Anxiety and anger immediately prior to myocardial infarction and long-term mortality: Characteristics of high-risk patients

Facial Emotion Expression and the Inducibility of Myocardial Ischemia During Cardiac Stress Testing: The Role of Psychological Background Factors

OBJECTIVE

Negative emotional states, such as anger and anxiety, are associated with the onset of myocardial infarction and other acute clinical manifestations of ischemic heart disease. The likelihood of experiencing these short-term negative emotions has been associated with long-term psychological background factors such as depression, generalized anxiety, and personality factors. We examined the association of acute emotional states preceding cardiac stress testing (CST) with inducibility of myocardial ischemia and to what extent psychological background factors account for this association.

METHODS

Emotional states were assessed in patients undergoing CST (n = 210; mean [standard deviation] age = 66.9 [8.2] years); 91 (43%) women) using self-report measures and video recordings of facial emotion expression. Video recordings were analyzed for expressed anxiety, anger, sadness, and happiness before CST. Psychological background factors were assessed with validated questionnaires. Single-photon emission computed tomography was used to evaluate inducibility of ischemia.

RESULTS

Ischemia occurred in 72 patients (34%). Emotional states were not associated with subsequent inducibility of ischemia during CST (odds ratio between 0.93 and 1.04; p values > .50). Psychological background factors were also not associated with ischemia (odds ratio between 0.96 and 1.06 per scale unit; p values > .20) and did not account for the associations of emotional states with ischemia.

CONCLUSIONS

Emotional states immediately before CST and psychological background factors were not associated with the inducibility of ischemia. These findings indicate that the well-documented association between negative emotions with acute clinical manifestations of ischemic heart disease requires a different explanation than a reduced threshold for inducible ischemia.

Autonomic Neural Circuit and Intervention for Comorbidity Anxiety and Cardiovascular Disease

Anxiety disorder is a prevalent psychiatric disease and imposes a significant influence on cardiovascular disease (CVD). Numerous evidence support that anxiety contributes to the onset and progression of various CVDs through different physiological and behavioral mechanisms. However, the exact role of nuclei and the association between the neural circuit and anxiety disorder in CVD remains unknown. Several anxiety-related nuclei, including that of the amygdala, hippocampus, bed nucleus of stria terminalis, and medial prefrontal cortex, along with the relevant neural circuit are crucial in CVD. A strong connection between these nuclei and the autonomic nervous system has been proven. Therefore, anxiety may influence CVD through these autonomic neural circuits consisting of anxiety-related nuclei and the autonomic nervous system. Neuromodulation, which can offer targeted intervention on these nuclei, may promote the development of treatment for comorbidities of CVD and anxiety disorders. The present review focuses on the association between anxiety-relevant nuclei and CVD, as well as discusses several non-invasive neuromodulations which may treat anxiety and CVD.

The Influence of Cognitive Behavioral Intervention for Anger Management on Endothelial Function in Patients With Recent Myocardial Infarction: A Randomized Clinical Trial

OBJECTIVE

Anger may cause adverse cardiovascular responses, but the effects of anger management on clinical cardiovascular outcomes are insufficiently understood. We sought to assess the influence of anger management through a cognitive behavioral intervention on endothelial function in patients with a recent myocardial infarction (MI).

METHODS

Patients with ST-elevation MI and a low anger control score were enrolled during hospitalization in a randomized, parallel, controlled clinical trial. Intervention was anger management with cognitive behavioral techniques implemented by a psychologist in two individual monthly sessions. The primary end point was the between-group difference in the variation of flow-mediated dilation (FMD) in the brachial artery from baseline to the 3-month follow-up. The second end point comprised major cardiovascular events at 24-month follow-up.

