Anxiety and Cardiac Disease

Una D. McCann, MD, James A. Fauerbach, PhD,
and Brett D. Thombs, PhD

Dr. McCann is associate professor, Dr. Fauerbach is associate professor, and Dr. Thombs is a postdoctoral fellow in the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins School of Medicine in Baltimore, Maryland.

Disclosure: Dr. McCann receives grant and/or research support from the National Institute on Drug Abuse and is on the speaker’s bureaus of Bristol-Myers Squibb and Pfizer. Drs. Fauerbach and Thombs do not have any affiliations or financial interests in a commercial organization that might pose a conflict of interest.

Funding/support: This work was supported by a grant from the United States Department of Education National Institute on Disability and Rehabilitation Research (grant no. H133A020101) awarded to Dr. Fauerbach.

Please direct all correspondence to: Una D. McCann, MD, Department of Psychiatry, The Johns Hopkins School of Medicine, 5510 Nathan Shock Dr, Baltimore, MD 21224; Tel: 410-550-1972; Fax: 410-550-0030; E-mail: [email protected].

Abstract

Does anxiety lead to increased cardiac morbidity? Scientists have hypothesized a relationship between emotions and the heart for centuries, and recent research supports that contention. In particular, a growing body of evidence indicates that negative emotions, including anxiety, are independent risk factors for cardiovascular disease, and that the presence of anxiety in patients with cardiovascular disease increases morbidity and possibly mortality. Clinicians treating patients with known or suspected cardiac disease are likely to encounter various forms of anxiety, ranging from normal reactions to acute illness to an anxiety disorder masquerading as cardiovascular disease. This article will review the various forms of anxiety most commonly associated with cardiovascular disease, as well as recommended treatment strategies.

Introduction

Links between the heart and emotion have been postulated for centuries. However, data supporting this connection have only become available recently. A growing body of evidence now suggests that negative affective states, including anxiety, lead to an increased risk for cardiovascular disease,^1-6 and that the presence of negative affective states are associated with poor long-term prognosis.^7-10 Although much of the literature exploring the relationship between cardiovascular disease and emotion has been focused on depression, care providers are equally likely to encounter the presence of anxiety in patients with confirmed or suspected cardiovascular disease.^9,11 In addition to being among the most common psychiatric illnesses in the United States,¹² the anxiety disorders as a group are over-represented in patients with cardiovascular disease.^13,14 However, with the exception of phobic anxiety, which has been linked to sudden cardiac death,¹⁵ research that has evaluated a potential link between anxiety and cardiac-related death has been mixed. Some studies^4-6,10,16,17 have found that anxiety is associated with increased cardiac mortality in patients with cardiac disease, while others have found no increase in mortality or even a protective effect of anxiety in patients following a myocardial infarction.^18-20

While it is not yet clear whether anxiety (or anxiety disorders) leads to a more rapid progression of coronary artery disease, the morbidity and costs associated with these disorders are sufficiently great to merit increased attention by caregivers. This article will focus on the recognition and management of anxiety in patients with known or suspected cardiac disease. For a review of studies evaluating the potential role of anxiety in the development of cardiovascular disease, readers are referred to the review by Kubzansky and Kawachi.²

“Normal Anxiety� and Cardiac Disease

Following a major heart event, such as a myocardial infarction or a coronary revascularization procedure, anxiety is the norm. Patients are suddenly confronted with their own mortality and are understandably concerned about the potential future impact of their diagnosis and illness on their occupations, personal lives, and relationships with others. It is important for the treating physician to anticipate this “normal illness-related anxiety� and address it promptly to prevent avoidable complications. Some practical guidelines for addressing normal illness-related anxiety in patients with cardiac disease are provided in Table 1.

Anxiety Disorders as a Consequence of Cardiac Events

Following a serious cardiac event, individuals can develop any of several anxiety disorders, including adjustment disorder with anxious mood, acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and panic disorder. The essential features of each of these disorders will be discussed in turn, along with suggested treatments.

Adjustment Disorder with Anxious Mood

By definition, adjustment disorder refers to an excessive and maladaptive emotional response to an identifiable, recent stressor. Adjustment disorder occurs within 3 months of the stressor and resolves within 6 months after resolution of the stressor. In the case of cardiac disease, this diagnosis would be appropriate for an individual who has an overall increase in anxiety (eg, is “on edgeâ€? or has trouble sleeping) and who avoids certain activities or behaviors secondary to fear that they will lead to cardiac problems. The treating physician should first go through the steps outlined in Table 1.¹⁷ Details of follow-up cardiac testing should be shared with the patient to provide reassurance that moderate activity is desirable. The physician should include specific examples of moderate activity. If available, the patient should be enrolled in a cardiac rehabilitation program. The patient should be instructed to avoid stimulants (eg, caffeine or certain over-the-counter cold preparations) that can exacerbate anxiety. Some patients benefit from cognitive-behavioral techniques, such as relaxation training. Use of medications is generally not indicated for adjustment disorder, but a short (1–2 week) course of a high-potency benzodiazepine (eg, clonazepam) may be appropriate for individuals with severe insomnia or phobic avoidance.

