Depression is associated with recurrent chest pain with or without coronary artery disease: A prospective cohort study in the emergency department

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Only a small fraction of acute chest pain in the emergency department (ED) is due to obstructive coronary artery disease (CAD). ED chest pain remains associated with high rates of recidivism, often in the presence of nonobstructive CAD. Psychological states such as depression, anxiety, and elevation of perceived stress may account for this finding. The objective of the study was to determine whether psychological states predict recurrent chest pain (RCP).


We conducted a prospective cohort study of low– to moderate–cardiac risk ED patients admitted to the Yale Chest Pain Center with acute chest pain. Depression, anxiety, and perceived stress were assessed in each patient using multistudy-validated screening scales: Patient Health Questionnaire (PHQ8), Clinical Anxiety Scale (CAS), and Perceived Stress Scale (PSS), respectively. All patients ruled out for infarction underwent appropriate cardiac stress testing. Primary outcome was RCP at 30 days evaluated by phone follow-up and medical record. The relationship between each psychological scale and RCP was evaluated using ordinal logistic regressions, controlling for known sociodemographic and cardiac risk factors. Depression (PHQ8 ≥ 10), anxiety (CAS ≥ 30), and perceived stress (PSS ≥ 15) were considered positive.


Between August 2013 and May 2015, 985 patients were screened at the Yale Chest Pain Center. Of 500 enrolled patients, 483 patients had complete data and 365 (76%) patients completed follow-up. Thirty-six percent (n = 131) had RCP within 1 month. On multivariable regression models, depression (odds ratio [OR] = 2.11, 95% CI 1.18–3.79) was a significant independent predictor of 30-day chest pain recurrence after adjustment, whereas PSS (OR = 0.96, 95% CI 0.60–1.53) and anxiety (OR = 1.59, 95% CI 0.80–3.20) were not. Similarly, there was a direct relationship between psychometric evaluation of depression (via PHQ8) and the frequency of chest pain.


Depression is independently associated with RCP regardless of significant cardiac ischemia on stress testing. Identification and targeted interventions may curtail recidivism with RCP.

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