Depression and Anxiety Screens as Predictors of 8-Year Incidence of Myocardial Infarction and Stroke in Primary Care Patients

Neuroprotective effects of psilocybin in a rat model of stroke

BACKGROUND

Psilocybin is a psychedelic 5HT2A receptor agonist found in "magic mushrooms". Recent studies have indicated that 5HT2A agonists, such as dimethyltryptamine, given before middle cerebral artery occlusion (MCAo), improve staircase behavior, increased BDNF expression, and reduce brain infarction in stroke rats. The objective of this study is to determine the protective effect of psilocybin in cellular and animal models of stroke.

METHODS

Adult male and timed-pregnant Sprague-Dawley rats were used for this study. The neural protective effects of psilocybin were determined in primary rat cortical neurons and adult rats. Rats were subjected to a 60-min middle cerebral artery occlusion. Brain tissues were collected for histological and qRTPCR analysis.

RESULTS

Psilocybin reduced glutamate-mediated neuronal loss in rat primary cortical neuronal cultures. Psilocybin-mediated protection in culture was antagonized by the BDNF inhibitor ANA12. Pretreatment with psilocybin reduced brain infarction and neurological deficits in stroke rats. Early post-treatment with psilocybin improved locomotor behavior, upregulated the expression of MAP2 and synaptophysin, and down-regulated the expression of IBA1 in the stroke brain. ANA12 significantly attenuated psilocybin-mediated reduction in brain infarction and improvements in locomotor behavior.

CONCLUSIONS

Psilocybin reduced brain infarction and improved locomotor behavior in stroke rats; the protective mechanisms involve regulating BDNF expression. Our data support a novel therapeutic approach of psilocybin in stroke.

Association of Depressive and Anxiety Symptoms With Risk of Cardiovascular Disease in Middle-Aged and Older Chinese Women

The objective of this study was to estimate the association of depressive and anxiety symptoms with the risk of cardiovascular disease (CVD) in middle-aged and older Chinese women and to further evaluate whether the association was influenced by sociodemographic factors. This cross-sectional study included 9544 women aged 40 to 70 years from the eastern, central, and western regions of China in 2018. Logistic regression models were utilized to examine odds ratios (ORs) and their 95% confidence intervals (CIs) for depressive and anxiety symptoms with CVD risk. Depressive (OR = 1.89) and anxiety symptoms (OR = 1.55) were independently associated with an increased risk of CVD after adjusting for potential confounders. Stratified analyses found that depressive symptoms were only significantly associated with higher risk of CVD in women aged over 50 years and with lower levels of education and household income, whereas anxiety symptoms were only significantly associated with an elevated risk of CVD in women aged 60 to 70 years, and living in rural areas, and with lower levels of education and household income. Our findings emphasize the improvement of recognizing and managing depressive and anxiety symptoms to reduce the risk of CVD in middle-aged and older women, particularly in older women of low socioeconomic status.

Association of anxiety with cardiovascular disease in a Chinese cohort of 0.5 million adults

BACKGROUND

Anxiety might be a potentially modifiable risk factor of cardiovascular diseases (CVDs). Evidence relating anxiety symptoms and generalized anxiety disorder (GAD) to CVDs from prospective cohort study was still lacking in China.

METHODS

Participants aged 30 to 79 years old from 10 areas across China were recruited during 2004-2008 and were followed up until 2017. 487,209 participants without CVDs at baseline remained for analyses. Anxiety symptoms (panic attacks and continuous anxiety) during the past 12 months were identified in a face-to-face interview. Participants with continuous anxiety were further assessed for GAD using Composite International Diagnostic Interview-Short Form. The primary outcomes were incident CVD, ischaemic heart disease (IHD), haemorrhagic stroke (HS), and ischaemic stroke (IS).

RESULTS

During 4.7 million person-years of follow-up, we documented 140,365 incident cases of CVD. For panic attacks, the multivariable-adjusted HRs (95 % CI) were 1.08 (1.04-1.13), 1.10 (1.02-1.19), 1.20 (1.05-1.38) and 1.20 (1.11-1.30) for CVD, IHD, HS and IS, respectively. Continuous anxiety was positively associated with incident CVD and IHD, and the corresponding HRs were 1.12 (1.04-1.20) and 1.21 (1.07-1.37).

