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Anxiety and cardiovascular risk: Review of Epidemiological and Clinical Evidence O Olafiranye1

, G Jean-Louis13 , F Zizi13 , J Nunes3,4 , and MT Vincent5

Affiliations: 1Brooklyn Health Disparities Center, Department of Medicine, SUNY Downstate Medical Center, NY; 2Sleep Disorders Center, Department of Neurology, SUNY Downstate Medical Center, NY; 3Brooklyn Research Foundation on Minority Health, Kingdbrook Jewish Medical Center, NY; 4Sophie Davis School of Biomedical Education, City College New York, NY and 5Department of Family Medicine, SUNY Downstate Medical Center, NY, USA

ABSTRACT An increasing body of evidence suggests that anxiety is an independent predictor of adverse cardiovascular (CV) events. Individuals with

high levels of anxiety are at increased risk of coronary heart disease, congestive heart failure, stroke, fatal ventricular arrhythmias, and sudden cardiac death. Anxiety following a major cardiac event can impede recovery, and is associated with a higher morbidity and mortality. This linkage between anxiety and CV disease is further corroborated by evidence suggesting that treatment of anxiety may improve cardiac symptoms. However, the mechanisms underlying the observed associations are not entirely delineated. Several intermediary mechanisms have been suggested, including sympathetic activation, impaired vagal control, reduced heart rate variability, stimulation of the hypothalamicpituitary axis, hyperventilation-induced coronary spasm, oxidative stress, increased inflammatory mediators, and unhealthy lifestyle. There is a need for several clinical trials to explicate the complex associations between anxiety and CV disease, which may be compounded by the involvement of other psychosocial factors. In this review, we examine the epidemiological evidence for the association between anxiety and CV disease, and discuss the proposed mechanisms that may be responsible for this association.

Keywords: cardiovascular risk, anxiety, psychological distress, emotion

Correspondence: Jean-Louis Girardin, Department of Medicine (Box 1199), SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 112032098, USA. Tel: (1)-7182702716; Fax: (1)-7182702917; e-mail:

BACKGROUND Coronary heart disease (CHD) is the leading cause of death

and disability in the United States (US) and other developed countries.1 By the year 2020, CHD is projected to be the leading cause of death, not only in the developed world but also in the developing world.24 It is well known in the psychological literature that negative emotions such as anxiety are common among patients with cardiovascular (CV) symptoms, but few studies have examined associations between these two conditions.

Anxiety is defined as an unpleasant emotion that is triggered by anticipation of future events and memories of past events, and it could manifest in different forms (panic disorder, phobic anxiety, generalized anxiety, anxiety reac- tions, and chronic anxiety).5,6 Anxiety affects about 24.9% of the population at some time in their lives7 with reported worldwide prevalence of 16.6%.8 Studies suggest that 3870% of all persons with congestive heart failure (CHF) have some form of anxiety, and older adults with CHF report anxiety levels that are estimated to be 60% higher than those without such symptoms.913 Among independently living women, our group observed a greater likelihood for highly anxious women to report CV symptoms.14

Although the association of traditional CV risk factors with

adverse outcomes has been well delineated,15 recent research indicates that the impact of psychosocial distress on CV

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morbidity and mortality is almost equal to the impact of demographic characteristics (age, sex, and race) and risk markers (smoking, alcohol, obesity, diabetes, dyslipidemia, and hypertension).16 Despite this observation, only a few studies have focused on the impact of anxiety and other psychosocial factors on CV outcomes. Underappreciation of the role of psychosocial factors in the development and progression of cardiac diseases may be one reason why they remain the number one cause of death in most developed countries. Although most of the studies exploring the relationship between CV disease and negative emotions have focused on depression, most patients with confirmed or suspected CV disease have some degree of anxiety.913 Anxiety following a major cardiac event can impede recovery, and is associated with higher morbidity and mortality.1721 Although several studies have found that anxiety is related to increased mortality,17,18,2225 some studies have found no difference or even a decrease in morbidity and mortality following myocardial infarction (MI).2629

The evidence suggests that treatment of psychosocial distress may decrease CV events.3033 However, the mechan- isms underlying the observed associations are not entirely delineated. Several intermediary mechanisms have been suggested, including sustained sympathetic activation, hyper- ventilation-induced coronary spasm, oxidative stress, in- creased inflammatory mediators, and unhealthy lifestyle changes.3439 There is a need for several randomized clinical


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