Scientists receive $3.4 million to study care options for patients with chest pain due to anxiety

Indiana University School of Medicine and Regenstrief Institute research scientists have received a $3.4 million award from the Patient-Centered Outcomes Research Institute (PCORI) to investigate the best care options for the 40 percent of people who go to the hospital emergency department with chest pain that is determined to be caused by anxiety rather than a cardiac event.

Emergency department care for anxiety typically ends with discharge once a heart attack or related problem has been ruled out. Many of these patients leave the hospital confused about the cause of their chest pain symptoms and what to do next. As a result, they often continue to suffer and may return due to persistent or recurrent symptoms.

Non-cardiac chest pain and anxiety can be a vicious cycle. Patients with low-risk chest pain due to anxiety are sent home because the emergency department is designed for emergencies and anxiety is not an emergency. There are barriers to addressing anxiety in the emergency setting including scarce time, competing priorities, discomfort with mental health issues and a perceived lack of resources. Yet even if and when roadblocks are eliminated, providers still don't know what anxiety treatment options will be most effective."

Kurt Kroenke, M.D., Regenstrief Institute Research Scientist and IU School of Medicine Chancellor's Professor of Medicine

Kurt Kroenke, M.D., is the dual principal investigator on the PCORI contract

Chest pain sends millions of Americans to the hospital every year fearing that they are having a heart attack. Yet historically, chest pain in 8 out of 10 patients evaluated in hospital emergency departments was not caused by a heart attack or other cardiac event. Anxiety -- undiagnosed, untreated or under-treated is the likely cause of physical symptoms in as many as half of those chest pain patients deemed at low risk for a cardiac event.

With input from patients with lived experiences, clinicians, researchers and health system leaders, Dr. Kroenke, a pioneer in the study of symptoms and a co-developer of the most frequently used primary care anxiety screening tool, and study principal investigator Paul Musey, M.D., IU School of Medicine assistant professor of emergency medicine, are investigating what emergency departments can do to support the large number of individuals whose chest pain derives from anxiety. Other key investigators are Jill Connors, PhD, from IU School of Medicine's Department of Surgery and Patrick Monahan, PhD, from the Department of Biostatistics. Dr. Monahan is a Regenstrief Institute affiliated scientist.

"This type of study is timely and well positioned with online and telehealth care delivery options given the increased awareness of the need to have the ability to provide virtual care for patients during this global pandemic," said Dr. Musey.

A total of 375 adults with chest pain determined upon examination in the emergency department to be due to anxiety will be randomized into three groups for the study. One group (low intensity support) will be referred to a primary care practice for treatment of anxiety. The second group (medium intensity support) will be referred to web-based, self-paced cognitive behavioral therapy (CBT) enhanced by peer support from individuals who understand the challenges of managing anxiety. The third group (high intensity support) will be referred to live video chat CBT sessions with a psychologist.

Emergency department care is stressful and costly. Detection of anxiety in low-risk chest pain patients and treatment referral options would have great value for both patients and healthcare systems.

To determine which care option is best, success will be measured by reductions in:

• clinical symptoms of anxiety;
• chest pain and related physical symptoms;
• impairments to work, family and social functioning; and
• return visits to the emergency department.

The research team's ultimate goal for the three-year project is to produce evidence that will help patients deal with both anxiety and pain as well as assisting clinicians to make appropriate decisions regarding how to treat anxiety in patients with chest pain who come to a hospital emergency department.