Inverse correlation between cardiac injury and cardiac anxiety: a potential role for communication

Quality of life and mental health of women who had cardiac disease in pregnancy and postpartum

Purpose

Cardiac disease is a leading cause of maternal morbidity and mortality yet there is limited research on women’s experiences and quality of life (QoL) outcomes. The aim of this study is to explore the general and health-related QoL (HRQoL) and mental health outcomes for women who have experienced cardiac disease in pregnancy and the first 12 months postpartum (CDPP).

Methods

This exploratory descriptive study recruited 43 women with acquired, genetic and congenital CDPP. Patient reported outcomes measures (PROMs) used were: WHOQoL-Bref, a Kansas City Cardiac Questionnaire (KCCQ), the Depression, Anxiety and Stress Scales-21 (DASS-21), the Cardiac Anxiety Questionnaire (CAQ) plus newly developed questions.

Results

Women reported low health satisfaction (51.7/100), physical health (55.2/100) and low HRQoL (63.1/100). Women had clinically significant scores for depression (24%), anxiety (22%) and stress (19.5%) (DASS-21) and 44.5% scored at least moderate anxiety on the CAQ. Most women (83.7%) were advised to avoid pregnancy which 88.9% found “upsetting” to “devastating”; 10.0% were offered counselling. Most women were concerned about reduced longevity (88.1%), offspring developing a cardiac condition (73.8%), and the limitations on enjoyment of life (57.1%). Women missed medical appointments due to cost (25.03%) and difficulty arranging childcare (45.5%).

Conclusion

The majority of women reported inadequate information and counselling support, with women with CDPP having sustained impaired QoL and mental health outcomes. The new and modified questions relating to mothering and children reflected the primacy of mothering to women’s identity and needs.

Supplementary information

The online version contains supplementary material available at 10.1186/s12884-022-05123-x.

Heart-Focused Anxiety Affects Behavioral Cardiac Risk Factors and Quality of Life: A Follow-Up Study Using a Psycho-Cardiological Rehabilitation Concept

BACKGROUND

Heart-focused anxiety (HFA) raises the risk for adverse outcomes in patients with heart disease. Despite this great importance, it is rarely assessed in clinical practice. Three dimensions are commonly defined in the context of HFA: heart-related fear, avoidance, and attention. The impact of these aspects on cardiac risk factors is essentially unclear. In this study, we investigated the relationship between HFA and behavioral cardiac risk factors as well as health-related quality of life (HRQoL), which represent important treatment outcomes of inpatient psycho-cardiological rehabilitation.

METHODS

A prospective observational design was used to examine 238 rehabilitation inpatients with comorbidity of cardiac disease and psychiatric disorder. We assessed HFA using the Cardiac Anxiety Questionnaire (CAQ), HRQoL using the SF-12 Health Survey, exercise capacity using the 6-minute walk test, and smoking behavior, respectively at admission (t0) and discharge (t1). Physical activity was assessed at t0 and in a follow-up survey 6 months after discharge (t2) using the International Physical Activity Questionnaire (IPAQ). Multiple regression models were used to analyze the predictive value of HFA for the outcome variables at t0, t1, and t2, adjusted for socio-demographic factors and depression. Predictive values for changes over time were evaluated by the regressor variable approach.

RESULTS

Exercise capacity and physical activity were negatively predicted by baseline heart-related avoidance, both cross-sectionally and prospectively. Avoidance at t1 also negatively predicted long-term changes over time in physical activity at t2. Total HFA and the subcomponent avoidance negatively predicted physical HRQoL both cross-sectionally and prospectively. Mental HRQoL was cross-sectionally predicted by heart-focused attention at t0, and prospectively predicted by total HFA and by avoidance. Regarding changes in the course of rehabilitation, baseline avoidance negatively predicted improvement in physical HRQoL during rehabilitation. Concerning smoking behavior, no associations with HFA were found.

CONCLUSIONS

HFA is a relevant inhibiting factor for the achievement of therapy goals in psycho-cardiological rehabilitation such as health behavior and HRQoL. Heart-related avoidance in particular, has a negative impact on exercise capacity, physical activity, and self-reported physical health. Its prospective negative predictive value for physical activity and physical health underlines the relevance of HFA for psycho-cardiological interventions.

Functional and Economic Impact of INOCA and Influence of Coronary Microvascular Dysfunction

OBJECTIVES

This study sought to better characterize the quality of life and economic impact in patients with symptoms of ischemia and no obstructive coronary disease (INOCA) and to identify the influence of coronary microvascular dysfunction (CMD).

BACKGROUND

Patients with INOCA have a high symptom burden and an increased incidence of major adverse cardiac events. CMD is a frequent cause of INOCA. The morbidity associated with INOCA and CMD has not been well-characterized.