LIMITATIONS

Anxiety symptoms were examined according to self-reported questionnaires, which could constitute key study limitations.

CONCLUSIONS

Among the Chinese adults, those with anxiety symptoms or GAD might be important at-risk population of CVD.

Chaihujialonggumulitang shows psycho-cardiology therapeutic effect on acute myocardial infarction with comorbid anxiety by the activation of Nrf2/HO-1 pathway and suppression of oxidative stress and apoptosis

BACKGROUND

Anxiety is a common comorbidity of cardiovascular diseases, which deteriorated cardiac function. Chaihujialonggumulitang (BFG) was reported to have antioxidant properties, alleviate myocardial ischemia injury and improve anxiety-like behavior. The Nuclear factor erythroid 2-related factor 2 (Nrf2) /heme oxygenase-1 (HO-1) pathway is the main mechanism to defend against oxidative stress, and improve cardiac function. This study was to investigate the possible mechanism of BFG in the treatment of psycho-cardiology.

METHODS

AMI with comorbid anxiety rat model was established by ligation of the left anterior descending coronary artery combined with uncertain empty bottle stimulation, followed by the administration of BFG (1 mL/100 g/d by gavage) or Dimethyl fumarate (DMF, 10 mg/kg/d by intraperitoneal injection) for 6 days. Echocardiography, myocardial injury markers, H&E, and Masson staining were employed to evaluate cardiac function. Behavioral tests and hippocampus neurotransmitters were applied to record anxiety-like behavior. We employed immunohistochemistry, RT-PCR, western blotting, and biochemical analysis to detect the protein and gene expression of Nrf2/HO-1 pathway-related factors, and oxidative stress and apoptosis parameters.

RESULTS

Rats in the AMI and complex groups showed cardiac function deterioration, as well as anxiety-like behavior. BFG improved echocardiography indicators, reduced myocardial injury markers, and attenuated myocardial pathological changes. BFG also ameliorated anxiety-like behaviors and elevated neurotransmitters levels. BFG promoted the activation of Nrf2/HO-1 pathway, increased antioxidant enzyme activities, reduced lipid peroxidation levels, and alleviated oxidative damage and apoptosis. DMF showed therapeutic effects and molecular mechanisms similar to BFG.

CONCLUSION

BFG may possess a psycho-cardiology therapeutic effect on AMI with comorbid anxiety by the activation of the Nrf2/HO-1 pathway and suppression of oxidative stress and apoptosis.

Anxiety as a risk factor for cardiovascular disease independent of depression: a prospective examination of community-dwelling men (the MrOS study)

OBJECTIVE

Anxiety and depression have been linked to increased risk of cardiovascular disease (CVD). Whether anxiety is a risk factor independent from depression, and if associations are limited to specific CVD outcomes remains unclear. Design: Participants (N = 3135) of the prospective Osteoporotic Fracturs in Men Sleep ancillary study were community-dwelling men (age ≥ 65) living in the US. Main outcome measures: The Goldberg Anxiety and Depression Scales, coronary heart disease (CHD) and cerebrovascular disease (CER). We used Cox proportional hazards models to calculate adjusted hazard ratios and 95% confidence intervals. Results: During 12 years of follow-up, we accrued 612 cases of CHD and 291 cases of CER (incident or repeat-event). Overall, we observed no association between anxiety or depression and CER. Anxiety was significantly associated with CHD, but this effect was attenuated after controlling for depression and covariates. Depression was significantly associated with CHD after similar adjustments. For men without prior history of CVD, neither anxiety nor depression were associated with incident CHD. Conclusions: Anxiety was not a significant independent predictor of CHD or CER, suggesting that previous findings of anxiety as a risk factor of CVD might be attributed to failure to control for the effect of depression.

