-associated virus, respectively) each were associated positively with magnitude of infant HIV-1-specific responses (P=0.01). Our data demonstrate the importance of antigenic exposure on the induction of infant HIV-1-specific cellular immune responses in the absence of infection