Built-up, high level of anxiety can lead to increased MI, mortality risk

Medical professionals should work with patients with CAD to assess their anxiety and promote a healthier lifestyle.

Patients with coronary artery disease and a high level of anxiety have nearly double the risk for myocardial infarction or death compared with those who reduce or manage their anxiety levels, according to study results published in the Journal of the American College of Cardiology.

“When patients have rising anxiety levels, they are at much higher risk,” said Charles M. Blatt, MD, assistant clinical professor of medicine at Harvard Medical School and director of research at the Lown Cardiovascular Research Foundation, Boston. “There is a firm biological basis for this being an important instigator of poor cardiovascular health.”

Previous study data have shown that stress and depression can have harmful effects on the heart and blood vessels, but until now there have been conflicting data on the impact of anxiety on cardiac health or the benefits of relieving anxiety over a prolonged period of time.

“Doctors have the potential of influencing patients’ anxiety levels by how they care for the patient, and if they are successful in allaying their anxiety, then these patients may do better,” Blatt told Today In Cardiology.

Assessing anxiety

Source: J Am Coll Cardiol. 2007;49:2021-2027.

Blatt and colleagues conducted the prospective cohort study among 516 patients with proven CAD who had not undergone CABG, stenting or angioplasty. The average age of participants was 62 years, and 82% were men.

The researchers followed patients for more than three years. At the beginning of the study and each year thereafter, the patients completed the Kellner Symptom Questionnaire, an internally validated 92-item list.

During the study period, 19 patients died and 44 had a nonfatal MI. Blatt and colleagues reported cumulative anxiety scores, adjusted for age, and divided patients into three groups.

Those with anxiety scores in the highest third had nearly double the risk for nonfatal MI or death compared with those in the lowest third (HR=1.97; 95% CI, 1.03-3.78). The data also showed a 6% increase in the risk for death or MI each time the average cumulative anxiety score increased by one unit (HR=1.06; 95% CI, 1.01-1.12).

An increase in anxiety during a period of time increased the risk for MI or death by 10% (P<.001), according to the researchers. Conversely, among the least likely to have an MI or die were patients whose anxiety level was in the highest third at baseline but in the lowest third when cumulative average anxiety levels were tallied.

“There is a distinct difference between those whose anxiety levels rise vs. those who stay the same or go down,” Blatt said. “Anxiety appears independent from depression and needs to be accounted for when patients are studied long-term.”

Importance of interventions

Findings from this study show not only the need for repeated measurements to accurately gauge the impact of anxiety but they also suggest an important role for physicians in reassuring patients with anxiety, according to Blatt.

Spending extra time with patients and families gives the cardiologist an opportunity to talk about the nature of CHD, adjust medications, encourage exercise and provide effective strategies to improve cardiac risk factors. It also helps establish a relationship that allays fears.

“The cardiologist as the ‘expert’ has an extraordinary power to influence a patient’s course,” Blatt said. “Spending time and listening to the patient helps to reduce a person’s anxiety and substantially improve prognosis.”

The next chapter of this study is to determine the most effective ways of relieving anxiety and improving cardiac health. The researchers plan to evaluate the impact of anti-anxiety medications and psychotherapy as forms of interventions, and Blatt and colleagues hope to take a closer look at the doctor–patient relationship. – by Tara Grassia

For more information:

• Shibeshi WA, Young-Xu Y, Blatt CM. Anxiety worsens prognosis in patients with coronary artery disease. J Am Coll Cardiol. 2007;49:2021-2027.