Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain
BMC Emergency Medicine volume 18, Article number: 10 (2018)
Approximately 80% of patients presenting to emergency departments (ED) with chest pain do not have any true cardiopulmonary emergency such as acute coronary syndrome (ACS). However, psychological contributors such as anxiety are thought to be present in up to 58%, but often remain undiagnosed leading to chronic chest pain and ED recidivism.
To evaluate ED provider beliefs and their usual practices regarding the approach and disposition of patients with low risk chest pain associated with anxiety, we constructed a 22-item survey using a modified Delphi technique. The survey was administered to a convenience sample of ED providers attending the 2016 American College of Emergency Physicians Scientific Assembly in Las Vegas.
Surveys were completed by 409 emergency medicine providers from 46 states and 7 countries with a wide range of years of experience and primary practice environment (academic versus community centers). Respondents estimated that 30% of patients presenting to the ED with chest pain thought to be low risk for ACS have anxiety or panic as the primary cause but they directly communicate this belief to only 42% of these patients and provide discharge instructions to 48%. Only 39% of respondents reported adequate hospital resources to ensure follow-up. Community-based providers reported more adequate follow-up for these patients than their academic center colleagues (46% vs. 34%; p = 0.015). Most providers (82%) indicated that they wanted to have referral resources available to a specific clinic for further outpatient evaluation.
Emergency Department providers believe approximately 30% of patients seeking emergency care for chest pain at low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety. This highlights an opportunity for patient centered communication.
Chest pain is one of the most common chief complaints evaluated in the Emergency Department (ED), accounting for approximately 20% of all annual ED visits nationwide . A small minority of these patients have a true cardiopulmonary emergency such as acute coronary syndrome (ACS) or pulmonary embolism (PE). Frequently, these patients have psychosomatic contributors to their symptoms, including panic or anxiety disorders. These disorders are present in up to 58%  of patients presenting with chest pain but remain undiagnosed in approximately 80% of these patients . Many adults with chest pain undergo extensive ED evaluations to rule out cardiopulmonary emergencies. In some cases, these evaluations can last 48 h including multiple tests, radiation exposure, and high cost, only to yield no named diagnosis . A significant fraction of these patients go on to develop chronic chest pain and continue to seek medical attention despite negative cardiac evaluations . Prior work has indicated emergency providers are hesitant to diagnose and discuss the role of anxiety  as a significant co-factor or etiology of their pain. However, the beliefs of ED providers regarding the prevalence of anxiety among patients with low risk chest pain and how they manage those patients both in the ED and at discharge have not been evaluated together.
We sought to evaluate ED provider beliefs regarding patients with low risk chest pain thought to be secondary to anxiety symptoms. Further, we wanted to evaluate if there was a discrepancy between these beliefs and their management practices.
This work was a hypothesis generating survey, conducted in accordance with guidelines by Mello et al., including both expert consensus and a modified Delphi technique [5, 6]. This protocol was deemed to be exempt by the IRB (protocol# 1601415405) at Indiana University School of Medicine. Authors PIM, JAL, CLH, and JAK initially determined that the objective of the hypothesis generating survey was to: evaluate the gap between ED provider beliefs regarding the approach and disposition of patients with low risk chest pain thought to be secondary to anxiety compared with their perceived practice patterns. The authors developed an initial set of themes which led to the generation of a 15-item survey which was test-administered to ED providers at Indiana University Department of Emergency Medicine. Responses from this test survey were analyzed along with feedback from participants by an advisory group who determined the final themes, domains, and survey architecture via a modified Delphi technique. This advisory group included individuals with expertise in both the subject areas as well as survey generation and administration in order to ensure face, content, and construct validity. The authors then generated a draft survey consisting of 26 items which were again vetted by the advisory group. Through an iterative process and consensus, edits were made and the items were reduced to a final survey consisting of 22 items. These included a mixture of multiple choice and visual analogue scale (0–100%) questions (Additional file 1: Appendix 1).
