Document Type : Original Article



BACKGROUND: Chest pain is one of the common causes for referrals to cardiologists, 50% of which
have no‑cardiac origin. The occurrence of chest pains is among the most important factors responsible
for psychological disorders. This study aimed to determine the prevalence of panic disorder and its
related factor in hospitalized patients with chest pain and normal angiography.
MATERIALS AND METHODS: In a cross‑sectional study, 144 patients who referred to Emam Ali
Cardiac Hospital of Kermanshah because of chest pain in 2013 and had a normal angiography during
admission were selected using census sampling method. The statistical indicators of Chi‑square
and logistic regression were applied.
RESULTS: From 144 patients with atypical chest pain, 95 were male (66%) and 49 were female (34%).
Overall, 41 patients met the criteria for panic diagnosis and thus, the prevalence of panic attacks
among patients with atypical chest pain was calculated as 28.5%. The results of multiple logistic
regression analysis showed that female gender, early age, and the being single were among the
predictive factors for the existence of panic disorder in patients with atypical chest pain and normal
angiography (P < 0.001).
CONCLUSIONS: Given the high prevalence of panic disorder in patients hospitalized for chest pain
with normal angiography, it is recommended to consider the importance of paying attention to this
disorder and identifying patients and referring them to professional psychiatrists.


  1. Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA,
    Hill NE, et al. One‑year psychosocial follow‑up of patients with
    chest pain and angiographically normal coronary arteries. Am J
    Cardiol 1988;62:209‑13.
    2. Haug TT, Mykletun A, Dahl AA. The association between anxiety,
    depression, and somatic symptoms in a large population: The
    HUNT‑II study. Psychosom Med 2004;66:845‑51.
    3. Sheps DS, Creed F, Clouse RE. Chest pain in patients with cardiac
    and noncardiac disease. Psychosom Med 2004;66:861‑7.
    4. Bass C, Mayou R. Chest pain and palpitations. In: Mayou RA,
    Bass C, Sharpe M, editors. Treatment of Functional Somatic
    Symptoms. Oxford: Oxford University Press; 1995.
    5. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of
    symptoms in medical outpatients and the adequacy of therapy.
    Arch Intern Med 1990;150:1685‑9.
    6. Kasper D, Braunwald E, Fauci A, Hauser S, Longo D, Jameson J,
    et al. Harrison’s Principles of Internal Medicine. 17th ed. New York:
    McGraw‑Hill Medical Publishing Division; 2008.
    7. Jerlock M, Welin C, Rosengren A, Gaston‑Johansson F. Pain
    characteristics in patients with unexplained chest pain and
    patients with ischemic heart disease. Eur J Cardiovasc Nurs
    8. Fass R, Navarro‑Rodriguez T. Noncardiac chest pain. J Clin
    Gastroenterol 2008;42:636‑46.
    9. Fenster PE. Evaluation of chest pain: A cardiology perspective for
    gastroenterologists. Gastroenterol Clin North Am 2004;33:35‑40.
    10. Ockene IS, Shay MJ, Alpert JS, Weiner BH, Dalen JE. Unexplained
    chest pain in patients with normal coronary arteriograms:
    A follow‑up study of functional status. N Engl J Med
    11. Dumville JC, MacPherson H, Griffith K, Miles JN, Lewin RJ.
    Non‑cardiac chest pain: A retrospective cohort study of patients
    who attended a rapid access chest pain clinic. Fam Pract
    12. Sekhri N, Feder GS, Junghans C, Hemingway H, Timmis AD.
    How effective are rapid access chest pain clinics? Prognosis of
    incident angina and non‑cardiac chest pain in 8762 consecutive
    patients. Heart 2007;93:458‑63.
    13. Robertson N, Javed N, Samani NJ, Khunti K. Psychological
    morbidity and illness appraisals of patients with cardiac and
    non‑cardiac chest pain attending a rapid access chest pain clinic:
    A longitudinal cohort study. Heart 2008;94:e12.
    14. Miller L. Psychotherapeutic approaches to chronic pain.
    Psychotherapy 1993;30:115.
    15. Foldes‑Busque G, Fleet R, Poitras J, Chauny JM, Belleville G,
    Denis I, et al. Preliminary investigation of the panic screening
    score for emergency department patients with unexplained chest
    pain. Acad Emerg Med 2011;18:322‑5.
    16. Beitman BD. Panic disorder in patients with angiographically
    normal coronary arteries. Am J Med 1992;92:33S‑40S.
    17. Mukerji V, Beitman BD, Alpert MA. Chest pain and
    angiographically normal coronary arteries. Implications for
    treatment. Tex Heart Inst J 1993;20:170‑9.
    18. Bruce SE, Yonkers KA, OttoMW, Eisen JL, WeisbergRB, PaganoM,
    et al. Influence of psychiatric comorbidity on recovery and recurrence
    in generalized anxiety disorder, social phobia, and panic disorder:
    A 12‑year prospective study. Am J Psychiatry 2005;162:1179‑87.
    19. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE.
    Prevalence, severity, and comorbidity of 12‑month DSM‑IV
    disorders in the national comorbidity survey replication. Arch
    Gen Psychiatry 2005;62:617‑27.
