Emergency Department Cardiopulmonary Evaluation Of Low-Risk Chest Pain Patients With Self-Reported Stress and Anxiety

Paul I. Musey Jr., MD; Jeffrey A. Kline, MD


J Emerg Med. 2017;52(3):273-279. 

In This Article

Abstract and Introduction


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.


Patients who present with chest pain account for approximately 7 million visits to United States (US) emergency departments (EDs).[1] Emergency medicine providers view chest pain as a high-risk complaint, as acute coronary syndrome (ACS) and pulmonary embolism (PE) are two entities included in the differential that are imminent threats to life. Thus, most resources and clinical efforts are focused on the detection and treatment ACS and PE. However, between 80% and 95% of all patients presenting to EDs with complaints of chest pain do not have cardiac disease, or any other cardiopulmonary emergency by conventional testing.[2–6] Further, previous findings indicate that up to 55% of patients with non-cardiopulmonary chest pain may be suffering from anxiety or panic disorders, and these psychiatric disorders remain undiagnosed in almost 90% of cases.[7–13] Costs associated with the evaluation of chest pain found not to be related to an emergent cardiopulmonary condition have been estimated to be between $315 million and $8 billion per year, usually with no definitive cause contributing to recurrent ED visits.[14,15]

We sought to measure the frequency of self-identified stress or anxiety among a large prospectively collected cohort of patients presenting to the ED with chest pain and compare their pretest probabilities, care processes, and outcomes.


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