The survey was then administered to a convenience sample of Emergency Medicine (EM) providers visiting the exhibitor hall at the 2016 American College of Emergency Physicians Scientific Assembly (ACEP16) in Las Vegas, Nevada from October 16–19, 2016. This forum was chosen because it represents the largest annual gathering of EM providers . Eligible survey participants included advanced practitioners (i.e.: nurse practitioners and physician’s assistants), emergency medicine residents, as well as physicians at the fellow or attending level who were practicing in academic and/or community settings. The investigators obtained a booth in the ACEP16 exhibitor hall and invited all eligible participants passing by the vicinity of the booth to complete the survey. A description and invitation to the booth was printed in the ACEP16 program and the meeting’s website. Additionally, the investigators handed out invitation cards at the meeting. To encourage participation, we provided a material incentive in the form of a raffle for a FitBit® activity monitor. The number of passers-by who were approached but declined participation was not tracked.
Participants first viewed a description and purpose of the survey prior to starting, and then completed the survey using either a laptop computer or electronic tablet. Study data were collected and managed using REDCap electronic data capture tools hosted at Indiana University . Exported data were analyzed using Microsoft Excel for Mac, Version 15.14, and IBM SPSS Statistics for Mac, Version 22.0. The survey data was exported from REDCap into both software packages, and both univariate and multivariate analysis was completed. Where appropriate, 95% confidence intervals are reported. All visual analog-scale data were found to be non-normally distributed by both Kolmogorov-Smirnov and Shapiro-Wilk normality testing. All data generated or analyzed during this study are included in this published article as a supplemental excel dataset (The complete dataset generated from this survey and the basis for this manuscript is available from the authors upon request).
Four-hundred-and-nine surveys were completed, representing approximately 5% of ACEP16 conference attendees. There was diversity in respondent geographic location (Fig. 1), years of experience, and primary practice environment. The majority of respondents practiced at academic centers (52%), had less than 10 years of experience (68%), and were male (72%) as shown in Table 1. Twenty-nine respondents (7.0%) identified their primary practice location as outside of the United States.
Current practice patterns
A majority of providers believed an “acceptable ACS miss rate” was either < 1% (52%) or 1–2% (44%) with only 4% of respondents willing to accept an ACS miss rate of 3–5% illustrated in Fig. 2. Providers estimated that 30% (95%CI 28–32) of patients presenting to the ED with chest pain, which they have stratified to be low risk by whatever method, have anxiety or panic as the primary cause as shown in Table 2. Of those patients, the majority are female (38% male, 95%CI 36–39). For patients whom they believe anxiety or panic is the primary problem, respondents indicated that they directly communicate this belief to only 42% of these patients, and offer anxiolytic treatment to only 41% in the ED. Additionally, they offer discharge instructions and prescriptions for anxiolytics in 48 and 21%, respectively. Though 54% of respondents indicated they believe they have a professional responsibility to provide patients with an actual ICD-code diagnosis of anxiety when life threats are ruled out, providers report documenting a specific ICD-code diagnosis of “anxiety” or “panic” only 29% of the time (95%CI 27–32). Providers appeared more likely to diagnose anxiety in patients under age 25 (Additional file 2: Table S1).
Addressing the problem of anxiety
Thirty-nine percent (161/407) of respondents reported adequate hospital resources to ensure follow-up for patients with low risk chest pain they suspect is secondary to anxiety. Community-based providers reported more adequate follow-up for these patients than their academic center colleagues (46% of community providers responded that they have adequate follow-up available, versus only 34% of academic center providers; 2-sided Fisher’s exact test 0.015), (Table 3). When asked about possible strategies that could be used to improve management for patients with chest pain due to anxiety, most providers (82%) said that it would helpful to have a referral available to a specific clinic for further outpatient evaluation. In discussing what tools would make a provider more comfortable diagnosing and referring these patients (Table 4), practice patterns of colleagues (48%, 95%CI 45–50) and local hospital policy (56%, 95%CI 53–59) were found to be less helpful than a multicenter trial (74%, 95%CI 72–76) or professional organization practice guidelines (71%, 95%CI 69–73).
