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

Lifestyle factors as determinants of atherosclerotic cardiovascular health

A sedentary lifestyle, low levels of physical activity and fitness, poor dietary patterns, and psychosocial stress are strongly associated with increased morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Conversely, engaging in regular physical activity, maintaining optimal fitness levels, adhering to a heart-healthy dietary pattern, effectively managing body weight, ensuring adequate sleep, implementing stress-reduction strategies, and addressing psychosocial risk factors are associated with a reduced risk of ASCVD. This comprehensive review synthesizes current evidence from large observational studies and randomized controlled trials on lifestyle factors as determinants of ASCVD health. It also briefly reviews mechanistic insights into how factors such as low shear stress, increased reactive oxygen species production, chronic inflammation, platelets and coagulation activation, endothelial dysfunction, and sympathetic hyperactivity contribute to the initiation and exacerbation of ASCVD risk factors. These include obesity, hyperglycemia, type 2 diabetes, hypertension, and dyslipidemia, subsequently leading to the development and progression of atherosclerosis, ultimately resulting in chronic ASCVD or acute cardiovascular events. To bridge the translational gap between epidemiologic and trial-based evidence and clinical practice, practical recommendations are summarized to facilitate the translation of scientific knowledge into actionable interventions to promote ASCVD health. Acknowledged is the gap between the evidence-based knowledge and adoption within healthcare systems, which remains a crucial objective in advancing cardiovascular health at the population level.

The effect of aromatherapy on patients with acute coronary syndrome: A systematic review and meta-analysis

OBJECTIVE

To systematically investigate the efficacy of aromatherapy in patients with acute coronary syndrome (ACS).

METHODS

We conducted a comprehensive search for papers published until November 2023 using the following databases: PubMed, Embase, and Cochrane Library. This study was conducted following the PRISMA and Cochrane Guidelines. The inclusion criteria were randomized controlled trials (RCTs) performed to assess the comparative effectiveness of inhalation aromatherapy versus controls in individuals diagnosed with ACS. The Jadad rating method was used to assess the quality of the included studies, and a meta-analysis was performed using the RevMan 5.4 software. Heterogeneity was quantified using the Higgins I2 (%) test.

RESULTS

A total of 12 RCTs with 476 patients with ACS were included. Aromatherapy has been shown to reduce anxiety scores significantly (standard mean difference [SMD]: -1.18, 95 % confidence interval [CI]: -1.33 to -1.03; P < 0.00001) along with reduction in systolic blood pressure (MD = -8.78, 95 % CI [-13.92, -3.65], P = 0.008); diastolic blood pressure (MD = -7.76, 95 % CI [-11.39, -4.12], P < 0.001); mean artery pressure MD = -9.68, 95 % CI [-13.93.-5.44]; P < 0.0001). However, no significant effects were reported on the heart rate (MD = -6.98, 95 % CI [-15.46, 1.50], P = 0.11) and respiratory rate (MD = -0.67, 95 % CI [-2.52, 1.19], P = 0.48). A greater frequency of aromatherapy was associated greater anxiety -1.80 incidence, with 95 % CI [-2.04, -1.56]. Citrus essential oils exhibited the strongest effect (SMD = -1.97, 95 % CI [-3.34, -0.60], P = 0.005) in reducing anxiety levels.

CONCLUSION

Aromatherapy appears to be an effective non-pharmacological intervention for reducing blood pressure and anxiety in individuals with ACS. This suggests that aromatherapy more than twice a day is effective in reducing anxiety levels. However, aromatherapy had no statistically significant impact on the heart or respiratory rates. Moreover, additional high-quality RCTs should be conducted to verify these results and explore the efficacy and mechanism of aromatherapy in patients with ACS.

