From Heartwire
Lisa Nainggolan
June 21, 2010 (Tilburg, the Netherlands and Stockholm, Sweden) - Two new studies firmly establish anxiety as an independent predictor for subsequent coronary heart disease years down the line [1,2]. Doctors, who often neglect to ask patients about their feelings, should pay heed to these findings, say the researchers.
Dr Annelieke M Roest (Tilburg University, the Netherlands) and colleagues performed the first-ever meta-analysis on the association of anxiety with the incidence of CHD in initially healthy people, using data from the US, Europe, and Asia. Even after multivariate adjustment, anxious people had around a 25% greater risk of CHD and an almost 50% higher risk of cardiac death over a mean follow-up period of 11.2 years.
In the second study, almost 50 000 Swedish men who were medically examined for military service and followed for an average of 37 years were assessed by Dr Imre Janszky (Karolinska Institute, Stockholm, Sweden) and coworkers. Depression was not a predictor for subsequent coronary disease, but those with anxiety disorders--as diagnosed by a psychiatrist--were twice as likely to suffer CHD or acute MI, even after adjustment for baseline confounders.
The new papers appear in the June 29, 2010 issue of the Journal of the American College of Cardiology, as does an accompanying editorial [3] by psychiatrist Dr Joel E Dimsdale (University of California, San Diego).
qAnxiety symptoms can be such a strong beacon, lighting the way to future coronary disease decades in advance.
Dimsdale says it is "odd that anxiety symptoms can be such a strong beacon, lighting the way to future coronary disease decades in advance." Cardiologists, he says "are certainly cognizant of anxiety's effects" on transient physiology, such as blood pressure, palpitations, and angina, but this new research suggests that asking about previous early-life anxiety might be relevant in clinical assessment for the diagnosis and prevention of cardiovascular disease.
And although trials are needed to see whether therapies aimed at alleviating anxiety would reduce cardiovascular risk, "until proven otherwise, the wise clinician might 'assume' that treatment of anxiety disorders might have benefits beyond immediate symptomatic and functional improvement," he observes.
Clinicians Should Be Aware of the Risk of Anxiety
In their meta-analysis, Roest and colleagues combined data from 20 studies, including approximately 250 000 initially healthy individuals from the US, Norway, the Netherlands, Sweden, Japan, and the UK. The studies were all prospective in nature and had to have included at baseline at least one self-report or interview-based assessment of anxiety symptoms or anxiety disorder. End points had to include cardiac mortality or MI.
Adjustment for confounding factors was performed in 18 of the 20 studies; the researchers found that anxious people were at higher risk of CHD (hazard ratio 1.26; p<0.0001) and cardiac death (HR 1.48; p=0.003), with a nonsignificant trend for an association between anxiety and nonfatal MI (HR 1.43; p=0.180).
"Our most important finding was that anxiety was associated with the development of incident CHD in initially healthy persons," Roest told heartwire .
"Clinicians should be aware of this; if they have anxious patients, they might be at risk to develop heart disease, and this was in initially healthy patients. But you also see this risk in patients who already have heart disease; there is a relationship with the progression of heart disease," she noted.
Anxiety, But Not Depression, Associated With CHD Risk
In the Swedish conscript study, depression and anxiety were diagnosed by psychiatrists during the medical exam of males aged 18 to 20 in 1969 and 1970. Data on well-established CHD risk factors and potential confounders were also collected. Participants were followed for CHD and AMI for 37 years.
Multivariate-adjusted hazard ratios for depression were 1.04 for CHD and 1.03 for AMI. For anxiety, these were 2.17 and 2.51, respectively.
"We uniquely investigated the long-term relationship between depression and anxiety, diagnosed by experts in men aged 18 to 20 years, and the subsequent long-term CHD outcome in a large sample of men. Anxiety . . . independently predicted CHD events. In contrast, we found no support for such an effect concerning early-onset depression in men," say Janszky et al.
They suggest that one of the reasons why many previous studies have found a link between depression and CHD could be because these often employed self-reporting of such symptoms.
"Anxiety and depression are independent psychopathological conditions, although they share common symptoms and are very often comorbid." Participants in prior studies may have been unable to distinguish one from the other, they propose.
Roest told heartwire it is important that studies look at the interaction of anxiety and depression, "because there is such a large overlap between them."
Anxiety Disorders as Prevalent as Hypertension
In his editorial, Dimsdale says that new risk factors for CHD need to be "carefully scrutinized for clinical utility." Anxiety disorders, he notes, "are as prevalent as hypertension" and are a major affliction of the young, with a lifetime prevalence of around 28%. Their impact on global functioning is roughly akin to that of lower back pain or leg ulcers. And when anxiety coexists with depression, the corresponding impact on quality of life "is even worse," he observes.
But physicians, he notes, "are frequently timid about assessing emotional symptoms. It is odd that we thread catheters, ablate lesions, and give rectal exams but are uncomfortable asking patients about their lives."
Roest agrees, telling heartwire , "There hasn't been a lot of research on anxiety; most has focused on depression, and what we know from depression is that it's very difficult for physicians to recognize it."
But Dimsdale says "assessment tools like the PRIME-MD [4] are readily available, with easy-to-ask questions," opening the door for discussion. These new findings suggest that including information about anxiety disorders in clinical assessments "might be relevant for the diagnosis (and prevention) of CHD," he concludes.
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