Anxiety as a risk factor for cardiovascular disease independent of depression: A narrative review of current status and conflicting findings

The aim of this paper is to summarise and evaluate the empirical support for the association between anxiety and cardiovascular disease (CVD) and to address challenges related to method and study design. We review results from meta-analyses and more recent findings on the association of anxiety and the risk of CVD. Depression and anxiety are often listed as psychosocial risk markers of CVD, but the role of anxiety as a risk factor for CVD has not received the same evidential support as the effects of depression. Through a narrative review we identified six meta-analyses as well as 15 recent large studies of anxiety and CVD that we summarise. Some of the conflicting findings may be artefacts of study design or population the sample is drawn from. Researchers should take care to be population specific, measurement specific and outcome specific, and to control for comorbid depression.

The cardioprotective and anxiolytic effects of Chaihujialonggumuli granule on rats with anxiety after acute myocardial infarction is partly mediated by suppression of CXCR4/NF-κB/GSDMD pathway

AIMS

Over-expression of CXCR4 activates nuclear translocation of NF-κB, induces high expression of NLRP3, GSDMD, IL-1β and IL-18, which promotes severe inflammatory response following myocardial infarction. Previous studies revealed inflammation induces anxiety after myocardial infarction. The Chaihujialonggumuli granule has anti-inflammatory properties and could tranquillize mind. But the mechanism of its efficacy remains unknown. This study was to investigate the possible mechanism of BFG on cardioprotective and anxiolytic.

METHODS

The expression of CXCR4, NF-κB, NLRP3and GSDMD was measured with western-blot, QRT-PCR. The expression location of CXCR4, NLRP3, GSDMD were determined by immunohistochemistry. IL-1β、IL-18 in the peripheral blood were measured by ELISA. HE staining, Masson staining and transmission electron microscopy were used to observe morphological changes of cardiomyocytes. Echocardiography was used to assess cardiac function after cardiac surgery. Elevated cross maze test and open field test were used to evaluate behaviours. Western blot was used to detect the protein expressions of 5-HT, DA, IL-1β, IL-18 and neuron damage was investigated by Nissl staining in the hippocampus.

RESULTS

The up-regulation of CXCR4, NF-κB, NLRP3 and GSDMD were found in the infarcted area after left coronary artery ligation. Pathological staining and analysis showed that more severe inflammatory cytokines infiltration, myocardial fibrosis, were found in myocardial tissue of the complex group rats. And when compared to the sham group, the levels of IL-1β, IL-18 was increased of the complex group in both peripheral blood and brain. Behavioural test and echocardiography indicated that the rats in complex group exploration behaviours was significantly reduced, and with poor cardiac functional recovery. The AMD3100 had an inhibitory impact of CXCR4 on the activition of its downstream effectors, alleviating inflammatory reaction. Furthermore, the BFG decreased the expression level of CXCR4, NF-κB, GSDMD, NLRP3 in the infarcted area after myocardial infarction, when compared to the complex group. The assays in the brain indicated the BFG suppressed expression and activity of IL-1β, IL-18, and improved 5-HT and DA synthesis.

CONCLUSIONS

In sum, our study indicated that BFG may reduce inflammation, treat co-existing anxiety after myocardial infarction through inhibition of CXCR4/NF-κB/GSDMD signalling.

Joint effect of depression and health behaviors or conditions on incident cardiovascular diseases: A Korean population-based cohort study

BACKGROUND

The precise relationships among depression, risk factors for cardiovascular disease (CVD), and incident CVD remain uncertain. This study examined the joint effect of depression and other CVD risk factors on the incidence of CVD.

METHODS

We conducted a prospective cohort study using South Korea's National Health Insurance Service-National Sample Cohort (NHIS-NSC). To estimate incident CVD, 199,544 participants without CVD diagnosed with depression between 2003 and 2005 were followed through 2013. The clinician's diagnosis used measurements for depression, CVD risk factors, and CVD.

RESULTS

Controlling for other CVD risk factors, depressed individuals had a higher risk for ischemic heart disease (AHR, 1.01; 99%%CI, 1.01-1.50) and other forms of heart disease likely related to atherosclerosis (AHR, 1.43; 99%%CI, 1.13-1.82). There were no statistically significant interactions between depression and CVD risk factors. However, when depression was comorbid with overweight or diabetes, there was a higher risk for incident ischemic heart disease, as compared to depression or CVD risk factors alone. For other forms of heart disease likely related to atherosclerosis, the coexistence of depression and physical inactivity or overweight showed a similar pattern to that shown in ischemic heart disease.