Stress-Induced Hypercoagulability: Insights from Epidemiological and Mechanistic Studies, and Clinical Integration

By integrating findings from comprehensive reviews, meta-analyses, and cutting-edge genetic studies, this article illuminates the significance of stress-induced hypercoagulability in clinical medicine. In particular, the findings from numerous prospective cohort studies indicate that stress and hemostatic factors of a hypercoagulable state are associated with increased incident risk and poor prognosis for atherosclerotic cardiovascular disease and venous thromboembolism. Mendelian randomization studies suggest that these associations are partially causal. The review synthesizes extensive research on the link between acute and chronic stress and hypercoagulability, outlining a potential pathway from stress to thrombosis risk. Consistent with the allostatic load concept, acute stress-induced hypercoagulability, initially adaptive, can turn maladaptive under chronic stress or excessive acute stress, leading to arterial or venous thrombotic events. Individuals with predisposing factors, including atherosclerosis, thrombophilia, or immobilization, may exhibit an increased risk of thrombotic disease during stress. Contextual sociodemographic characteristics, the stress experience, and coping resources additionally modulate the extent of stress-induced hypercoagulability. Research into the neuroendocrine, cellular, and molecular bases reveals how stress influences platelet activation coagulation and fibrinolysis. The activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, along with vagal withdrawal, and the effects of catecholamines, cortisol, and vasopressin, are the central mechanisms involved. Hemoconcentration, inflammation, endothelial dysfunction, and thrombopoiesis additionally contribute to stress-induced hypercoagulability. Further research is needed to prove a causal link between chronic stress and hypercoagulability. This includes exploring its implications for the prevention and management of thrombotic diseases in stressed individuals, with a focus on developing effective psychosocial and pharmacological interventions.

Anxiety, a significant risk factor for coronary artery disease: what is the best index

BACKGROUND

Coronary artery disease (CAD) is known as the leading cause of disability and death globally. Anxiety disorders are also recognized as common types of mental disorders that substantially impact global health. Iran ranks among the countries with a high incidence of CAD and anxiety disorders. Therefore, the present study aims to determine the potential association and epidemiological aspects of anxiety and CAD within the population of Mashhad, the second most popoulos city in Iran.

METHODS

The present study is based on extracted data from the Mashhad stroke and heart atherosclerotic disorder (MASHAD) study which is a 10-year prospective cohort study intended to assess the effects of various CAD risk factors among Mashhad city residents. Anxiety scores were assessed at the baseline using Beck Anxiety Inventory and individuals were classified based on the BAI 4-factor structure model which included autonomic, cognitive, panic, and neuromotor components. Accordingly, the association between baseline anxiety scores and the BAI four-factor model with the risk of CAD events was analyzed using SPSS software version 21.

RESULTS

Based on the results, 60.4% of the sample were female, and 5.6% were classified as having severe forms of anxiety. Moreover, severe anxiety was more prevalent in females. Results showed a 1.7% risk of CAD (p-value < 0.001) over 10 years with one unit increase in anxiety score. Based on the 4-factor model structure, we found that only panic disorder could significantly increase the risk of CAD by 1.1% over the 10-year follow-up (p-value < 0.001).

CONCLUSION

Anxiety symptoms, particularly panic disorder, are independently and significantly associated with an increased overall risk of developing CAD over a 10-year period. Therefore, further studies are warranted to investigate the mechanisms through which anxiety may cause CAD, as well as possible interventions to mitigate these processes.

Effects of Aromatherapy on Anxiety and Blood Pressure in Patients with Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials

Introduction: Patients with acute coronary syndrome (ACS) often experience high levels of anxiety, which can significantly impact their prognosis. However, evidence regarding anxiety reduction by aromatherapy in patients with ACS is lacking. This study aimed to investigate the effects of aromatherapy on anxiety in patients with ACS. Methods: The literature search was conducted using PubMed, CINAHL, Embase, Web of Science, Cochrane Library, and PsycINFO from their inception until February 21, 2024. Based on inclusion criteria, randomized controlled trials (RCTs) on aromatherapy in patients with ACS aged ≥ 18 years were included. The risk of bias in the included studies was assessed using the revised Cochrane risk-of-bias tool for RCTs. Results: A total of 14 studies were included in the final analysis. Aromatherapy significantly reduced anxiety among patients with ACS, with a large effect size (standardized mean difference [SMD] = -1.66, 95% confidence interval [CI]: -2.47 to -0.85). The effect on systolic blood pressure (SBP) was -0.65 (95% CI: -1.15 to -0.15), indicating a moderate effect size, whereas there was no significant effect on diastolic blood pressure. Inhalation therapy demonstrated a large effect size (SMD = -1.70, 95% CI: -2.33 to -1.08), whereas massage therapy did not show a significant effect on reducing anxiety. Discussion/Conclusions: The findings show that aromatherapy can effectively reduce anxiety and SBP in patients with ACS. In particular, inhalation therapy showed a significant effect on reducing anxiety levels. Applying aromatherapy in clinical settings to reduce anxiety among patients with ACS should be considered. However, the limited number of studies analyzed hinders a comprehensive evaluation of the effectiveness of massage therapy. Hence, further research is necessary to elucidate its potential role in reducing anxiety among patients with ACS.

