Anxiety associations with cardiac symptoms, angiographic disease severity, and healthcare utilization: The NHLBI-sponsored Women's Ischemia Syndrome Evaluation

Abstract

Background Anxiety is common among patients presenting with suspected coronary artery disease (CAD). In a sample of women with signs and symptoms of ischemia, we examined three anxiety markers as predictors of CAD endpoints including: 1) cardiac symptom indicators; 2) angiographic CAD severity; and 3) healthcare utilization (cardiac hospitalizations & 5-year cardiovascular [CVD] healthcare costs). Methods Participants completed a baseline protocol including coronary angiogram, cardiac symptoms, psychosocial measures and a median 5.9-year follow-up to track hospitalizations. We calculated CVD costs based on cardiac hospitalizations, treatment visits, and CVD medications. Anxiety measures included anxiolytic medication use, Spielberger Trait Anxiety Inventory (STAI) scores, and anxiety disorder treatment history. Results The sample numbered 514 women with anxiety measure data and covariates (mean age=57.5[11.1]). One in five (20.4%) women reported using anxiolytic agents. Anxiety correlated with cardiac symptom indicators (anxiolytic use with nighttime angina & nitroglycerine use; STAI scores & anxiety disorder treatment history with nighttime angina, shortness of breath, & angina frequency). Anxiety disorder treatment history (but not STAI scores or anxiolytics) predicted less severe CAD. Anxiolytic use (but not STAI scores or anxiety disorder treatment history) predicted hospitalizations for chest pain and coronary catheterization (HR’s=2.0, 95% CI’s=1.1–4.7). Anxiety measures predicted higher 5-year CVD costs (+9.0–42.7%) irrespective of CAD severity. Conclusions Among women with signs and symptoms of myocardial ischemia, anxiety measures predict cardiac endpoints ranging from cardiac symptom severity to healthcare utilization. Based on these findings, anxiety may warrant greater consideration among women with suspected CAD.

Psychosocial predictors of long-term mortality among women with suspected myocardial ischemia: the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation

“…For example, BDI scores, antidepressant use, and a history of depression treatment were each adversely related to mortality and CVD events (heart failure, myocardial infarction, and stroke) in previous WISE research (Rutledge et al, 2006; Vaccarino et al, 2008, 2007), and both anxiety and depression symptoms were linked to higher rates of CVD risk factors and increased healthcare costs (Rutledge et al, 2013, 2009). This is the first psychosocial WISE report to focus exclusively on total mortality events as the extended follow-up period provided sufficient statistical power to focus exclusively on this most important endpoint.…”

“…Similar to the WISE results reported here, female Veterans obtaining cardiac catheterization in the latter study showed low rates of obstructive CAD but relatively high rates of psychiatric comorbidities such as depression and anxiety (e.g., 55.3 and 20.1 % of the women in the latter sample met criteria for depression and posttraumatic stress disorder based on medical chart review). In the WISE sample, >45 % reported elevated depressive symptoms (≥10 on the BDI) and over 20 % (Rutledge et al, 2013) reported clinical anxiety as indicated by anxiolytic medication. The results from both studies suggest that depression and anxiety conditions are common in this clinical population and may play an important role in the clinical presentation dynamics of women undergoing coronary angiogram testing.…”

“…Unlike general population studies, women in WISE were recruited based upon suspected cardiac symptoms but had low rates of obstructive CAD, suggesting that anxiety may have contributed to the symptoms reported by many women or their motivation to participate in a study investigating suspected myocardial ischemia. In addition to mortality events, higher anxiety was also inversely correlated with the presence of CAD on angiogram testing (Rutledge et al, 2013). Because CAD severity was strongly and positively associated with premature mortality but negatively associated with anxiety, the relationship between anxiety and premature mortality was also not surprisingly negative.…”

Prevalence and Implications of Severe Anxiety in a Prospective Cohort of Acute Chest Pain Patients

“…Anxiety is more common in patients with established heart disease 18 and has been linked to poorer outcomes for patients with demonstrated heart disease or ischemia. 19,20 …”

Personality subtypes and chest pain in patients with nonobstructive coronary artery disease from the TweeSteden Mild Stenosis study: mediating effect of anxiety and depression

“…In the present study, we hypothesize that stable personality subtypes can be considered as an underlying factor for both the presence of chest pain as well as momentary negative mood states. Several psychological constructs have been associated with the presence of chest pain in the absence of obstructive CAD, including increased depressive symptoms (Wheeler et al., ) and anxiety (Rutledge et al., ). We have previously shown that Type D personality was associated with an increased prevalence of chest pain in patients with nonobstructive CAD (Mommersteeg et al., ).…”