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Role of Cardiac Disease Severity in the Predictive Value of Anxiety for All-Cause Mortality

From the Department of Cardiology (T.M.), University of Marburg, Marburg, Germany, and Department of Psychosomatic Medicine and Psychotherapy (U.B., C.H.-L.), University of Göttingen, Göttingen, Germany.

Address correspondence and reprint requests to Christoph Herrmann-Lingen, Psychosomatic Medicine and Psychotherapy, von-Siebold-Str. 5, D-37075 Göttingen, Germany. E-mail: cherrma{at}gwdg.de

Objective: To identify moderators that influence the relationship of anxiety and long-term prognosis in patients with coronary heart disease (CHD). It has been an ongoing source of controversy what the long-term effects of anxiety are on mortality in patients with CHD, suggesting heterogeneity in prognostic parameters.

Methods: The prognostic role of anxiety was examined in a large sample of patients (n = 4864), who completed the Hospital Anxiety and Depression Scale (HADS) before routine exercise testing. At 5-year follow-up, survival data were obtained and mortality was assessed by means of Cox proportional hazard models.

Results: In the whole sample, higher anxiety scores were associated with reduced mortality (adjusted hazard ratio [HR] = 0.77; 95% confidence interval (CI) = 0.67–0.88; p < .001). Similar findings were obtained in the subgroup of patients without clinical evidence of CHD (n = 2514; HR = 0.74; 95% CI = 0.59–0.93; p = .01). In patients with CHD but without a history of myocardial infarction (MI), anxiety remained a significant predictor of better survival (HR = 0.70; 95% CI = 0.51–0.97; p = .031). In post-MI patients, no beneficial effect of anxiety was observed. In the subgroup of post-MI patients with reduced ejection fraction, anxiety was associated with increased mortality (n = 536; HR = 1.32; CI = 1.07–1.65; p = .011).

Conclusion: Anxiety exhibits opposite effects on survival in patients with stable cardiac conditions versus post-MI patients with reduced systolic left ventricular (LV) function. We found that a noninvasive physical risk index and the degree of LV dysfunction seem to modulate the prognostic significance of anxiety. These data suggest that the combined screening for anxiety symptoms and LV dysfunction may improve risk stratification in patients with CHD.

Key Words: anxiety • coronary heart disease • myocardial infarction • prognosis • risk stratification

Abbreviations: CHD = coronary heart disease; HADS = Hospital Anxiety and Depression Scale; LV = left ventricle; MI = myocardial infarction.