LIMITATIONS

The severity of depression was not reported for depressed patients, and our dataset provided a limited number of covariates. Also, the self-reported health behavior data may be biased.

CONCLUSION

As depression could be a significant predictor of incident CVD independently with other CVD risk factors, professionals should recognize and manage depression as a major CVD risk factor.

Sex- and Gender-Stratified Risks of Psychological Factors for Incident Ischemic Heart Disease: Systematic Review and Meta-Analysis

Background

Psychological factors are associated with an increased risk of developing ischemic heart disease (IHD). Women more often report psychological factors, and sex and gender differences are present in IHD. In this meta‐analysis we examine the risks of psychological factors for IHD incidence in women and men. We hypothesize that a broad range of psychological factors are related to a higher risk for incident IHD, with a higher risk for women.

Methods and Results

PubMed, EMBASE, and PsycINFO were searched for studies assessing the risk between psychological factors and incident IHD. Psychological factors included depression, anxiety or panic disorder, social support, hostility, anger, personality (type D), type A behavior pattern, posttraumatic stress disorder, and psychological distress. In the primary analyses, 62 studies (77 separate reports) that included 2 145 679 women and 3 119 879 men and reported confounder‐adjusted hazard ratios or relative risks were included. Pooled effect confounder‐adjusted estimates from random‐effects models showed that psychological factors (all combined) were associated with incident IHD in women (hazard ratio: 1.22; 95% CI, 1.14–1.30) and men (hazard ratio: 1.25; 95% CI, 1.19–1.31). No sex and gender differences were found for these pooled effect estimates (P=0.547).

Conclusions

Psychological factors are associated with incident IHD in both women and men, but no significant differences were observed between women and men. IHD is predominantly being studied as obstructive coronary artery disease, which is more prevalent in men. Data are needed on psychological predictors and other manifestations of IHD such as coronary microvascular disease, which is more common in women.

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.

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.

Younger Age and Depressive Symptoms Predict High Risk of Generalized Anxiety After Stroke and Transient Ischemic Attack

Background and Purpose—

Depression and anxiety are common after stroke/transient ischemic attack (TIA). These conditions are associated with poor functional outcome and worse quality of life. However, few studies have explored predictors of poststroke risk of generalized anxiety, especially in patients without comorbid depressive symptoms. We aimed to explore predictors of high risk of generalized anxiety after stroke/TIA.

Methods—

Consecutive stroke and TIA referrals to the Sunnybrook Stroke Prevention Clinic over a 2-year period (April 2012–April 2014) who spoke English, were not severely aphasic, and who consented to complete neuropsychological testing were included in this analysis. Generalized anxiety and depressive symptoms were assessed using the Generalized Anxiety Disorder 7-item scale and Center for Epidemiological Studies Depression Scale, respectively.

Results—

Two hundred and fifty-eight patients completed the Generalized Anxiety Disorder 7-item scale, of whom 56 (22%) were at high risk for generalized anxiety (scores ≥10). Younger age (odds ratio=0.96; 95% CI, 0.93–0.99; P =0.004) and greater depressive symptoms (odds ratio=1.20; 95% CI, 1.14–1.26; P ≤0.001) were significant predictors of being at high risk for generalized anxiety after stroke/TIA. Younger patients (≤50 years) were significantly more likely to be at high risk for both depression and generalized anxiety than older patients (30% versus 12%, χ 2 [1, N=258]=10.98, P =0.001). Our model explained 56% of the variance in risk of generalized anxiety after stroke. In patients without severe depressive symptoms (n=193, 75%), age and severity of depressive symptoms remained the only factors associated with risk of generalized anxiety.

Conclusions—

Anxiety is common after stroke/TIA and is highly correlated with poststroke depressive symptoms and age, even among those without severe depressive symptoms. Given the greater frequency of both generalized anxiety and depressive symptoms in young survivors, routine screening for depression and further evaluation of anxiety after stroke/TIA is warranted.