    20. Eaton WW, Kessler RC, Wittchen HU, Magee WJ. Panic and panic
    disorder in the United States. Am J Psychiatry 1994;151:413‑20.
    21. Husser D, Bollmann A, Kühne C, Molling J, Klein HU. Evaluation
    of noncardiac chest pain: Diagnostic approach, coping strategies
    and quality of life. Eur J Pain 2006;10:51‑5.
    22. Dammen T, Ekeberg O, Arnesen H, Friis S. Personality profiles
    in patients referred for chest pain. Investigation with emphasis
    on panic disorder patients. Psychosomatics 2000;41:269‑76.
    23. EslickGD, JonesMP, TalleyNJ. Non‑cardiac chest pain: Prevalence,
    risk factors, impact and consulting – A population‑based study.
    Aliment Pharmacol Ther 2003;17:1115‑24.
    24. Fass R, Achem SR. Noncardiac chest pain: Epidemiology,
    natural course and pathogenesis. J Neurogastroenterol Motil
    25. Hocaoglu C, Gulec MY, Durmus I. Psychiatric comorbidity in
    patients with chest pain without a cardiac etiology. Isr J Psychiatry
    Relat Sci 2008;45:49‑54.
    26. Sherbourne C, Wells K, Judd L. Functioning and well‑being of
    patients with panic disorder. Yearb Psychiatry Appl Ment Health
    27. Mendlowicz MV, Stein MB. Quality of life in individuals with
    anxiety disorders. Am J Psychiatry 2000;157:669‑82.
    28. Heldt E, Blaya C, Isolan L, Kipper L, Teruchkin B, Otto MW, et al.
    Quality of life and treatment outcome in panic disorder: Cognitive
    behavior group therapy effects in patients refractory to medication
    treatment. Psychother Psychosom 2006;75:183‑6.
    29. Weissman MM, Markowitz JS, Ouellette R, Greenwald S,
    Kahn JP. Panic disorder and cardiovascular/cerebrovascular
    problems: Results from a community survey. Am J Psychiatry
    30. Coryell W, Noyes R, Clancy J. Excess mortality in panic disorder.
    A comparison with primary unipolar depression. Arch Gen
    Psychiatry 1982;39:701‑3.
    31. Edlund MJ, Swann AC. The economic and social costs of panic
    disorder. Hosp Community Psychiatry 1987;38:1277‑9, 1288.
    32. Papanicolaou MN, Califf RM, Hlatky MA, McKinnis RA,
    Harrell FE Jr., Mark DB, et al. Prognostic implications of
    angiographically normal and insignificantly narrowed coronary
    arteries. Am J Cardiol 1986;58:1181‑7.
    33. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory
    care: Incidence, evaluation, therapy, and outcome. Am J Med
  2. 34. Katerndahl DA, Trammell C. Prevalence and recognition of panic
    states in STARNET patients presenting with chest pain. J Fam
    Pract 1997;45:54‑63.
    35. Sheikh JI, Leskin GA, Klein DF. Gender differences in panic
    disorder: Findings from the national comorbidity survey. Am J
    Psychiatry 2002;159:55‑8.
    36. Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S,
    Hwu HG, et al. The cross‑national epidemiology of panic disorder.
    Arch Gen Psychiatry 1997;54:305‑9.
    37. Joyce PR, Bushnell JA, Oakley‑Browne MA, Wells JE,
    Hornblow AR. The epidemiology of panic symptomatology and
    agoraphobic avoidance. Compr Psychiatry 1989;30:303‑12.
    38. Kessler RC, Chiu WT, Jin R, Ruscio AM, Shear K, Walters EE. The
    epidemiology of panic attacks, panic disorder, and agoraphobia in
    the national comorbidity survey replication. Arch Gen Psychiatry
    39. Stansfeld SA, Marmot MG. Social class and minor psychiatric
    disorder in British civil servants: A validated screening
    survey using the general health questionnaire. Psychol Med
    40. HuffmanJC, PollackMH. Predicting panic disorder among patients
    with chest pain: An analysis of the literature. Psychosomatics
    41. Eslick GD. Noncardiac chest pain: Epidemiology, natural history,
    health care seeking, and quality of life. Gastroenterol Clin North
    Am 2004;33:1‑23.
    42. Chiocca JC, Olmos JA, Salis GB, Soifer LO, Higa R,
    Marcolongo M, et al. Prevalence, clinical spectrum and
    atypical symptoms of gastro‑oesophageal reflux in argentina:
    A nationwide population‑based study. Aliment Pharmacol Ther
    43. Wong WM, Lai KC, Lam KF, Hui WM, Hu WH, Lam CL, et al.
    Prevalence, clinical spectrum and health care utilization of
    gastro‑oesophageal reflux disease in a Chinese population:
    A population‑based study. Aliment Pharmacol Ther
    44. Tew R, Guthrie EA, Creed FH, Cotter L, Kisely S, Tomenson B.
    A long‑term follow‑up study of patients with ischaemic heart
    disease versus patients with nonspecific chest pain. J Psychosom
    Res 1995;39:977‑85.