Psychotropic drugs and myocardial infarction: cause for or caused by panic?

Anxiety and coronary heart disease: a synthesis of epidemiological, psychological, and experimental evidence

The purpose of this review is to examine the epidemiological, psychological, and experimental evidence for an association between anxiety and coronary heart disease (CHD). Papers published during the years 1980-1996 on anxiety and CHD and relevant publications from earlier years were selected for this review. Epidemiologic evidence suggests that anxiety may be a risk factor for the development of CHD. Chronic anxiety may increase the risk of CHD by: (a) influencing health behaviors (e.g. smoking); (b) promoting atherogenesis (e.g. via increased risk of hypertension); and (c) triggering fatal coronary events, either through arrhythmia, plaque rupture, coronary vasospasm, or thrombosis. Electrophysiologic evidence is particularly compelling: anxiety appears to be associated with abnormal cardiac autonomic control, which may indicate increased risk of fatal ventricular arrhythmias. The strength, consistency, and dose-response gradient of the association between anxiety and CHD, together with the biologic plausibility of the experimental evidence, suggest that anxiety may contribute to risk of CHD and that the relationship warrants further investigation.

Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up

BACKGROUND

There is suggestive evidence that depression increases risk of myocardial infarction (MI), but there are no prospective studies in which the measure of depression corresponds to clinical criteria. This study examines prospectively whether a major depressive episode increases the risk of incident MI and evaluates the role of psychotropic medication use in this relationship.

METHODS AND RESULTS

The study is based on a follow-up of the Baltimore cohort of the Epidemiologic Catchment Area Study, a survey of psychiatric disorders in the general population. A history of major depressive episode, dysphoria (2 weeks of sadness), and psychotropic medication use were assessed in 1981, and self-reported MI was assessed in 1994. Sixty-four MIs were reported among 1551 respondents free of heart trouble in 1981. Compared with respondents with no history of dysphoria, the odds ratio for MI associated with a history of dysphoria was 2.07 (95% CI, 1.16 to 3.71), and the odds ratio associated with a history of major depressive episode was 4.54 (95% CI, 1.65 to 12.44), independent of coronary risk factors. In multivariate models, use of barbiturates, meprobamates, phenothiazines, and lithium was associated with an increased risk of MI, whereas use of tricyclic antidepressants and benzodiazepines was not. Among individuals with no history of dysphoria, only lithium use was significantly associated with MI.

CONCLUSIONS

These data suggest that a history of dysphoria and a major depressive episode increase the risk of MI. The association between psychotropic medication use and MI is probably a reflection of the primary relationship between depression and MI.

Prospective study of phobic anxiety and risk of coronary heart disease in men

BACKGROUND

To examine prospectively the association between self-reported symptoms of phobic anxiety and subsequent risk of coronary heart disease, a 2-year follow-up study was conducted of a cohort of 33,999 US male health professionals, aged 42 to 77 years in 1988, who were free of diagnosed cardiovascular disease at baseline. Levels of phobic anxiety were assessed using the Crown-Crisp index, a short, diagnostic self-rating scale used for common phobias. Main outcomes were incidents of coronary heart disease consisting of nonfatal myocardial infarction (MI) and fatal coronary heart disease (CHD).

METHODS AND RESULTS

One hundred sixty-eight incident cases of CHD occurred during 2 years of follow-up (128 cases of nonfatal MI and 40 cases of fatal CHD). The age-adjusted relative risk of fatal CHD among men with highest levels of phobic anxiety (scoring 4 or higher on the Crown-Crisp index) was 3.01 (95% confidence interval, 1.31 to 6.90) compared with men with the lowest levels of anxiety (scoring 0 or 1 on the phobia index). Risk of fatal CHD increased with levels of phobic anxiety (P trend = .002). When fatal CHD was further categorized into sudden and nonsudden coronary death, the excess risk was confined to sudden death (relative risk among men scoring 3 or higher on the phobia index was 6.08; 95% confidence interval, 2.35 to 15.73). No association was found between phobic anxiety and risk of nonfatal MI. These findings remained essentially unchanged after adjusting for a broad range of cardiovascular risk factors.

CONCLUSIONS

The specificity, strength, and dose-response gradient of the association, together with the consistency and biological plausibility of the experimental and epidemiologic evidence, support a strong causal association between phobic anxiety and fatal CHD.