RESULTS

A total of 43 patients (age = 56 [9] years; 23.3% women) were randomized to the intervention group and 47 patients (age = 58 [10] years; 19.1% women) to the control group. Baseline clinical characteristics were not statistically different between groups. Both groups showed a significant improvement in anger control from baseline to end point; however, the difference in intergroup variation was not statistically significant. The difference in FMD variation from baseline to the 3-month follow-up was significantly higher in the intervention group. The partial η2 was 0.057 (p = .024), indicating a medium effect size. There was no difference between groups regarding major cardiovascular events.

CONCLUSIONS

Anger management by cognitive behavioral techniques may improve endothelial function in post-MI patients with low anger control, but it remains unclear via which mechanism these effects occurred. Further studies with larger numbers of patients, assessments of changes in anger, improved comparability of preintervention FMD, and longer follow-up are warranted.Trial Registration:ClinicalTrials.gov identifier: NCT02868216.

What will we ask to artificial intelligence for cardiovascular medicine in the next decade?

Artificial intelligence (AI) comprises a wide range of technologies and methods with heterogeneous degrees of complexity, applications and abilities. In the cardiovascular field, AI holds the potential to fulfil many unsolved challenges, eventually translating into improved patient care. In particular, AI appears as the most promising tool to overcome the gap between ever-increasing data-rich technologies and their practical implementation in cardiovascular research, in the cardiologist routine, in the patient daily life and at the healthcare-policy level. A multiplicity of AI technologies is progressively pervading several aspects of precision cardiovascular medicine including early diagnosis, automated imaging processing and interpretation, disease sub-phenotyping, risk prediction and remote monitoring systems. Several methodological, logistical, educational and ethical challenges are emerging by integrating AI systems at any stage of cardiovascular medicine. This review will discuss the basics of AI methods, the growing body of evidence supporting the role of AI in the cardiovascular field and the challenges to overcome for an effective AI-integrated cardiovascular medicine.

Anxiety and prognosis of patients with myocardial infarction: A meta-analysis

Although anxiety is highly prevalent after myocardial infarction (MI), but the association between anxiety and MI is not well established. This study aimed to provide an updated and comprehensive evaluation of the association between anxiety and short-term and long-term prognoses in patients with MI. Anxiety is associated with poor short-term and long-term prognoses in patients with MI. We performed a systematic search in the PubMed and Cochrane databases (January 2000-October 2020). The study endpoints were complications, all-cause mortality, cardiac mortality, and/or major adverse cardiac events (MACEs). Pooled data were synthesized using Stata SE12.0 and expressed as risk ratios (RRs) and 95% confidence intervals (CIs). We included 9373 patients with MI from 16 published studies. Pooled analyses indicated a correlation between high anxiety and poor clinical outcomes (RR: 1.19, 95% CI: 1.13-1.26, p < .001), poor short-term complications (RR: 1.23, 95% CI: 1.09-1.38, p = .001), and poor long-term prognosis (RR: 1.27, 95% CI: 1.13-1.44, p < .001). Anxiety was also specifically associated with long-term mortality (RR: 1.16, 95% CI: 1.01-1.33, p = .033) and long-term MACEs (RR: 1.54, 95% CI: 1.26-1.90, p < .001). This study provided strong evidence that increased anxiety was associated with poor prognosis in patients with MI. Further analysis revealed that MI patients with anxiety had a 23% increased risk of short-term complications and a 27% increased risk of adverse long-term prognosis compared to those without anxiety.

Association Between Anger and Mortality in Women and Men: A Prospective Cohort Study in a Japanese Community

Background: Anger is a common problem in society, and anger's relationship with mortality, in particular with cardiovascular mortality, has been studied mainly in male western population. There are no prospective studies in Japan, about the association between anger and mortality. Materials and Methods: This study examined the association of anger with all-cause and cause-specific mortality in a Japanese community. Data came from the Takayama Study, which recruited residents aged ≥35 years in 1992 from Takayama City in Gifu, Japan. The current study used information on anger that was obtained from the second survey in 2002. A total of 11,902 healthy participants aged ≥45 years completed a self-administered questionnaire. Anger was assessed using the Spielberger Trait Anger Scale. Results: The main causes of deaths during the follow-up period from 2002 to 2013 were 460 for neoplasm, 254 for cardiovascular, and 435 for other causes. After adjusting for potential confounders, we found a significant positive association between the trait anger score and the risk of cardiovascular mortality for women, with a hazard ratio for high versus low score of trait anger of 1.81 (95% confidence interval 0.91-3.63, p for trend = 0.04), but not for men. Conclusions: Data suggest that for Japanese women, high trait anger score may be associated with an increased risk of cardiovascular mortality. Potential gender differences in the association between trait anger and mortality should be further studied from the cultural context.

