Emergency departments (ED) save lives, but some modifiable ED factors may cause patients harm in the long term. The goal of the proposed research is to benefit millions of patients by identifying those ED factors that are associated wit poor long-term psychiatric and medical prognosis after ED treatment. Most medical contexts are calm and predictable, but EDs frequently are not. Overcrowding and associated factors vary substantially through the course of a single day in almost every ED in the US, with some hours characterized by calm and quiet and others by overcrowding and chaos. We have found that patients treated for acute cardiac events when the ED is crowded are at increased risk for developing posttraumatic stress disorder (PTSD) symptoms, and that PTSD symptoms after a cardiac event are associated with a doubling of risk for a subsequent cardiac event or mortality. Further, research conducted in the past two years has shown that acute cardiac patients treated in crowded EDs are at increased risk for in-hospital and one-year mortality. It is possible that ED factors increase the risk of PTSD, which in turn may lead to worse cardiac outcomes. Although many of the hypothesized iatrogenic aspects of EDs are modifiable, clinical guidelines ignore them and very few EDs have taken the steps necessary to address them. In fact, while ST-segment elevation myocardial infarction [STEMI] patients are treated in accordance with well-defined clinical pathways that ensure they are moved quickly through the ED, no such guidelines govern the ED treatment of over one million patients hospitalized annually in the United States with non-ST-segment elevation MI (NSTEMI) or unstable angina (UA). Thus, these patients are often exposed to potentially harmful ED factors for 12 hours or longer while they wonder whether they are having a life-threatening heart attack. Whether ED factors increase risk for PTSD and subsequent cardiac events/mortality in NSTEMI/UA patients have not been tested comprehensively. We propose observing a cohort of patients with NSTEMI/UA from presentation in the ED through inpatient care. We will measure three potentially harmful ED factors: (1) crowding (census, wait time, and exposure to others'critical care);(2) interpersonal factors (doctor-patient communication, presence and effectiveness of social support);and (3) patient reactions (physiological arousal and psychological arousal). Research coordinators will first capture real-time crowding data and patients'psychological reactions briefly in the ED then assess patient reactions and interpersonal factors comprehensively during inpatient stay. A clinician will interview participants by telephone to determine PTSD status one month after baseline, and we will ascertain cardiac event recurrence and all-cause mortality (ACM) one year after baseline. Potentially harmful ED factors are modifiable. This research will determine whether ED factors increase risk of cardiac recurrence, mortality, and PTSD in the more than one million NSTEMI/UA patients treated in US EDs every year, identify those factors that are most important to target, and point to interventions to offset that risk.

Public Health Relevance

The emergency department (ED) is designed to save lives, but ED factors such as overcrowding, poor doctor- patient communication and lack of appropriate social support in the ED may increase the risk of cardiac event recurrence, mortality, and/or PTSD in the more than one million non-ST-elevation myocardial infarction and unstable angina patients treated each year. Identifying modifiable ED factors that are associated with an increased risk will improve clinical care for cardiac patients in ways that can be tested i future randomized trials that evaluate medical and psychological prognoses.

National Institute of Health (NIH)
National Heart, Lung, and Blood Institute (NHLBI)
Research Project (R01)
Project #
Application #
Study Section
Social Psychology, Personality and Interpersonal Processes Study Section (SPIP)
Program Officer
Stoney, Catherine
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Columbia University (N.Y.)
Internal Medicine/Medicine
Schools of Medicine
New York
United States
Zip Code
Whang, William; Davidson, Karina W; Palmeri, Nicholas O et al. (2016) Relations among depressive symptoms, electrocardiographic hypertrophy, and cardiac events in non-ST elevation acute coronary syndrome patients. Eur Heart J Acute Cardiovasc Care 5:455-60
Chang, Bernard P; Sumner, Jennifer A; Haerizadeh, Myrta et al. (2016) Perceived clinician-patient communication in the emergency department and subsequent post-traumatic stress symptoms in patients evaluated for acute coronary syndrome. Emerg Med J 33:626-31
Haerizadeh, Mytra; Moise, Nathalie; Chang, Bernard P et al. (2016) Depression and doctor-patient communication in the emergency department. Gen Hosp Psychiatry 42:49-53
Sundquist, Kevin; Chang, Bernard P; Parsons, Faith et al. (2016) Treatment rates for PTSD and depression in recently hospitalized cardiac patients. J Psychosom Res 86:60-2
Homma, Kirsten; Chang, Bernard; Shaffer, Jonathan et al. (2016) Association of social support during emergency department evaluation for acute coronary syndrome with subsequent posttraumatic stress symptoms. J Behav Med 39:823-31
Chang, Bernard P; Carter, Eileen; Suh, Edward H et al. (2016) Patient treatment in ED hallways and patient perception of clinician-patient communication. Am J Emerg Med 34:1163-4
Edmondson, Donald; Arndt, Jamie; Alcántara, Carmela et al. (2015) Self-Esteem and the Acute Effect of Anxiety on Ambulatory Blood Pressure. Psychosom Med 77:833-41
Sumner, Jennifer A; Kronish, Ian M; Pietrzak, Robert H et al. (2015) Dimensional structure and correlates of posttraumatic stress symptoms following suspected acute coronary syndrome. J Affect Disord 186:178-85
Papini, Santiago; Sullivan, Gregory M; Hien, Denise A et al. (2015) Toward a translational approach to targeting the endocannabinoid system in posttraumatic stress disorder: a critical review of preclinical research. Biol Psychol 104:8-18
Cohen, Beth E; Edmondson, Donald; Kronish, Ian M (2015) State of the Art Review: Depression, Stress, Anxiety, and Cardiovascular Disease. Am J Hypertens 28:1295-302

Showing the most recent 10 out of 19 publications