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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. linicians 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 mas!uerading as cardiovascular disease. "his 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-
and that the presence of negative affective states are associated with poor long-term
prognosis.
!-1"
Although much of the literature exploring the relationship between cardiovascular disease and emotion has been
focused on depression, care providers are e#ually likely to encounter the presence of anxiety in patients with confirmed or
suspected cardiovascular disease.
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%n addition to being among the most common psychiatric illnesses in the &nited 'tates,
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the
anxiety disorders as a group are over-represented in patients with cardiovascular disease.
1),1*
However, with the exception of
phobic anxiety, which has been linked to sudden cardiac death,
1+
research that has evaluated a potential link between anxiety and
cardiac-related death has been mixed. 'ome studies
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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.
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-hile 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. 0his
article will focus on the recognition and management of anxiety in patients with known or suspected cardiac disease. 1or a
review of studies evaluating the potential role of anxiety in the development of cardiovascular disease, readers are referred to
the review by 2ub3ansky and 2awachi.
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Normal Anxiety and Cardiac Disease
1ollowing a ma4or heart event, such as a myocardial infarction or a coronary revasculari3ation procedure, anxiety is the
norm. 5atients 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. %t is
important for the treating physician to anticipate this 6normal illness-related anxiety7 and address it promptly to prevent
avoidable complications. 'ome practical guidelines for addressing normal illness-related anxiety in patients with cardiac
disease are provided in 0able 1.
Anxiety Disorders as a Consequence of Cardiac Events
1ollowing a serious cardiac event, individuals can develop any of several anxiety disorders, including ad4ustment disorder with
anxious mood, acute stress disorder .A'8/, posttraumatic stress disorder .50'8/, and panic disorder. 0he essential features
of each of these disorders will be discussed in turn, along with suggested treatments.
Adjustment Disorder with Anxious ood
9y definition, ad4ustment disorder refers to an excessive and maladaptive emotional response to an identifiable, recent
stressor. Ad4ustment disorder occurs within ) months of the stressor and resolves within months after resolution of the
stressor. %n the case of cardiac disease, this diagnosis would be appropriate for an individual who has an overall increase in
anxiety .eg, is 6on edge7 or has trouble sleeping/ and who avoids certain activities or behaviors secondary to fear that they
will lead to cardiac problems. 0he treating physician should first go through the steps outlined in 0able 1.
1!
8etails of follow-up
cardiac testing should be shared with the patient to provide reassurance that moderate activity is desirable. 0he physician
should include specific examples of moderate activity. %f available, the patient should be enrolled in a cardiac rehabilitation
program. 0he patient should be instructed to avoid stimulants .eg, caffeine or certain over-the-counter cold preparations/ that
can exacerbate anxiety. 'ome patients benefit from cognitive-behavioral techni#ues, such as relaxation training. &se of
medications is generally not indicated for ad4ustment disorder, but a short .1:( week/ course of a high-potency
ben3odia3epine .eg, clona3epam/ may be appropriate for individuals with severe insomnia or phobic avoidance.
Acute !tress Disoder and "osttraumatic !tress Disorder
'erious cardiac events are traumatic and life-threatening. 'ome 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/.
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-hen these symptoms have been present for <1 month .but develop within * weeks of the traumatic event/,
they are considered A'8. %f they persist for =1 month, they are classified as 50'8. 5lease refer to 0ables ( and ) for Diagnostic
and Statistical Manual of Mental Disorders, 1ourth >dition,
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criteria for A'8 and 50'8. A'8 should generally be treated using
cognitive-behavioral therapy .?90/ and supportive psychotherapeutic methods. &seful behavioral methods include
psychoeducation, desensiti3ation to avoided situations through graded exposure .either imaginal or actual/, and progressive
relaxation techni#ues. %n 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.
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Although ?90 has been
the most studied psychotherapy for A'8 and 50'8, readers are encouraged to refer to a recent practice guideline,
(+
which
provides a comprehensive review of a variety of treatment approaches.
%n cases where symptoms meet criteria for 50'8, medication should also be considered. 0he first-line drugs for the treatment of
50'8 are the selective serotonin reuptake inhibitors .''@%s/. 8ata for other classes of drugs, particularly in patients who develop
symptoms of 50'8 following a cardiac event, are limited, although use of anticonvulsants, tricyclic antidepressants, mood
stabili3ers, monoamine oxidase inhibitors, and neuroleptics has been employed in other populations with 50'8 .for a review, see
8avidson and colleagues
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/. 9en3odia3epines should generally be avoided, both because of the increased risk for substance abuse
in patients with 50'8, and because ben3odia3epines may interfere with the efficacy of cognitive-behavioral methods.
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?ertain patients with cardiac disease may be at particularly high risk for the development of 50'8. 1or example, a recent study
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found the prevalence of 50'8 in cardiac arrest survivors to be (!A after =( years following the incident, a significantly higher
rate than would be expected given that the lifetime prevalence of 50'8 is !.,A.
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%n another study involving pediatric patients +:
1( years of age who underwent cardiac surgery,
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1(A met criteria for 50'8 and ()A had increases in 50'8 symptomatology *:
, weeks after surgery.
A third population that appears to be at risk for the development of 50'8 or panic disorder are patients with automatic
implantable cardioverter defibrillators .A%?8s/, in whom unexpected firing of the defibrillator has been reported to lead to the full
spectrum of 50'8 symptoms
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or panic disorder.
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"anic Disorder
%n addition to panic disorder associated with A%?8s, some patients develop repeated, unexpected panic attacks after
experiencing a myocardial infarction.
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0hese panic attacks are fre#uently triggered by palpitations or other physical
symptoms that the patient experienced during the original heart attack. As with idiopathic panic disorder, patients
fre#uently develop agoraphobia and avoidance of activities that they associate with cardiac symptoms .eg, exercise/. 'ince
exercise is a fundamental part of cardiac rehabilitation, the development of panic disorder can impede progress toward
recovery, in addition to reducing the #uality of life. 0reatment of postmyocardial infarction panic should include
psychoeducation, ?90, and, in some cases, treatment with an ''@%.

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