Complementary Therapies Used by Indonesians With Myocardial Infarction

This descriptive, cross-sectional study was conducted to identify types, frequency, methods, duration, and purpose of complementary therapies used by Indonesians with myocardial infarction. The majority of the respondents used biologically based therapies, with the most common subtype being herbs. The purpose of using biologically based therapies was for health promotion.

The association of chronic anxiousness with cardiovascular disease and mortality in the community: results from the Gutenberg Health Study

In a large German community sample of adults, we investigated the association of chronic anxiousness with cardiovascular disease and mortality. Self-reported anxiousness from 11,643 German adults between 40 and 80 years of age from the Gutenberg Health Study (GHS) was analyzed over 5 years. Multivariable regression modeling assessed the relation between the variables, cardiovascular disease and mortality. Twelve percent of the participants reported consistently raised (chronic) anxiousness over at least 2.5 years. Anxiousness was more often reported by female, younger participants with a lower socioeconomic status, smokers and those with a family history of stroke and myocardial infarction. New onset of cardiovascular disease was linked to chronic anxiousness in men and new onset of anxiousness in women. However, chronic anxiousness did not predict all-cause mortality. Our results revealed that anxiousness is highly prevalent in German adults from middle to old age, affecting women in particular. In our study, we found sex-specific associations between new onset of cardiovascular disease and different forms of anxiousness in men and women. We suggest that even subclinical levels of anxiety need to be considered as cardiovascular risk factors. To elucidate potential harm of anxiousness for mental and physical health, we propose sex-specific analyses in further research studies, taking age and the course of anxiousness into account.

How Does Mental Health Impact Women's Heart Health?

From adolescence until old age, women are more vulnerable to common mental disorders (CMDs; depression and anxiety) than men at all stages of the life course. By middle age, women who have clinical depression are at twice the risk of having an incident cardiovascular disease (CVD) than those without. This has important implications for the way we prevent, identify and treat both CMDs and coronary heart disease in women. In this paper, we discuss the various genetic, biological, ethnic/racial, and psychological pathways by which women's vulnerability to CMDs elevate their CVD risk and recovery from a cardiac event. We review the evidence from trials that have, to date, failed to show that treating depression can reduce or delay the onset or recurrence of CVD events, especially for female patients. We discuss the value of lifestyle-based therapies for treating depression, to which women may be more responsive, and finish by discussing how population-based approaches including risk factor assessment could be tailored to consider these factors.

Anxiety and clinical outcomes of patients with acute coronary syndrome: a meta-analysis

OBJECTIVES

Anxiety has been suggested to be associated with poor outcomes in patients with acute coronary syndrome (ACS). However, results of previous follow-up studies were inconsistent. The aim of this meta-analysis was to evaluate the association between anxiety and clinical outcomes in patients with ACS, and to investigate the potential role of depression underlying the above association.

DESIGN

A meta-analysis of prospective follow-up studies.

SETTING

Hospitals.

PARTICIPANTS

Patients with ACS.

INTERVENTIONS

We included related prospective follow-up studies up through 20 July 2019 that were identified by searching PubMed and Embase databases. A random-effect model was used for the meta-analysis. Anxiety was evaluated by validated instruments at baseline.

PRIMARY AND SECONDARY OUTCOME MEASURES

We determined the association between anxiety and risks of mortality and adverse cardiovascular events (MACEs) in patients with ACS.