Acute Stress Disoder and Posttraumatic Stress Disorder

Serious cardiac events are traumatic and life-threatening. Some patients develop intrusive thoughts, memories, or nightmares about their cardiac event; avoidance of situations that remind them of the event; and increased arousal (eg, irritability, insomnia).²¹ When these symptoms have been present for <1 month (but develop within 4 weeks of the traumatic event), they are considered ASD. If they persist for >1 month, they are classified as PTSD. Please refer to Tables 2 and 3 for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,²² criteria for ASD and PTSD. ASD should generally be treated using cognitive-behavioral therapy (CBT) and supportive psychotherapeutic methods. Useful behavioral methods include psychoeducation, desensitization to avoided situations through graded exposure (either imaginal or actual), and progressive relaxation techniques. In psychotherapy, patients should be encouraged to discuss their emotions about the event (eg, fear, anger, guilt) and reassured that these are normal and common reactions to life-threatening events.^23,24 Although CBT has been the most studied psychotherapy for ASD and PTSD, readers are encouraged to refer to a recent practice guideline,²⁵ which provides a comprehensive review of a variety of treatment approaches.

In cases where symptoms meet criteria for PTSD, medication should also be considered. The first-line drugs for the treatment of PTSD are the selective serotonin reuptake inhibitors (SSRIs). Data for other classes of drugs, particularly in patients who develop symptoms of PTSD following a cardiac event, are limited, although use of anticonvulsants, tricyclic antidepressants, mood stabilizers, monoamine oxidase inhibitors, and neuroleptics has been employed in other populations with PTSD (for a review, see Davidson and colleagues²⁴). Benzodiazepines should generally be avoided, both because of the increased risk for substance abuse in patients with PTSD, and because benzodiazepines may interfere with the efficacy of cognitive-behavioral methods.^26,27

Certain patients with cardiac disease may be at particularly high risk for the development of PTSD. For example, a recent study²⁸ found the prevalence of PTSD in cardiac arrest survivors to be 27% after >2 years following the incident, a significantly higher rate than would be expected given that the lifetime prevalence of PTSD is 7.8%.²⁹ In another study involving pediatric patients 5–12 years of age who underwent cardiac surgery,³⁰ 12% met criteria for PTSD and 23% had increases in PTSD symptomatology 4–8 weeks after surgery.

A third population that appears to be at risk for the development of PTSD or panic disorder are patients with automatic implantable cardioverter defibrillators (AICDs), in whom unexpected firing of the defibrillator has been reported to lead to the full spectrum of PTSD symptoms^31,32 or panic disorder.³³

Panic Disorder

In addition to panic disorder associated with AICDs, some patients develop repeated, unexpected panic attacks after experiencing a myocardial infarction.³⁴ These panic attacks are frequently triggered by palpitations or other physical symptoms that the patient experienced during the original heart attack. As with idiopathic panic disorder, patients frequently develop agoraphobia and avoidance of activities that they associate with cardiac symptoms (eg, exercise). Since exercise is a fundamental part of cardiac rehabilitation, the development of panic disorder can impede progress toward recovery, in addition to reducing the quality of life. Treatment of postmyocardial infarction panic should include psychoeducation, CBT, and, in some cases, treatment with an SSRI.

Anxiety Disorders Masquerading as Cardiac Disease

Panic Disorder

The symptoms of a panic attack often mimic those of a heart attack, and can include chest pain, shortness of breath, stomach discomfort, dizziness, and a sense of impending death. Indeed, until properly diagnosed, many patients believe that they are having heart attacks when they panic, leading to repeated emergency room visits and expensive diagnostic procedures. While panic attacks themselves are not deadly, there is accumulating evidence that patients with panic disorder have reduced heart-rate variability, a known risk factor for cardiac arrhythmia and sudden death.^35,36 Furthermore, although the link between post-myocardial infarction anxiety and subsequent cardiac morbidity and/or mortality is not as well established as it is for postmyocardial infarction depression, there is a growing consensus that anxiety in patients with cardiac disease may be a risk factor for sudden cardiac death.³⁷ Therefore, the recognition of panic disorder in the absence of ischemic heart disease is important both for heart health and psychological well-being.

The treatment of idiopathic panic disorder in the absence of known cardiovascular disease is the same as that for postcardiac event panic disorder. CBT and/or pharmacotherapy with one of the SSRIs are considered first-line treatments. As with the anxiety disorders described above, patients should be advised regarding the importance of minimizing the use of caffeine and stimulant drugs, and of maintaining good sleep hygiene.

Conclusion

Anxiety and cardiovascular disease frequently coexist, and there is evidence to suggest that anxiety may be an independent risk factor for cardiac disease, in addition to leading to poorer outcomes. Nearly all patients who have experienced a serious cardiac event develop “illness-related anxiety,� and some patients go on to develop ASD, PTSD, or panic disorder. Patients with anxiety disorders can also present with cardiac symptoms in the absence of demonstrable cardiac disease. Given emerging evidence that idiopathic anxiety disorders are associated with reduced heart-rate variability and are an independent risk factor for cardiac disease, the presence of “noncardiogenic chest pain� should not be trivialized. In general, first-line treatment of anxiety in these patients should be approached using a multidisciplinary approach involving psychoeducation, CBT, and, in some cases, use of an SSRI. PP

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