This study incorporated both a diverse geographical representation, and a wide range of practice settings and experience. The main message of this work is that physicians believe that approximately 30% of patients seeking emergency care for low risk chest pain have anxiety or panic as a primary problem, yet fewer than half provide any treatment or information to help the patient manage anxiety. The authors recognize that the primary imperative of emergency care is to protect and intervene against threats to a patient’s life. However, in patients without a serious cardiopulmonary disease, untreated anxiety can degrade quality of life and worsen perceptions of wellness [9, 10], contributing to systemic inflammation , which ironically creates the pathophysiology of coronary artery disease [12, 13]. Additionally, this is associated with an increased health resource burden [14,15,16,17,18]. We would argue that the most important of these to the emergency clinician is the detrimental effect on patient quality of life and unnecessary ED resource utilization and recidivism. Prior work in a large cohort of ED patients with chest pain discovered that only 0.2% were given an ICD9 diagnosis of anxiety; however, none of the 8% of patients who self-identified anxiety as likely the cause for their chest pain symptoms at follow-up were given this diagnosis even secondarily . This low rate of anxiety diagnoses in patients with non-life threatening chest pain in the ED was further demonstrated in a national sample using the National Hospital Ambulatory Medical Care Survey, where only 2.3% received this diagnosis . Whereas, a systematic review by Webster et al. incorporated nine studies and found the likely prevalence of diagnosable anxiety in patients with non-cardiac chest pain to be between 21 and 58% . Our current work is consistent with that of Al-Ani et al., who found that 30% of chest pain patients who had been risk-stratified to be low-risk for ACS were identified as suffering from anxiety and 80% of those patients were untreated . This highlights the fact that at least in this evaluation, EM provider gestalt regarding anxiety in the presence of low-risk anxiety is in line with objective measures shown previously. Taken together, these data indicate the need for a more patient-centered approach to communicating with and managing anxiety in patients with low risk chest pain. Helpful methods could include using formal anxiety risk stratification tools such as the Hospital Anxiety Depression Scale (HADS) or Generalized Anxiety Disorder scale (GAD-7). Both of these validated tools have been used to evaluate for the presence of anxiety in this patient population previously [21,22,23].
Furthermore, even after workup and provider reassurance, patients who present with possible cardiac symptoms are often left with “residual anxiety” despite normal test results . Reassurance of negative test results alone may not help reduce patient concerns about the potentially life-threatening causes of their chest pain [24,25,26]. Ackerman et al. defined the ideal content for ED discharge communication for patients with chest pain including directed follow-up suggestions and advice on self-care,  which are all important parts of the patient-provider interaction, particularly in the emergency department. Our data suggest these steps to be absent in current emergency care and may represent a missed opportunity to affect the trajectory of care . This low rate of discharge communication is likely heavily influenced by the fact that the majority of respondents (61%) found their hospital resources for appropriate follow-up to be inadequate. Not surprisingly, 82% of providers wanted a specific clinic to direct their patients for further evaluation for anxiety.
Implications of these data are that patients could benefit from targeted interventions which minimize psychological distress, improve quality of life  and prevent futile emergency department visitation. There are a number of psychological interventions which are available for this patient population which include cognitive behavioral therapy (CBT), relaxation therapy, hyperventilation, hypnotherapy etc. . Foremost and most well established is cognitive behavioral therapy (CBT), which has been shown to be both acceptable to patients and effective in reducing chest pain and improving quality of life [15, 27]. Even brief interventions have been successful as van Beek et al. randomized subjects with non-cardiac chest pain and anxiety after psychological testing to usual treatment vs an abbreviated CBT course (6 sessions) showing a significant decrease in both depression and anxiety symptoms . Unfortunately, CBT interventions are not a readily available resource for ED referral and can be expensive . However, it appears the intervention need not be extensive or expensive, as simply providing self-help information explaining the connection between anxiety and chest pain can make a difference in both psychological and/or physical symptoms [18, 30, 31]. Other anxiety management strategies include training in breathing techniques and mindfulness-based exercises may show effectiveness in this patient population [32,33,34,35]. However, any intervention requires a frank conversation about anxiety and appropriate discharge instructions.
The primary limitation of the work is that persons who completed our survey were self- selected by their decision to attend the national meeting, and their willingness to complete our survey. Additionally, we did not provide a formal definition or diagnostic criteria for anxiety to the provider as part of the survey. Thus, these results represent provider beliefs and gestalt based in large part on subjective assessments without the benefit of screening tests such as the HADS  or GAD-7 [22, 23] or formal evaluation using the Structured Clinical Interview for DSM Disorders (SCID) . Thus, the objective reality of those beliefs were not assessed or quantified. However, we thought it important to explore as physician gestalt would likely be a trigger for further screening or referral for formal evaluation. Additionally, these screening tools and assessments are not regularly employed in this ED patient population and thus providers may not have been familiar.
