The Association of Emergency Department Crowding During Treatment for Acute Coronary Syndrome With Subsequent Posttraumatic Stress Disorder Symptoms

Our recent meta-analysis of 24 studies (N = 2383 patients) found that 12% of patients with acute coronary syndrome (ACS) (including patients with ST-segment elevation myocardial infarction [STEMI], non-STEMI, and unstable angina [UA]) develop posttraumatic stress disorder (PTSD) symptoms owing to their ACS, and that these PTSD symptoms 1 month post-ACS are associated with a doubling of risk for ACS recurrence or mortality in the subsequent 1 to 3 years.¹ Although we reviewed the known risk factors for ACS-induced PTSD, including demographic and psychological factors, we noted that no study has addressed the possibility that the medical environments in which initial ACS diagnosis and treatment occur might contribute to the traumatic nature of patients' experience during their ACS events. The emergency department (ED) is the initial medical environment for most patients with ACS, and the ED they enter is often overcrowded and chaotic.² This overcrowding problem has recently been identified as a public health problem by the Institute of Medicine,³ due in part to associated delays in treatment and lower patient satisfaction. Emergency department crowding may contribute to poor cardiovascular outcomes in patients who present with chest pain,⁴ and we believe that crowded EDs may also contribute to increased risk for ACS-induced PTSD. We hypothesized that greater ED crowding would be associated with increased ACS-induced PTSD symptoms 1 month after presentation at an ED with an ACS event.