METHODS

Sixty-six patients with INOCA underwent stress cardiac magnetic resonance with calculation of myocardial perfusion reserve (MPR); MPR 2.0 to 2.4 was considered borderline-reduced (possible CMD) and MPR <2.0 was defined as reduced (definite CMD). Subjects completed quality of life questionnaires to assess the morbidity and economic impact of INOCA. Questionnaire results were compared between INOCA patients with and without CMD. In addition, logistic regression was used to determine the predictors of CMD within the INOCA population.

RESULTS

The prevalence of definite CMD was 24%. Definite or borderline CMD was present in 59% (MPR ≤2.4). Patients with INOCA reported greater physical limitation, angina frequency, and reduced quality of life compared to referent stable coronary artery disease and acute myocardial infarction populations. In addition, Patients with INOCA reported frequent time missed from work and work limitations, suggesting a substantial economic impact. No difference was observed in reported symptoms between INOCA patients with and without CMD. Glomerular filtration rate and body-mass index were significant predictors of CMD in multivariable regression analysis.

CONCLUSIONS

INOCA is associated with high morbidity similar to other high-risk cardiac populations, and work limitations reported by Patients with INOCA suggest a substantial economic impact. CMD is a common cause of INOCA but is not associated with increased morbidity. These results suggest that there is significant symptom burden in the INOCA population regardless of etiology.

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates

BACKGROUND

Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses.

METHODS

We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained.

RESULTS

There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features.

CONCLUSIONS

The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

Association between heart-focused anxiety, depressive symptoms, health behaviors and healthcare utilization in patients with coronary heart disease

OBJECTIVE

To analyze the association between heart-focused anxiety, depressive symptoms, health behaviors and healthcare utilization in patients with coronary heart disease (CHD).

METHODS

N = 1007 patients with CHD were recruited in hospital and followed for one year in a two-site cohort study. Heart focused anxiety (Cardiac Anxiety Questionnaire [CAQ] with the three subscales fear, attention, and avoidance), depressive symptoms (depression module from the Patient Health Questionnaire [PHQ-9]), health behaviors and healthcare utilization (smoking status, alcohol consumption, physical activity, outpatient physician/psychotherapist visits) were assessed six months after the initial hospitalization. Multiple regression models were used for statistical analysis.

RESULTS

About one third of the sample exhibited clinically significant CAQ scores. Higher CAQ-avoidance scores were associated with current smoking (OR = 1.62; 95%CI: 1.33-1.98), reduced alcohol intake (OR = 0.83; 95%CI: 0.71-0.98), non-participation in a coronary exercise group (OR = 1.76; 95%CI: 1.42-2.17), less regular physical activity (OR = 2.69; 95%CI: 2.32-3.12), and more frequent contact to general practitioners (GPs; b = 0.07, SE: 0.03). CAQ-attention was associated with non-smoking (OR = 0.51; 95%CI: 0.37-0.70), exercise group participation (OR = 0.69; 95%CI: 0.51-0.94), more frequent regular physical activity (OR = 0.55; 95%CI: 0.44-0.68), and more frequent contact to specialists for internal medicine (b = 0.09, SE: 0.04). CAQ-fear was not associated with any of the health behavior or healthcare use measures. Depressive symptoms were associated with reduced regular physical activity (OR = 1.05; 95%CI: 1.02-1.08) and increased contact to mental care specialists (b = 0.03, SE: 0.01) and GPs (b = 0.02, SE: 0.01).

CONCLUSIONS

Heart-focused anxiety and depressive symptoms may impede secondary prevention in patients with CHD and increase outpatient healthcare utilization.

Prognostic association of cardiac anxiety with new cardiac events and mortality following myocardial infarction

BACKGROUND

General anxiety and depressive symptoms following a myocardial infarction are associated with a worse cardiac prognosis. However, the contribution of specific aspects of anxiety within this context remains unclear.

AIMS

To evaluate the independent prognostic association of cardiac anxiety with cardiac outcome after myocardial infarction.

METHOD

We administered the Cardiac Anxiety Questionnaire (CAQ) during hospital admission (baseline, n = 193) and 4 months (n = 147/193) after discharge. CAQ subscale scores reflect fear, attention, avoidance and safety-seeking behaviour. Study end-point was a major adverse cardiac event (MACE): readmission for ischemic cardiac disease or all-cause mortality. In Cox regression analysis, we adjusted for age, cardiac disease severity and depressive symptoms.

RESULTS

The CAQ sum score at baseline and at 4 months significantly predicted a MACE (HR_baseline = 1.59, 95% CI 1.04-2.43; HR_4-months = 1.77, 95% CI 1.04-3.02) with a mean follow-up of 4.2 (s.d. = 2.0) years and 4.3 (s.d. = 1.7) years respectively. Analyses of subscale scores revealed that this effect was particularly driven by avoidance (HR_baseline = 1.23, 95% CI 0.99-1.53; HR_4-months = 1.77, 95% CI 1.04-1.83).

CONCLUSIONS

Cardiac anxiety, particularly anxiety-related avoidance of exercise, is an important prognostic factor for a MACE in patients after myocardial infarction, independent of cardiac disease severity and depressive symptoms.