ED providers believe 30% of patients seeking emergency care for chest pain stratified to be low risk for ACS have anxiety as a primary problem, yet fewer than half discuss this concern or provide information to help the patient manage anxiety. These data support the need for a more patient-centered approach to communication and management of anxiety in patients with low risk chest pain. Further investigation to elicit reasons why providers would be hesitant to discuss suspected anxiety in the setting of low risk chest pain and contributing biases is needed.
2016 American College of Emergency Physicians Scientific Assembly
Acute coronary syndrome
Cognitive behavior therapy
Generalized Anxiety Disorder – 7
Hospital Anxiety Depression Scale
Structured Clinical Interview for DSM Disorders
National Hospital Ambulatory Medical Care Survey: 2013 Emergency Department Summary Tables [https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2013_ed_web_tables.pdf]. Accessed 22 Oct 2017.
Webster R, Norman P, Goodacre S, Thompson A. The prevalence and correlates of psychological outcomes in patients with acute non-cardiac chest pain: a systematic review. Emerg Med J. 2012;29:267–73.
Foldes-Busque G, Marchand A, Chauny J-M, Poitras J, Diodati J, Denis I, Lessard M-J, Pelland M-E, Fleet R. Unexplained chest pain in the ED: could it be panic? Am J Emerg Med. 2011;29:743–51.
Musey PI Jr, Kline JA. Emergency department cardiopulmonary evaluation of low-risk chest pain patients with self-reported stress and anxiety. J Emerg Med. 2016;
Mello MJ, Merchant RC, Clark MA. Surveying emergency medicine. Acad Emerg Med. 2013;20:409–12.
Hsu C-C, Sandford BA. The Delphi technique: making sense of consensus. Practical assessment, research & evaluation. 2007;12:1–8.
Lloyd J. ACEP elects new officers. Washington, DC: American College of Emergency Physicians; 2016.
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–81.
Webster R, Norman P, Goodacre S, Thompson AR, McEachan RRC. Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department. Psychol Health. 2014;29:1265–82.
Webster R, Thompson AR, Norman P. 'Everything's fine, so why does it happen?' a qualitative investigation of patients' perceptions of noncardiac chest pain. J Clin Nurs. 2015;24:1936–45.
Khandaker GM, Zammit S, Lewis G, Jones PB. Association between serum C-reactive protein and DSM-IV generalized anxiety disorder in adolescence: findings from the ALSPAC cohort. Neurobiol Stress. 2016;4:55–61.
Roifman I, Beck PL, Anderson TJ, Eisenberg MJ, Genest J. Chronic inflammatory diseases and cardiovascular risk: a systematic review. Can J Cardiol. 2011;27:174–82.
Tona F, Serra R, Di Ascenzo L, Osto E, Scarda A, Fabris R, Montisci R, Famoso G, Tellatin S, Foletto M, et al. Systemic inflammation is related to coronary microvascular dysfunction in obese patients without obstructive coronary disease. Nutr Metab Cardiovasc Dis. 2014;24:447–53.
Jonsbu E, Dammen T, Morken G, Martinsen EW. Patients with noncardiac chest pain and benign palpitations referred for cardiac outpatient investigation: a 6-month follow-up. Gen Hosp Psychiatry. 2010;32:406–12.
Kisely SR, Campbell LA, Yelland MJ, Paydar A. Psychological interventions for symptomatic management of non-specific chest pain in patients with normal coronary anatomy. Cochrane Database Syst Rev. 2012;6:CD004101.
Jonsbu E, Martinsen EW, Morken G, Moum T, Dammen T. Illness perception among patients with chest pain and palpitations before and after negative cardiac evaluation. Biopsychosoc Med. 2012;6:19.
Kisely S, Guthrie E, Creed F, Tew R. Predictors of mortality and morbidity following admission with chest pain. J R Coll Physicians Lond. 1997;31:177–83.
Lewis C, Pearce J, Bisson JI. Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review. Br J Psychiatry. 2012;200:15–21.
Hsia RY, Hale Z, Tabas JA, National Study A. Of the prevalence of life-threatening diagnoses in patients with chest pain. JAMA Intern Med. 2016;176:1029–32.
Al-Ani M, Winchester DE. Prevalence and overlap of noncardiac conditions in the evaluation of low-risk acute chest pain patients. Crit Pathw Cardiol. 2015;14:97–102.
Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale. An updated literature review. J Psychosom Res. 2002;52:69–77.
