The Impact of Anxiety Disorders on Assessment of Myocardial Ischemia and Exercise Stress Test Performance

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.

Retrospective analysis of exercise capacity in patients with coronary artery disease after percutaneous coronary intervention or coronary artery bypass graft

Objectives

To describe the current state of exercise capacity as well as to identify its predictors in patients with coronary artery disease (CAD) following percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in the mainland of China.

Methods

A retrospective study design was employed. We evaluated 230 CAD patients following PCI or CABG in a cardiac rehabilitation center from January 2019 to October 2019. The patients were referred to undergo incremental cardiopulmonary exercise testing with a cycle ergometer. The Zung Self-Rating Anxiety Scale and the Zung Self-Rating Depression Scale were used to evaluate patients’ mental health. Statistical analysis was performed using the chi-square test, Fisher’s exact test, t-test, Mann-Whitney U test, and binary logistic regression.

Results

Among the 230 patients, 223 patients demonstrated reduced exercise capacity. Resutlts of the logistic regression analysis showed that anxiety (OR = 1.13, 95% CI 1.01–1.32, P = 0.029) was an independent risk factor for reduced exercise capacity in patients following the PCI or CABG.

Conclusions

Exercise capacity of Chinese CAD patients after PCI or CABG was relatively poor. Alleviating symptoms of anxiety and making exercise prescriptions according to the results of the cardiopulmonary exercise test should be considered during the intervention to improve CAD patients’ exercise capacity.

Health Locus of Control Is Associated With Physical Activity and Other Health Behaviors in Cardiac Patients

PURPOSE

Physical inactivity, smoking, and excessive alcohol use are well-recognized modifiable risk factors for cardiovascular disease (CVD), yet uptake of strategies to mitigate these poor health behaviors varies widely among patients with cardiovascular disease. Part of this variation may be explained by health locus of control (HLOC), defined as the extent to which individuals believe their health is a consequence of their own actions, chance, or the influence of others (eg, physicians).

METHODS

A total of 599 cardiac outpatients (30% female, 61.4 ± 9.4 y of age) completed the Multidimensional Health Locus of Control questionnaire and a structured health behavior questionnaire assessing physical activity, smoking, and alcohol use, at baseline and a 4-y follow-up. Relationships between health behaviors and HLOC were assessed cross-sectionally and longitudinally using general linear models and logistic regression models adjusting for medical and sociodemographic factors.

RESULTS

Higher Internal HLOC was found to be associated with higher levels of leisure time physical activity (LTPA) (β = .21, P = .0008), while lower Internal HLOC was associated with decreasing levels of alcohol consumption over time (β = .26, P = .03). Increasing Chance HLOC was related to lower levels of leisure time physical activity (β = -.15, P = .047) and increased likelihood of being a smoker (β = .10, P = .01), and increasing physician HLOC was associated with decreased likelihood of being a smoker (β = -.17, P = .01).

CONCLUSIONS

Associations between HLOC and multiple health behaviors were observed in a large sample of cardiac outpatients. Results suggest that assessing and targeting HLOC beliefs of cardiac patients may be clinically relevant for behavior change in settings, such as in rehabilitation programs where behavior change is a goal.

Do Women With Anxiety or Depression Have Higher Rates of Myocardial Ischemia During Exercise Testing Than Men?

BACKGROUND

Women diagnosed with coronary artery disease (CAD) typically experience worse outcomes relative to men, possibly through diagnosis and treatment delays. Reasons for these delays may be influenced by mood and anxiety disorders, which are more prevalent in women and have symptoms (eg, palpitations and fatigue) that may be confounded with CAD. Our study examined sex differences in the association between mood and anxiety disorders and myocardial ischemia in patients with and without a CAD history presenting for exercise stress tests.

METHODS AND RESULTS

A total of 2342 patients (women n=760) completed a single photon emission computed tomographic exercise stress test (standard Bruce Protocol) and underwent a psychiatric interview (The Primary Care Evaluation of Mental Disorders) to assess mood and anxiety disorders. Ischemia was assessed using single photon emission computed tomography, with odds ratio used to calculate the effect of sex and mood/anxiety on the presence of ischemia during stress testing by CAD history in a stratified analyses, adjusted for relevant covariates. There was a sex by anxiety interaction with ischemia in those without a CAD history (P=0.015): women with anxiety were more likely to exhibit ischemia during exercise than women without anxiety (odds ratio, 1.75; 95% confidence interval, 1.05-2.89). No significant effects were observed for men nor mood.

CONCLUSIONS

Women with anxiety and no CAD history had higher rates of ischemia than women without anxiety. Results suggest that anxiety symptoms, many of which overlap with those of CAD, might mask CAD symptoms among women (but not men) and contribute to referral and diagnostic delays. Further research is needed to confirm this hypothesis.

The interaction between anxiety and depressive symptoms on brachial artery reactivity in cardiac patients

The association between anxiety, depression, and endothelial function (EF) was assessed in a sample of 295 cardiac outpatients (n=222 men; mean age=59). Patients were administered the Beck Depression Inventory-II and the State-Trait Anxiety Inventory, trait scale. EF was assessed through forearm hyperemic reactivity, a nuclear medicine variation of the flow-mediated dilatation technique, which calculates the rate of uptake ratio (RUR) between hyperaemic and non-hyperaemic arms. Neither effect of anxiety (F=1.40, p=.24) nor depression (F=2.66, p=.10) was found in a model predicting EF, however there was an interaction (F=4.11, p=.04). Higher anxiety and lower depressive symptoms were associated with superior RUR compared to lower anxiety and lower depressive symptoms. Anxiety had no influence on RUR in those patients with higher depressive symptoms, who generally displayed the lowest levels of RUR, i.e., poor function. It is speculative whether this potential protective role of anxiety may be guided by behavioral or physiological mechanisms.

Relationship of fatigue and exercise capacity with emotional and physical state in patients with coronary artery disease admitted for rehabilitation program

BACKGROUND

The relationship between subjective fatigue, exercise capacity, and symptoms of depression and anxiety in patients with coronary artery disease (CAD) needs to be specified.

METHODS

In this cross-sectional study, a total of 1,470 (64% men; mean age 57 ± 11 years) consecutive CAD patients admitted for cardiac rehabilitation after treatment of acute cardiac events were evaluated for demographic characteristics, for past and current diagnosis and treatment, for New York Heart Association (NYHA) class, for symptoms of depression and for symptoms of anxiety using the Hospital Anxiety and Depression Scale, and for subjective fatigue using the Multidimensional Fatigue Inventory. On the next day, all patients underwent exercise capacity evaluation using a standard bicycle ergometer testing procedure.

RESULTS

In univariate regression analyses, there was the strongest positive association between scores on all Multidimensional Fatigue Inventory subscales and scores on the Hospital Anxiety and Depression Scale depression and anxiety subscales and between exercise capacity and NYHA class. Multivariate regression analyses revealed that symptoms of depression were the strongest positive determinants of all dimensions of subjective fatigue and, together with other significant variables, accounted for 17% to 29% of the variance. However, neither depressive nor anxious symptoms were significant determinants of exercise capacity. The association between subjective fatigue and exercise capacity and vice versa was minimal.

CONCLUSION

Subjective fatigue in CAD patients is strongly related to symptoms of depression and symptoms of anxiety. In contrast, exercise capacity in CAD patients is strongly related to NYHA functional class, with no relationship to symptoms of depression and anxiety.