Psychological impact of first admission with cardiovascular disease in a tertiary hospital in Oman

Background and objectives

Cardiovascular diseases (CVD) are associated with substantial psychological effects that can adversely influence long term prognosis. The aim of this study was to determine the psychological effect of the first hospital admission for acute coronary syndrome (ACS) or congestive heart failure (CHF) in an adult Omani population.

Methods

This cross-sectional questionnaire based study used the Hospital Anxiety and Depression Scale. Patients were recruited from the in-patient cardiology and medical wards of our institution. Patients with a prior hospital admission for CHF and ACS were excluded. The questionnaire was administered between days 3 and 7 after admission once patients were clinically stable.

Results

The study included 116 patients (mean age 60.3 + 13.8 years; 78 (67.8%) men), comprising 52 patients with ACS and 64 patients with CHF. Based on the scores, a total of 45 (38.8%) patients had moderate to severe anxiety, and 32 (27.6%) had moderate to severe depression. Patients with severe anxiety tended to be younger, and no other factors predicted anxiety or depression. The proportion of patients with severe depression was higher among patients with CHF (31.4%), and no other differences were observed between patients with ACS or CHF.

Conclusion

A substantial proportion of patients admitted to our institution in Oman with CVD had severe anxiety and depression. Treating physicians and caregivers should be more open to identifying these patients, and steps should be taken to address their psychological wellbeing along with the medical management of their illness.

Anxiety and depression in patients aged 80 years and older following aortic valve therapy. A six-month follow-up study

BACKGROUND

Little is known about mental health following advanced cardiac procedures in the oldest patients.

AIMS

To study changes in anxiety and depression from baseline to one- and six-month follow-up in older patients following transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR).

METHODS

Prospective cohort study of patients ≥ 80 years undergoing elective TAVI or SAVR in a tertiary university hospital. Anxiety and depression were assessed with the Hospital Anxiety and Depression Scale. Differences between TAVI/SAVR were analyzed using Welch's t test or chi-squared. Changes over time and group differences were established with longitudinal models using generalized least squares.

RESULTS

In 143 patients (83.5 ± 2.7 years), 46% (n = 65) received TAVI. Anxiety was identified in 11% of TAVI patients at baseline. One- and six-months later, percentages were 8% and 9%. In SAVR patients, 18% had baseline scores indicating anxiety. One and six-months later, percentages were 11% and 9%. Depression was identified in 15% of TAVI patients. One- and six-months later, percentages were 11% and 17%. At baseline, 11% of SAVR patients had scores indicating depression. One- and six-months after SAVR, percentages were 15% and 12%. Longitudinal analyses showed reductions (P < 0.001) in anxiety from baseline to one-month, and stable scores between one- and six-months for both treatment groups. There was no change over time for depression among treatment groups (P = 0.21).

DISCUSSION AND CONCLUSIONS

SAVR or TAVI in patients ≥ 80 years was associated with anxiety reduction between baseline and follow-up. For depression, there was no evidence of change over time in either treatment group.

Screening for anxiety and depression in clinical practice: translating scores from World Health Organization-5/Anxiety Symptom Scale-2/Major Depression Inventory-2 to Hospital Anxiety and Depression Scale

AIMS

The aim of this study was to evaluate if a combination of World Health Organization-5 (WHO-5), Anxiety Symptom Scale-2 (ASS-2), and Major Depression Inventory-2 (MDI-2) can replace the Hospital Anxiety and Depression Scale (HADS) as screening tool for anxiety and depression in cardiac patients across diagnoses and whether it is feasible to generate crosswalks (translation tables) for use in clinical practice.