RESULTS

Our analysis included 17 studies involving 39 038 patients wqith ACS. Anxiety was independently associated with increased mortality risk (adjusted risk ratio (RR) 1.21, 95% CI 1.07 to 1.37, p=0.002) and MACEs (adjusted RR 1.47, 95% CI 1.24 to 1.74, p<0.001) in patients with ACS. Subgroup analyses showed that depression may at least partly confound the association between anxiety and poor outcomes in patients with ACS. Adjustment of depression significantly attenuated the association between anxiety and MACEs (adjusted RR 1.25, 95% CI 1.04 to 1.52, p=0.02). Moreover, anxiety was not significantly associated with mortality risk after adjusting for depression (adjusted RR 0.88, 95% CI 0.66 to 1.17, p=0.37).

CONCLUSIONS

Anxiety is associated with increased risk of mortality and MACEs in patients with ACS. However, at least part of the association may be confounded by concurrent depressive symptoms in these patients.

The association between anxiety disorders and in-hospital outcomes in patients with myocardial infarction

BACKGROUND

Anxiety disorders are prevalent in patients with myocardial infarction (MI), but the effects of anxiety disorders on in-hospital outcomes within MI patients have not been well studied.

HYPOTHESIS

To examine the effects of concurrent anxiety disorders on in-hospital outcomes in MI patients.

METHODS

We conducted a retrospective cohort study in patients with a principal diagnosis of MI with and without anxiety disorders in the National Inpatient Sample 2016. A total of 129 305 primary hospitalizations for acute MI, 35 237 with ST-segment elevation myocardial infarction (STEMI), and 94 068 with non-ST elevation myocardial infarction (NSTEMI) were identified. Of these, 13 112 (10.1%) had anxiety (7.9% in STEMI and 11.0% in NSTEMI). We compared outcomes of anxiety and nonanxiety groups after propensity score matching for the patient and hospital demographics and relevant comorbidities.

RESULTS

After propensity score matching, the anxiety group had a lower incidence of in-hospital mortality (3.0% vs 4.4%, P < .001), cardiac arrest (2.1% vs 2.8%, P < .001), cardiogenic shock (4.9% vs 5.6%, P = .007), and ventricular arrhythmia (6.7% vs 7.9%, P < .001) than the nonanxiety group. In the NSTEMI subgroup, the anxiety group had significantly lower rates of in-hospital mortality (2.3% vs 3.5%, P < .001), cardiac arrest (1.1% vs 1.5%, P = .008), and cardiogenic shock (2.8% vs 3.5%, P = .008). In the STEMI subgroup, we found no differences in in-hospital outcomes (all P > .05) between the matched groups.

CONCLUSION

Although we found that anxiety was associated with better in-hospital outcomes, subgroup analysis revealed that this only applied to patients admitted for NSTEMI instead of STEMI.

[Effect of chronic emotional stress induced by empty bottle stimulation on inflammatory factors in rats with acute myocardial infarction: analysis of the CXCL12/CXCR4 axis]

OBJECTIVE

To investigate the effect of chronic emotional stimulation induced by empty bottle stimulation on CXCL12/CXCR4-mediated inflammatory response in rats with acute myocardial infarction (AMI).

METHODS

Rat models of anxiety were established by a 21-day stimulation with uncertain empty bottle drinking water, and myocardial infarction was induced by ligating the left anterior descending branch of the coronary artery; compound models were established by performing myocardial infarction operation on the 15th day of anxiety modeling. The rats were randomly divided into 4 groups: shamoperated group (n=6), myocardial infarction group (n=6), compound model group (with myocardial infarcted and anxiety; n= 6), and inhibitor group (compound models treated daily with 1 mg/kg AMD3100 for 6 days; n=7). Echocardiography was used to examine the LVEF and LVFS to evaluate the cardiac function of the rats. Elevated maze test and open field test were used to evaluate the behaviors of the rats. The expressions of CXCL12, CXCR4, IL-1β, IL-18 and neutrophil active protease (NE) in the myocardial tissues and blood samples were detected with ELISA and immunohistochemistry.

