reviewed by Martino Pepe

We welcome another landmark contribution to refine our care of patients with cardiovascular disease, published in the European Journal of Preventive Cardiology, focusing on the interplay between psychiatric disease and urgent care for chest pain.(1) Indeed, for both cardiologists and emergency physicians, the combination of severe mental illness and acute chest pain represents a major challenge, with psychiatric complexity and cardiovascular risk colliding and often obscuring the urgency of accurate diagnosis.(2) These individuals shoulder a heavy load of risk factors, autonomic dysregulation, and stress-induced ischemia, yet may recognize symptoms late, describe them vaguely, or arrive dulled by antipsychotics, mood stabilizers, benzodiazepines, or polypharmacy that hampers history-taking and examination.(3) Beyond the mechanisms examined by Nørskov et al., symptom appraisal may be so challenging for patients with severe mental illness and their relatives that emergency services are not even contacted, and longer-term adherence to cardioprotective therapies—well beyond the study’s 30-day follow-up—may be poor; both factors could further worsen cardiovascular prognosis. Schizophrenia, bipolar disorder, major depression, and comorbid substance use further fragment communication, impair insight, and erode trust, so that apparently “atypical” chest pain is hastily dismissed as panic, somatization, or drug craving rather than possible infarction. Within crowded emergency departments, triage algorithms assume clear narration of symptoms, while dispatcher notes highlighting agitation or overdose risk may bias staff toward psychiatric explanations, delaying electrocardiography, biomarker sampling, or cardiology consultation when every minute counts. Even when ambulances are dispatched promptly, terse handovers emphasize behavioral disturbance and psychotropic use more than cardiovascular vulnerability, encouraging reassurance that the problem is primarily psychiatric, and therefore manageable without immediate invasive investigation or treatment.(4) The result is a paradoxical pattern in which those at heightened cardiovascular risk receive less meticulous early evaluation and less guideline-directed therapy than ostensibly healthier counterparts, underscoring the need to redesign acute care pathways at this mind–heart intersection.

Contemporary cohorts of patients with severe mental illness presenting with chest pain reveal systematic underdiagnosis and undertreatment, despite similar formal access to emergency triage and, not rarely, more rapid ambulance dispatch than that offered to psychiatrically healthy peers.(5) Communication barriers, fluctuating insight, cognitive impairment, and the sedating or disorganizing effects of antipsychotics and benzodiazepines blunt symptom narratives, inviting clinicians to reframe chest pain as anxiety, somatization, or behavioural disturbance rather than potential acute coronary syndrome. Consequently, these patients undergo fewer troponin measurements, non-invasive tests, and coronary angiographies, and are less frequently offered guideline-directed antiplatelet, lipid-lowering, and revascularization strategies, thereby institutionalizing therapeutic minimalism that contradicts their high burden of cardiovascular risk factors.(6) Such diagnostic and therapeutic inertia carries prognostic penalties, with higher rates of recurrent ischemia, heart failure, and rehospitalization, compounded by poorer attendance at follow-up, fragile adherence to cardioprotective medication, and the relapse-prone course of the underlying psychiatric disorder itself. Psychotropic polypharmacy, particularly second-generation antipsychotics and some mood stabilizers, further worsens cardiometabolic profiles, promotes dyslipidaemia, diabetes, and weight gain, and increases arrhythmic vulnerability, thereby amplifying baseline risk precisely in those least likely to receive assertive cardiological evaluation. Taken together, the interplay of communication hurdles, pharmacological toxicity, and fragmented, psychiatry-blind secondary prevention forges a vicious circle in which mental illness and heart disease mutually reinforce each other, translating potentially modifiable disparities into avoidable excess mortality.

Psychotropic medications, long considered ancillary to the cardiologist’s remit, are rapidly emerging as double-edged swords for patients with severe mental illness who seek urgent care for chest pain.(7) Antipsychotics, mood stabilizers, and antidepressants may induce weight gain, dyslipidemia, QT prolongation, and autonomic imbalance, silently magnifying baseline cardiovascular risk while simultaneously clouding the clinical picture with sedation, akathisia, or anxiety-like symptoms mimicking angina. In such patients, the very drugs that restore psychic equilibrium may impair the clarity of communication, limiting the ability to provide a coherent history, to recognize red-flag symptoms, and to engage in time-sensitive shared decision-making for diagnostic and therapeutic steps—effects that, together with stigma, can lead to misclassification of chest pain as functional or panic-related and to underuse of electrocardiography, troponin testing, and early coronary imaging. Prognosis may thus be compromised twice over, by accelerated atherosclerosis and arrhythmic vulnerability on the one hand, and by diagnostic delay or therapeutic nihilism on the other, culminating in preventable myocardial damage. Only through explicitly integrated psycho-cardiology pathways, including systematic medication reconciliation and liaison-psychiatry input at triage, can clinicians begin to disentangle drug effects from primary cardiac disease.(8) Such models must also prioritize empathic, jargon-free explanations tailored to cognitive capacity, thereby restoring trust, improving adherence to dual cardiologic and psychiatric regimens, and ultimately offering these vulnerable patients a fairer chance at both mental and cardiovascular survival.

In conclusion, closing the gap at this mind–heart crossroads requires genuinely integrated pathways in which psychotropic regimens, communication barriers, and hidden cardiometabolic injury are treated as central elements of chest pain assessment, not peripheral curiosities. By embedding liaison psychiatry in acute cardiac care, adapting triage to impaired narratives, and ensuring equitable diagnostics and guideline-based therapy, we can begin to turn avoidable excess mortality into preventable harm.

Figure 1. Disentangling the conundrum of urgent care for chest pain in patients with psychiatric disease.

(source: created by Giuseppe Biondi-Zoccai)

Acknowledgement: This manuscript was drafted and illustrated with the assistance of artificial intelligence tools, in keeping with established best practices (Biondi-Zoccai G. ChatGPT for Medical Research. Torino: Minerva Medica; 2024). The final content, including all conclusions and opinions, has been thoroughly revised, edited, and approved by the authors. The authors take full responsibility for the integrity and accuracy of the work and retain full credit for all intellectual contributions. Compliance with ethical standards and guidelines for the use of artificial intelligence in research has been ensured.

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.