METHODS AND RESULTS

We used data from the Danish 'Life with a heart disease' survey, in which 10 000 patients with a hospital contact and discharge diagnosis of ischaemic heart disease, heart failure, heart valve disease, or atrial fibrillation in 2018 were invited. Potential participants received an electronic questionnaire including 51 questions on health, well-being, and evaluation of the health care system. Crosswalks between WHO-5/ASS-2 and HADS anxiety dimension (HADS-A) and between WHO-5/MDI-2 and HADS depression dimension (HADS-D) were generated and tested using item response theory (IRT). A total of 4346 patients responded to HADS, WHO-5, ASS-2, and MDI-2. Model fit of the bi-factor IRT models illustrated appropriateness of a bi-factor structure and thus of essential uni-dimensionality [root mean square error of approximation (RMSEA) (P value) range 0.000-0.053 (0.0099-0.7529) for anxiety and 0.033-0.061 (0.0168-0.2233) for depression]. A combination of WHO-5 and ASS-2 measured the same trait as HADS-A, and a combination of WHO-5 and MDI-2 measured the same trait as HADS-D. Consequently, crosswalks (translation tables) were generated.

CONCLUSIONS

Our study shows that it is feasible to use crosswalks between HADS-A and WHO-5/ASS-2 and HADS-D and WHO-5/MDI-2 for screening cardiac patients across diagnoses for anxiety and depression in clinical practice.

Associations of health-related quality of life with major adverse cardiovascular and cerebrovascular events for individuals with ischaemic heart disease: systematic review, meta-analysis and evidence mapping

OBJECTIVE

To investigate the association between health-related quality of life (HRQoL) and major adverse cardiovascular and cerebrovascular events (MACCE) in individuals with ischaemic heart disease (IHD).

METHODS

Medline(R), Embase, APA PsycINFO and CINAHL (EBSCO) from inception to 3 April 2023 were searched. Studies reporting association of HRQoL, using a generic or cardiac-specific tool, with MACCE or components of MACCE for individuals with IHD were eligible for inclusion. Risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale to assess the quality of the studies. Descriptive synthesis, evidence mapping and random-effects meta-analysis were performed stratified by HRQoL measures and effect estimates. Between-study heterogeneity was assessed using the Higgins I2 statistic.

RESULTS

Fifty-one articles were included with a total of 134 740 participants from 53 countries. Meta-analysis of 23 studies found that the risk of MACCE increased with lower baseline HeartQoL score (HR 1.49, 95% CI 1.16 to 1.93) and Short Form Survey (SF-12) physical component score (PCS) (HR 1.39, 95% CI 1.28 to 1.51). Risk of all-cause mortality increased with a lower HeartQoL (HR 1.64, 95% CI 1.34 to 2.01), EuroQol 5-dimension (HR 1.17, 95% CI 1.12 to 1.22), SF-36 PCS (HR 1.29, 95% CI 1.19 to 1.41), SF-36 mental component score (HR 1.18, 95% CI 1.08 to 1.30).

CONCLUSIONS

This study found an inverse association between baseline values or change in HRQoL and MACCE or components of MACCE in individuals with IHD, albeit with between-study heterogeneity. Standardisation and routine assessment of HRQoL in clinical practice may help risk stratify individuals with IHD for tailored interventions.

PROSPERO REGISTRATION NUMBER

CRD42021234638.

Spiritual Well-Being and Death Anxiety: A Cross-Sectional Study Among Iranian Patients With Acute Coronary Syndrome

Acute coronary syndrome (ACS) patients experience a tremendous psychological burden, typically in the form of death worry due to acute medical conditions and the possibility of mortality. The unfavourable conditions of ACS patients cause them to reconsider the meaning of life and their spiritual well-being. This study evaluated the association between death anxiety and spiritual well-being in a total of 241 ACS patients in Shahroud, northeast of Iran. The data were collected using the Templer Death Anxiety Scale, and the Spiritual Well-being Scale by convenience sampling method. All patients indicated a high degree of death anxiety, and roughly half reported a moderate level of spiritual well-being. There was a significant and direct correlation between death anxiety and spiritual well-being levels. Older age, single status, and non-smoking were other predictors of good spiritual well-being. A multidisciplinary health team should identify and implement approaches to promote spiritual well-being and reduce mental suffering.

