Chest pain and panic disorder in the ED?

Letters

CJEM 2003;5(5):308

To the editor: In the July issue of CJEM, Fleet et al published an excellent study suggesting that emergency physicians often fail to diagnose panic disorder (PD) in emergency department (ED) patients with chest pain.¹ This may be true, but I wonder whether the right physicians have been targeted. If panic disorder goes undiagnosed for 2 years after an ED visit, is the emergency physician at fault? Are we overlooking the need for family physicians to consider this diagnosis? Surely primary care doctors, who know their patients well, are in a better position to make the diagnosis than an ED doctor who sees them at one point in time. Clearly, when patients make multiple trips to EDs for non-cardiac chest pain, family physicians have an equal or greater responsibility for diagnosing PD than ED physicians. The vast majority of ED patients with chest pain have family doctors, and it seems intuitive that primary care physicians have a huge opportunity to reduce avoidable ED visits by patients with this chronic, debilitating condition. If, as Fleet and colleagues suggest, family doctors miss the diagnosis 61% of the time, then the information presented in this study would serve them well.

In a related commentary,² Lee and Dade suggest we develop "protocols" to refer potential PD patients to mental health experts; yet this seems impractical in a cash-starved system where mental health providers are overstretched and when it is within the scope of family doctors to treat this illness.

Many, if not most ED physicians, are loath to diagnose PD during our one and only encounter with a patient who has chest pain -- even if this patient has diagnostic features of PD. Many DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed) symptoms of PD are also symptoms of organic diseases. For example, recent studies have shown that many patients with paroxysmal supraventricular tachycardia were initially misdiagnosed as having panic disorder.^3,4

This study also raises the more important question of whether emergency physicians are responsible for identifying chronic diseases and functional conditions not being addressed in the community when our generally accepted mandate is to never err in cases of acute illness. Is it reasonable to expect emergency physicians to discern arthritides from fibromyalgia and inflammatory bowel from irritable bowel? And to do so during a single, brief ED visit? Panic disorder is one of many chronic debilitating diseases. Should ED doctors focus on all of them?

If PD is patently obvious, patients should be advised of the diagnosis and referred for definitive evaluation. Furthermore, there is nothing wrong with raising the spectre of the diagnosis, even when there is uncertainty, contingent on family doctor follow-up and diagnostic confirmation. Perhaps the best thing you can do with this article is copy it and give it to your primary care colleagues, for they are certain to have the biggest impact.

Norman L. Epstein, MD
Credit Valley Hospital
University of Toronto
Toronto, Ont.

References

1. Fleet RP, Lavoie KL, Martel JP, Dupuis G, Marchand A, Beitman BD. Two-year follow-up status of emergency department patients with chest pain: Was it panic disorder? Can J Emerg Med 2003;5(4):247-54.
2. Lee J, Dade LA. The buck stops where? What is the role of the emergency physician in managing panic disorder in chest pain patients? Can J Emerg Med 2003;5(4):237-8.
3. McCrank E, Schurmans K, Lefcoe D. Paroxysmal supraventricular tachycardia misdiagnosed as panic disorder [letter]. Arch Intern Med 1998;158(3):297.
4. Vanek M. Cardiac care 2000. PSVT: heart or panic disorder? Emerg Med Serv 2000;29(9):63-5.