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Anxiety and cardiovascular risk


trials to explicate the complex associations between anxiety and CV disease, which may be compounded by the involve- ment of other psychosocial factors. In this review, we examine the evidence linking anxiety to CV disease, and discuss the proposed mechanisms that may be responsible for this association.


LINK BETWEEN ANXIETY AND CARDIOVASCULAR SYMPTOMS


Evidence from CHD studies


Epidemiological evidence indicates that pathophysiological correlates of negative emotions may contribute to athero- sclerosis.3 However, several studies evaluating the link between negative emotions and cardiac disease have focused on depression.4 Recent studies have demonstrated a relation- ship between hostility or anger and measurements of subclinical atherosclerosis,4043 and have also linked hostility to progression of atherosclerosis during serial coronary angiography.44 In a population-based sample of 726 men and women who were healthy at baseline, Paterniti and colleagues45 showed that high levels of sustained anxiety were independently associated with increased progression of atherosclerosis over a 4-year period, as measured by changes in common carotid artery intima media thickness. Among hypertensive patients, White and Baker46 found a mean increase of 27 mmHg in systolic blood pressure (SBP) and 5 mmHg in diastolic blood pressure (DBP), and an increase of 14 beats/min in the heart rate during the hour of a panic attack. In other studies, anxiety level was positively correlated with SBP,4749 but not with DBP.50


Three large-scale, community-based studies including one involving 34000 men showed significant relationships be- tween anxiety disorders and CV death.17,18,25 Haines and colleagues25 followed 1457 initially healthy men for about 10 years in the Northwick Park heart study. Those with the highest levels of phobic anxiety had a higher risk of fatal CHD than men reporting no anxiety, after controlling for a range of known coronary risk factors.25 Furthermore, a recent study from a US population showed that anxiety was associated with 60% excess risk of CHD among men and women, an effect that was independent of traditional CHD risk factors.51 Chronic anxiety appears to increase the risk of incident CHD, with risk estimates from 1.5 to 7, depending on the type of anxiety measure used and the form of the analysis.17,18,25,5158 Among healthy individuals, higher levels of anger symptoms were significantly associated with a 1.5- to threefold excess risk of incident CHD over a 5- to 15-year follow-up period.5963


In two studies involving patients participating in cardiac rehabilitation programs, anxiety symptoms predicted worse long-term prognosis.19,20 As these studies included psycho- logical treatment components during follow-up, it is difficult to interpret the results. In another study, 222 patients who received usual care for 1 year were examined during hospitalization for MI. The results of that study indicated


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an increase in CV risk associated with anxiety symptoms that was independent of history of major depression and previous MI.21 Other studies have also shown associations of anxiety with cardiovascular events,23,6469 but differences in the measures used, timing of measurement, and variations in sample sizes make it difficult to establish a head-to-head comparison of those findings.


Findings of positive relationships between anxiety and CV


disease are not universal. One large study involving over 2000 patients with CAD assessed before routine stress tests found that anxiety, measured with the anxiety subscale of the Hospital Anxiety and Depression Scale,70 was associated with lower mortality rates.27 Investigators in that study speculated that anxiety might be related to increased tendencies to seek medical attention or alter risk factors.27 Another study that evaluated 344 patients after MI reported no relationship between either anxiety or depression and 1- year mortality.26 However, the mortality rate was low (4%) in that study.


Evidence from CHF studies Evidence supporting a prognostic impact of anxiety on CHF


is scant and not entirely consistent. Riedinger and collea- gues71 demonstrated that anxiety was an independent pre- dictor of adverse cardiac events among patients with recent MI and low ejection fraction. In another study, anxiety was directly related to brain natriuretic peptide level,72 suggesting a relationship between anxiety and CHF.72 However, these findings are not consistent with other studies showing that poor outcomes and rehospitalization were associated with depression, but not with anxiety.7378 Friedman et al73 found an association between anxiety and outcomes among patients with heart failure, but this association was not maintained after controlling for potential confounders. Jiang et al74 did not find a significant association between anxiety symptoms and mortality in hospitalized patients with heart failure. The reasons for these discrepancies are not completely under- stood, but they may be related to differences in study population and methodology.


Evidence from psychosocial intervention studies


The impact of psychosocial interventions on CV outcomes represents a new area of interest. Epidemiological evidence suggesting that treatment of anxiety and other psychosocial factors may improve CV symptoms and decrease adverse outcomes corroborate the link between psychosocial risks and CV disease. In the initial successful intervention trial in this arena, the Ischemic Heart Disease study, a unique home- based stress reduction program, showed that treatment was associated with reduction in cardiac events.30 The Recurrent Coronary Prevention Project Study succeeded in decreasing both type A behavior and negative affect, and also reduced the rates of CV mortality and non-fatal MI by using behavior modification.31 Furthermore, among patients referred to cardiac rehabilitation programs, Dusseldorp et al32 observed differential reduction in the odds ratio for mortality and recurrent MI following reduction in psychological stress. In a


M&B 2011; 2:(1). July 2011


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