Prevalence of depression and anxiety and their association with cardiovascular risk factors in Northeast Brasil primary care patients

SUMMARY BACKGROUND: Depression and anxiety disorders (DAD) are the most prevalent mental health conditions worldwide. Among the adult population served in basic care, it is estimated that depression affects about 14.3% of these individuals worldwide, and between 21.4% and 31% in Brasil. Anxiety affects up to 33.7% of the population during their lifetimes. OBJECTIVES: estimate the prevalence proportions of DAD among patients in a municipality in Northeast Brasil and study the association between DAD and cardiovascular risk factors. METHODS: a cross-sectional study with the medical records of patients from primary care centers in Jaboatão dos Guararapes, Pernambuco. Patients aged ≥ 18 years and regularly followed-up were included. Exclusion criteria: a history of traumatic brain injury, alcohol or drug abuse, previous stroke, medical conditions or medications that mimic DAD symptoms. Subjects were divided into two groups depending on the presence or absence of DAD, and cardiovascular risk factors were compared between groups. RESULTS: A total of 1030 subjects were initially included, of whom 215 (20%) were excluded. No-DAD subjects had more history of myocardial infarction and alcoholism. The prevalence of depression was 10.3%, anxiety disorder was 27.1%, and mixed DAD represented 4.5%. There was a significant association between DAD and hypertension (OR = 2.11; 95%CI: 1.16 –3.84; p=0.01), obesity (OR = 4.47; 95%CI: 1.74 –11.46; p=0.002), and hyperlipidemia (OR = 3.88; 95%CI: 1.81-8.3; p<0.001). CONCLUSION: DAD were associated with an increased risk for arterial hypertension, obesity, and hyperlipidemia.

Antidepressant prescription in acute myocardial infarction is associated with increased mortality 1 year after discharge

AIMS

To assess the impact of antidepressant (AD) prescription at discharge on 1-year outcome of patients presenting with acute myocardial infarction (AMI) in Switzerland.

METHODS

We used data from the AMIS Plus registry including patients admitted between March 2005 and August 2016 with AMI to a Swiss hospital who were followed up by telephone, 12 months after discharge. We compared patients who received AD medication at discharge with those who did not, with regard to baseline characteristics and outcomes in 1-year follow-ups using logistic regression. Outcome endpoints included mortality, re-hospitalisation, cerebrovascular events, re-infarction, percutaneous coronary intervention (PCI), coronary artery bypass graft as well as pacemaker and/or cardioverter-defibrillator implantations. Additionally, work and daily life conditions were compared between the groups.

RESULTS

Among 8911 AMI patients, 565 (6.3%) received AD at discharge. These patients were predominantly female, older, experienced more often non-ST-segment elevation myocardial infarction, were in higher Killip classes, and had more frequently hypertension, diabetes, dyslipidaemia, obesity and comorbidities. They underwent less frequently PCI, and stayed in hospital longer. The AD-receiving group had higher crude all-cause mortality at 1-year follow-up than the non-receiving group (7.4% vs 3.4%; p < .001) and AD prescription was an independent predictor for mortality (OR 1.67; CI: 1.17 to 2.40).

CONCLUSION

AD medication at discharge was associated with poorer prognosis in AMI patients at 1-year follow-up. However, this study has limited data on depression diagnosis and drug classes. Further research is needed to pinpoint the causes and underlying pathomechanisms for the higher mortality observed in this patient group.

Association Between Alexithymia and Risk of Incident Cardiovascular Diseases in the SUpplémentation en VItamines et Minéraux AntioXydants (SU.VI.MAX) Cohort

OBJECTIVE

Although it has been suggested that alexythymia is associated with cardiovascular diseases, studies are scarce and a causal relationship is questionable. This study explored the prospective association between alexithymia and cardiovascular events in middle-aged participants without cardiovascular history at baseline.