RESULTS

The LVEF and LVFS were lower in the compound model group than in the sham group and myocardial infarction group (P &lt; 0.05), and were higher in inhibitor group than in the compound model group (P &lt; 0.05). LVID; d and LVID; s were lower in the inhibitor group than in the compound model group (P &lt; 0.05). Compared to those in the sham group and myocardial infarction group, the rats in the compound model group more obviously preferred to stay in the closed arm (P &lt; 0.05) in EPM; the rats in the inhibitor group had more times of entering and staying in the open arm than the compound model rats (P &lt; 0.05); the horizontal and vertical movements were less in the compound model rats than in those in the sham group and the myocardial infarction group (P &lt; 0.05) in OFT, and the vertical movement of the rats in inhibitor group was higher than those in the compound model group (P &lt; 0.05). The expression of CXCR4 in the marginal zone of myocardial infarction was significantly higher in the compound model group than in the sham-operated group, myocardial infarction group and inhibitor group (P &lt; 0.05). The expressions of IL-1β, IL-18 and NE in the inhibitor group were significantly lower than those in the compound model group (P &lt; 0.05). Compared with at in the sham-operated group, the number of Nissl bodies in the compound model group decreased significantly (P &lt; 0.01).

CONCLUSIONS

Chronic emotional stress induced by empty bottle stimulation can lead to dysfunction of the CXCL12/CXCR4 axis, which causes inflammatory cascade after myocardial infarction to worsen myocardial cell necrosis, cardiac function and hippocampal neuronal damage after the infarction.

Anger and long-term mortality and ventricular arrhythmias in patients with a first-time implantable cardioverter-defibrillator: data from the MIDAS study

Aims

Psychosocial factors increase risk for incident heart disease and poor prognosis. In patients with an implantable cardioverter-defibrillator (ICD), negative emotions have been associated with increased mortality risk, although the association with ventricular arrhythmias (VAs) is less consistent. Anger has been linked to incident ICD shocks, but no prospective study has examined the association of anger (state and trait) with mortality or VAs in the ICD population. In a consecutively recruited cohort of first-time ICD patients, we examined the association of state and trait anger with 7-year mortality risk and time to first VA.

Methods and results

A consecutive cohort of patients implanted with a first-time ICD (n = 388; 80% men) between 2003 and 2010 completed the State-Trait Anger Scale and were followed for 7 years. Outcomes were mortality and time to first appropriate ICD therapy. State anger at the time of implant was associated with increased mortality risk in adjusted analyses, with a 1-point increase in score on the state anger measures associated with a 5% [hazard ratio 1.05; 95% confidence interval 1.01–1.09; P = 0.015] increased 7-year mortality risk. We found no statistically significant differences in mortality risk for trait anger, nor an effect for state or trait anger on time to first treated VA (all ps &gt; 0.05).

Conclusion

This is the first study to examine the association of state and trait anger with long-term clinical outcomes in ICD patients. Evaluating anger reduction strategies in newly implanted ICD patients, such as self-regulation or mindfulness techniques, may be warranted for reducing mortality risk.

Anxiety Disorders in Patients With Somatic Diseases

OBJECTIVE

Anxiety disorders are among the most frequent mental disorders and are associated with a range of short- and long-term impairments and disabilities. Relatively little is known about anxiety disorders in patients with somatic diseases, and the present literature review highlights the current research in this field, data about prevalences of anxiety disorders in patients with somatic diseases, and the effectiveness of interventions. This article also introduces a comprehensive model of inpatient treatment and summarizes the evidence pertinent to this approach.

METHODS

A narrative review is presented with regard to prevalence and treatment of anxiety disorders in patients with somatic diseases. The effects of inpatient treatment are illustrated based on a case report.