Ruiz MA, Zamorano E, Garcia-Campayo J, Pardo A, Freire O, Rejas J. Validity of the GAD-7 scale as an outcome measure of disability in patients with generalized anxiety disorders in primary care. J Affect Disord. 2011;128:277–86.
Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092–7.
McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora's box: the unpredictability of reassurance by a normal test result. BMJ. 1996;313:329–32.
Ackermann S, Heierle A, Bingisser M-B, Hertwig R, Padiyath R, Nickel CH, Langewitz W, Bingisser R. Discharge communication in patients presenting to the emergency department with chest pain: defining the ideal content. Health Commun. 2016;31:557–65.
Serinken M, Zencir M, Karcioglu O, Sener S, Turkcuer I. Value of the timing of informing the emergency department patients on cardiac test results: a randomized controlled study. Eur J Emerg Med. 2009;16:74–9.
Webster R, Thompson AR, Norman P, Goodacre S. The acceptability and feasibility of an anxiety reduction intervention for emergency department patients with non-cardiac chest pain. Psychol Health Med. 2017;22:1–11.
van Beek MH, Oude Voshaar RC, Beek AM, van Zijderveld GA, Visser S, Speckens AE, Batelaan N, van Balkom AJ. A brief cognitive-behavioral intervention for treating depression and panic disorder in patients with noncardiac chest pain: a 24-week randomized controlled trial. Depress Anxiety. 2013;30:670–8.
Esler JL, Bock BC. Psychological treatments for noncardiac chest pain: recommendations for a new approach. J Psychosom Res. 2004;56:263–9.
Hirai M, Clum GA. A meta-analytic study of self-help interventions for anxiety problems. Behav Ther. 2006;37:99–111.
Arnold J, Goodacre S, Bath P, Price J. Information sheets for patients with acute chest pain: randomised controlled trial. BMJ. 2009;338:b541.
Hoge EA, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry. 2013;74:786–92.
Keng SL, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 2011;31:1041–56.
Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014;52:S19–24.
Vollestad J, Nielsen MB, Nielsen GH. Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. Br J Clin Psychol. 2012;51:239–60.
First MB, Williams JBW, Karg RS, Spitzer RL. Structured clinical interview for Dsm-5, clinician version. Arlington: American Psychiatric Association; 2015.
Alexander B. Niculescu, MD, PhD, Professor of Psychiatry, Indiana University School of Medicine. Julie L. Welch, MD, Associate Professor of Clinical Emergency Medicine, Indiana University School of Medicine. Megan Palmer, PhD. Associate Dean for Faculty Affairs and Professional Development and Associate Professor in the Department of Emergency Medicine, Indiana University School of Medicine. Cherri D. Hobgood, MD, Chair, Department of Emergency Medicine, Indiana University School of Medicine.
Availability of data and material
The complete dataset generated from this survey and the basis for this manuscript is available from the authors upon request.
Ethics approval and consent to participate
Submitted to and deemed exempt by the IRB (protocol# 1601415405) at Indiana University School of Medicine. However, verbal informed consent was obtained from all participants prior to taking the survey. Participants were informed that this was a research study, the purpose, scope, length and its voluntary nature. They also had the opportunity to ask questions prior to deciding to participate. Additionally, before subjects could start the survey they had to read and acknowledge the following statement in the electronic survey before they could continue: “You are being asked to participate in a research project entitled “ED Provider Beliefs and Opinions Regarding Anxiety Associated Non-Cardiac Chest Pain”; which is being conducted by Paul Musey, a faculty member at Indiana University. This survey is anonymous. No one, including the researcher, will be able to associate your responses with your identity. Your participation is voluntary. You may choose not to take the survey or to stop responding at any time. Your completion of the survey serves as your voluntary agreement to participate in this research project.”
Consent for publication
Not applicable, all figures and tables were created by the authors.
Paul Musey, MD - Research funding from Trevena, Inc. Jeffrey Kline, MD - Consultant to Janssen, Stago Diagnostica, Research funding from NIH, Mallingkrodt, Roche Diagnostics.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Musey, P.I., Lee, J.A., Hall, C.A. et al. Anxiety about anxiety: a survey of emergency department provider beliefs and practices regarding anxiety-associated low risk chest pain. BMC Emerg Med 18, 10 (2018). https://doi.org/10.1186/s12873-018-0161-x
- Emergency department
- Chest pain
- Psychological conditions