METHODS

The 26-item Toronto Alexithymia Scale (TAS-26) was completed by 5586 participants of the French SUpplémentation en VItamines et Minéraux AntioXydants cohort (41.4% of men, M [SD] age = 52.2 [6.3] years) in 1996-1997. Covariates measured at baseline included age, occupational status, depressive symptoms, smoking status, body mass index, hypertension, diabetes, hypercholesterolemia, and hypertriglyceridemia. The follow-up ran from January 1, 1998, to the date of the first cardiovascular event, the date of death or September 1, 2007, whichever occurred first. Cardiovascular events were validated by an independent expert committee. Hazard ratios and 95% confidence intervals were computed with Cox regressions.

RESULTS

During an average of 8.9 years of follow-up, 171 first cardiovascular events were validated. After adjustment for age, sex, and occupational status, there was no association between baseline alexithymia and cardiovascular events at follow-up (hazard ratio [95% confidence interval] for 15 points of TAS-26 = 1.00 [0.81-1.23], p > .99). Adjusting for all covariates, using binary TAS-26 cut-offs or TAS-26 subscores yielded similar nonsignificant results.

CONCLUSIONS

In this large prospective study, alexithymia and cardiovascular events were not associated among a nonclinical population. This casts some doubt on whether alexithymia could be a meaningful target in the prevention of cardiovascular diseases.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov (NCT00272428).

Persistent anxiety and in-hospital complications after acute coronary syndrome

OBJECTIVES

To investigate the effects of pre-event persistent anxiety on in-hospital complications and length of stay (LOS) in patients who experienced acute coronary syndrome (ACS).

METHODS

This was a prospective study with patients seeking treatment for ACS events. Anxiety was measured 2 times before the event in 600 patients with pre-existing coronary heart disease (CHD). Patients were followed for 2 years or until they developed an ACS event. 120 patients developed ACS events (rate 20%). Complications and LOS were abstracted from medical records.

RESULTS

Persistently non-anxious patients have lower anxiety scores at 3 months follow-up than baseline (mean [standard deviation (SD)], 6.1 [0.24] vs. 3.9 [0.95], P <0.01). Patients with persistent anxiety had significantly higher complication rates than non-anxious patients (mean [SD], 0.71 [0.12] vs. 0.15 [0.11], P <0.05). In a multiple logistic regression, persistent anxiety was an independent predictor of complications. Patients who were persistently anxious were at 5 times higher risk for developing complications (odds ratio = 5.0, 95% confidence interval: 1.27-38.8, P < 0.05).

CONCLUSION

Anxiety measured up to 2 years before an ACS event was predictive of in-hospital complications. Clinicians caring for patients with CHD need to be as equally aware of the importance of assessing and treating persistent anxiety as clinicians caring for patients hospitalized for an ACS.

Anxiety disorders and risk of stroke: A systematic review and meta-analysis

BACKGROUND

Anxiety disorders are the most common mental health problem worldwide. However, the evidence on the association between anxiety disorders and risk of stroke is limited. This systematic review and meta-analysis presents a critical appraisal and summary of the available evidence on the association between anxiety disorders and risk of stroke.

METHODS

Cohort studies reporting risk of stroke among patients with anxiety disorders were searched in PubMed, Embase, PsycINFO, Scopus, and the Web of Science, from database inception to June 2016. The quality of the studies was assessed using standard criteria. A meta-analysis was undertaken to obtain pooled estimates of the risk of stroke among patients with anxiety disorders.

RESULTS

Eight studies, including 950,759 patients, from the 11,764 references initially identified, were included in this review. A significantly increased risk of stroke for patients with anxiety disorders was observed, with an overall hazard ratio: 1.24 (1.09-1.41), P=0.001. No significant heterogeneity between studies was detected and the funnel plot suggested that publication bias was unlikely. Limited evidence suggests that the risk of stroke is increased shortly after the diagnosis of anxiety and that risk of stroke may be higher for patients with severe anxiety.

CONCLUSIONS

Anxiety disorders are a very prevalent modifiable condition associated with risk of stroke increased by 24%. This evidence could inform the development of interventions for the management of anxiety and the prevention of stroke. Further studies on the risk of stroke in patients with anxiety, and the explanatory factors for this association, are required.