RESULTS

This review indicates that anxiety disorders are more common in patients with somatic diseases, with prevalence estimates ranging from 2.5% to 55%, than in the general population. Several outpatient treatment options exist, with substantial support for the effectiveness of cognitive behavioral therapy, psychodynamic therapy, and pharmacotherapy. We also provide evidence in support of psychosomatic inpatient treatment for patients with anxiety disorders that are comorbid with somatic diseases.

CONCLUSIONS

Anxiety disorders are common in patients with somatic diseases, and several effective treatment options exist, including cognitive behavioral therapy and pharmacological interventions. We also provide support for the effectiveness of inpatient treatment with unique opportunities for multidisciplinary psychosomatic treatment of anxiety disorders with comorbid somatic diseases.

Death anxiety in patients with myocardial infarction or cancer

OBJECTIVE

The aim of this study was to find out the level of death anxiety among 3 groups: patients with acute myocardial infarction, patients with cancer and healthy individuals in two training and research hospitals; also to evaluate its relationship with several sociodemographic and clinical variables.

MATERIALS AND METHOD

This study was conducted with one hundred and eighty persons (108 male, 72 female) who have been referred to cardiology or oncology departments and the healthy individuals. Participants completed sociodemographic and clinical data form, State and Trait Anxiety Inventory (STAI-I, STAI-II), Thorson Powell Death Anxiety Scale (TPDAS), Death Depression Scale (DDS).

RESULTS

Participants included in the present study were 40% female with an average age of 53.48 for whole group. The mean TPDAS score for patients with AMI was 51.60 ± 16.40, for patients with cancer 37.10 ± 10.23 and for healthy individuals 43.40 ± 13.35. In AMI group there were positive correlations between STAI-I and TPDAS, DDS scores and also between STAI-II and DDS. In cancer group positive correlations were between STAI-I, II and TPDAS, DDS. TPDAS and DDS were positively correlated in all three groups. Women and participants who were unemployed scored higher on DDS.

CONCLUSION

In this study patients with AMI had higher death anxiety than patients with cancer or healthy individuals. Generally death anxiety was related with education, employment and socioeconomic status. Prospective studies carefully searching for different variables in different medical groups would reveal and help us to understand the importance of death anxiety and its impact on courses of physical and mental disorders.

Gender-Based Differences in Anxiety and Depression Following Acute Myocardial Infarction

Background

Among patients with heart disease, depression and anxiety disorders are highly prevalent and persistent. Both depression and anxiety play a significant role in cardiovascular disease progression and are acknowledged to be independent risk factors. However, there is very little gender-related analysis concerning cardiovascular diseases and emotional disorders.

Objective

We aimed to evaluate depression and anxiety levels in patients suffering from myocardial infarction [MI] within the first month after the MI and to assess the association between cardiovascular disease risk factors, demographic indicators and emotional disorders, as well as to determine whether there are gender-based differences or similarities.

Methods

This survey included demographic questions, clinical characteristics, questions about cardiovascular disease risk factors and the use of the Hospital Anxiety and Depression Scale [HADS]. All statistical tests were two-sided, and p values < 0.05 were considered statistically significant.

Results

It was determined that 71.4% of female and 60.4% of male patients had concomitant anxiety and/or depression symptomatology (p = 0.006). Using men as the reference point, women had an elevated risk of having some type of psychiatric disorder (odds ratio, 2.86, p = 0.007). The HADS-D score was notably higher in women (8.66 ± 3.717) than men (6.87 ± 4.531, p = 0.004). It was determined that male patients who developed depression were on average younger than those without depression (p = 0.005).

Conclusions

Women demonstrated an elevated risk of having anxiety and/or depression disorder compared to men. Furthermore, depression severity increased with age in men, while anxiety severity decreased. In contrast, depression and anxiety severity was similar for women of all ages after the MI. A higher depression score was associated with diabetes and physical inactivity, whereas a higher anxiety score was associated with smoking in men. Hypercholesterolemia was associated with both higher anxiety and depression scores, and a higher depression score was associated with physical inactivity in women.