Chest pain and its importance in patients with panic disorder: an updated literature review.

Chest pain is a common symptom in the general population, reported by 12% to 16% of people.1,2 The probability of experiencing chest pain increases by 8% to 9% per decade of life after age 30. Most people who have chest pain report at least 2 episodes lasting under 4 hours; 35% seek care for their pain.1 In primary care populations, chest pain is even more prevalent, reported in 7% to 24% of patients3–5; 4.8% of patients are referred, usually to cardiologists.6 The presence of chest pain in primary care patients is associated with poorer functional status, especially in role functioning.5 In addition, chest pain results in substantial use of resources. Not only do 91% of patients report their chest pain to their physician,4 but 83% of those are evaluated at a mean cost of $272 per evaluation. Only 6% of these evaluations lead to an organic diagnosis, which means that the average testing cost per organic diagnosis made is $4354.3 Although cardiac diagnoses are made 8% to 34% of the time, and psychiatric diagnoses are made 6% to 37% of the time,3,7–9 the etiology of the chest pain is often not determined.3 Cardiology and mental health referrals are made 1% to 2% and 6% to 14% of the time, respectively, from practice settings.8,9 Prescribed medications are reported as helpful in 58% of patients,4 but this effectiveness is primarily in those whose chest pain has a recognized organic cause. Overall, 65% of primary care patients with chest pain report improvement with or without treatment.3 Patients with chest pain, whether or not they have cardiac disease, use similar strategies to cope with their pain.10 However, emergency department use is higher among patients without significant coronary disease11; emergency department use is predicted by duration of pain during the episode, the presence of other cardiac symptoms, and family history. In addition to these factors, cardiac distress is also dependent on age, education, and medical burden.12 Even after being informed of a normal coronary angiography, patients with chest pain continue to suffer. Sixty percent continue to have chest pain, 17% are rehospitalized, 45% think exertion is dangerous, and 30% limit their physical activity.13 Although clonidine and prazosin have not been shown to help these patients, a variety of medications have at least some efficacy, including estrogen, doxazosin, enalapril, aminophylline, and imipramine.14 Many of these patients may have a mental disorder. Patients whose chest pain is believed to have a psychosomatic cause express significantly more concern about their pain than do their physicians.7 However, unlike chest pain patients without psychiatric disease, those with psychiatric problems cope more through avoidance and wishful thinking and less through seeking support or problem-focused strategies.10 Anxiety disorders are particularly prevalent among primary care patients with chest pain.5 Patients without cardiac or esophageal disease as the cause of their chest pain have increased rates of panic disorder, obsessive-compulsive disorder, and somatic anxiety.15 Of these, panic disorder is the best recognized and most studied disorder. The purpose of this article is to combine literature and systematic reviews16 to identify characteristics of the chest pain associated with the presence of panic disorder, review the consequences and possible mechanisms of chest pain in panic disorder, and discuss the recognition of panic disorder in patients presenting with chest pain. FOR CLINICAL USE ♦ Although panic disorder is associated with nonanginal chest pain among emergency room patients, panic disorder can occur with typical angina. ♦ Although routine screening for panic disorder among demographic and symptomatic subgroups of patients presenting with chest pain has been advocated, the likelihood ratios of these decision tools are inadequate for diagnosis. ♦ Even if panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.