Anxiety and Heart Disease
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Anxiety is an emotional response to a situation, which has both psychological and physiological consequences. Anxiety may be a normal response to daily life situations. However, a heightened or an inappropriate level of anxiety may lead to several deleterious consequences to overall health. There is mounting research about the role of anxiety in the pathophysiology of heart disease.
In the past decade, there has been increasing interest in the relationship between anxiety and heart disease. As reviewed by Rozanski et al. (1999) prior to 1999, there were a limited number of prospective studies demonstrating a relationship between anxiety and subsequent cardiovascular disease (CVD) outcomes in healthy populations and in patients with prevalent CVD.
After these initial studies, additional prospective studies examining the relationship between anxiety and CVD outcomes in participants without prior CVD history have been published. For example, Albert et al. (2005) investigated the relationship between anxiety and CVD events in women without a history of CVD and found that anxiety was associated with a higher risk of sudden cardiac death and fatal coronary heart disease. However, these relationships were attenuated after adjustment for medical factors. On the other hand, Shen et al. (2008) showed that in older men without CVD history, anxiety was associated with incident myocardial infarction even after adjustment for medical factors, medication use, adverse health behaviors, and other psychosocial factors including depression. More recently, Janszky et al. (2010) showed that in young Swedish men, anxiety was associated with an increased risk of incident coronary heart disease events including myocardial infarction during long-term follow-up (mean = 37-year follow-up) in unadjusted and adjusted multivariable models. In 2010, Roest et al. (2010a) published a meta-analysis of 20 studies showing that anxiety was associated with incident coronary heart disease events and cardiac death, independent of medical factors and health behaviors. No relationship was found between anxiety and nonfatal myocardial infarction in five studies that examined myocardial infarction as a separate outcome.
Additional prospective studies have also examined the relationship between anxiety and CVD outcomes in participants with prevalent CVD. For instance, Shibeshi et al. (2007) showed in patients with coronary artery disease that a high level of anxiety over time predicted an increased risk of nonfatal myocardial infarction or death after adjustment for possible confounders. Huffman et al. (2008) showed that anxiety was associated with an increased risk of CVD complications during a hospitalization for a myocardial infarction in adjusted models. More recently, Martins et al. (2010) demonstrated that anxiety was independently associated with CVD events in men with stable coronary artery disease. In 2010, Roest et al. (2010b) published a meta-analysis examining the relationship between anxiety and CVD outcomes in post-myocardial infarction patients. Anxiety was associated with an increased risk of CVD events independent of other prognostic factors.
Although the evidence base is growing in the area of anxiety and heart disease, several questions remain.
First, given that depression is highly comorbid with anxiety, it has not been determined with a high level of certainty whether the relationship of anxiety with CVD events is independent of depression. In the meta-analysis by Roest et al. (2010b), which included participants without CVD history, only 5 of the 20 studies adjusted for depression, although the associations in 4 of the 5 studies remained significant. In patients with preexisting CVD, this issue may be more complex. Few studies have ascertained the independent contributions of anxiety and depression on CVD outcomes. Strik et al. (2003) found that although both anxiety and depression were separately associated with increased CVD events in post-myocardial infarction patients, the association between anxiety (and not depression) and CVD events remained significant when both psychosocial factors were placed into the same multivariable model. Doering et al. (2010) showed that in adjusted models, the combined presence of persistent anxiety and depression over 3 months was associated with mortality in patients with ischemic heart disease, whereas persistent anxiety only and persistent depression only were not. In addition to depression, some evidence suggests that the combination of anxiety and Type D personality may be cardiotoxic. van den Broek et al. (2009) showed that anxiety was associated with ventricular arrhythmias in patients with implantable cardioverter-defibrillators but only in the presence of Type D personality. Therefore, the CVD risk associated with anxiety may depend on comorbid depression and/or Type D personality. The contributions of other psychosocial/personality factors remain unknown.
Second, the mechanisms underlying the association between anxiety and CVD events also are unknown. Possible candidates include accelerated subclinical atherosclerosis, autonomic dysregulation, ventricular electrical instability, unhealthy lifestyles, and reduced treatment adherence.
Third, the construct of anxiety is broad, and it is unclear what constitutes the main “ingredients” of anxiety-associated CVD risk. In the prospective studies of non-CVD and CVD participants, anxiety has been assessed using self-report measures and also by interviewer assessment. Further, phobic anxiety, generalized anxiety, neurotic anxiety, somatic symptoms of anxiety, social introversion, manifest anxiety, and psychasthenia are among the different manifestations of anxiety that have been associated with increased CVD risk.
Lastly, it is currently not known whether treating anxiety using pharmacologic or non-pharmacologic strategies reduces the risk of CVD events.
References and Further Reading
- Shen, B. J., Avivi, Y. E., Todaro, J. F., Spiro, A., III, Laurenceau, J.-P., Ward, K. D., et al. (2008). Anxiety characteristics independently and prospectively predict myocardial infarction in men: The unique contribution of anxiety among psychologic factors. Journal of the American College of Cardiology, 51, 113–119.CrossRefGoogle Scholar
- Strik, J. M. H., Denollet, J. K. L., Lousberg, R., & Honig, A. (2003). Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. Journal of the American College of Cardiology, 42(10), 1801–1807.CrossRefGoogle Scholar