Prevalence of posttraumatic stress disorder following acute coronary syndrome and clinical characteristics of patients referred to cardiac rehabilitation

BACKGROUND

Studies have demonstrated that patients who have experienced acute coronary syndrome (ACS) have an increased risk of developing posttraumatic stress disorder (PTSD) and experiencing worse survival outcomes than those who do not develop PTSD. Nevertheless, the prevalence rates of PTSD following ACS vary widely across studies, and it is noteworthy that in most cases, the diagnosis of PTSD was based on self-report symptom questionnaires, rather than being established by psychiatrists. Additionally, the individual characteristics of patients who develop PTSD after ACS can differ widely, making it difficult to identify any consistent patterns or predictors of the disorder.

AIM

To investigate the prevalence of PTSD among a large sample of patients undergoing cardiac rehabilitation (CR) after ACS, as well as their characteristics in comparison to a control group.

METHODS

The participants of this study are patients who have experienced ACS with or without undergoing percutaneous coronary intervention and are enrolled in a 3-wk CR program at the largest CR center in Croatia, the Special Hospital for Medical Rehabilitation Krapinske Toplice. Patient recruitment for the study took place over the course of one year, from January 1, 2022, to December 31, 2022, with a total of 504 participants. The expected average follow-up period for patients included in the study is about 18 mo, and currently ongoing. Using self-assessment questionnaire for PTSD criteria and clinical psychiatric interview, a group of patients with a PTSD diagnosis was identified. From the participants who do not have a PTSD diagnosis, patients who would match those with a PTSD diagnosis in terms of relevant clinical and medical stratification variables and during the same rehabilitation period were selected to enable comparability of the two groups.

RESULTS

A total of 507 patients who were enrolled in the CR program were approached to participate in the study. Three patients declined to participate in the study. The screening PTSD Checklist-Civilian Version questionnaire was completed by 504 patients. Out of the total sample of 504 patients, 74.2% were men (n = 374) and 25.8% were women (n = 130). The mean age of all participants was 56.7 years (55.8 for men and 59.1 for women). Among the 504 participants who completed the screening questionnaire, 80 met the cutoff criteria for the PTSD and qualified for further evaluation (15.9%). All 80 patients agreed to a psychiatric interview. Among them, 51 patients (10.1%) were diagnosed with clinical PTSD by a psychiatrist according to Diagnostic and Statistical Manual of Mental Disorders criteria. Among the variables analyzed, there was a noticeable difference in the percentage of theoretical maximum achieved on exercise testing between the PTSD and non-PTSD groups. Non-PTSD group achieved a significantly higher percentage of their maximum compared to the PTSD group (P = 0.035).

CONCLUSION

The preliminary results of the study indicate that a significant proportion of patients with PTSD induced by ACS are not receiving adequate treatment. Furthermore, the data suggest that these patients may exhibit reduced physical activity levels, which could be one of the possible underlying mechanisms in observed poor cardiovascular outcomes in this population. Identifying cardiac biomarkers is crucial for identifying patients at risk of developing PTSD and may derive benefits from personalized interventions based on the principles of precision medicine in multidisciplinary CR programs.

Effects of Plant-Emitted Monoterpenes on Anxiety Symptoms: A Propensity-Matched Observational Cohort Study

Immersive experiences in green areas, particularly in forests, have long been known to produce beneficial effects for human health. However, the exact determinants and mechanisms leading to healthy outcomes remain to be elucidated. The purpose of this observational cohort study was to investigate whether inhaling plant-emitted biogenic volatile compounds, namely monoterpenes (MTs), can produce specific effects on anxiety symptoms. Data from 505 subjects participating in 39 structured forest therapy sessions at different Italian sites were collected. The air concentration of monoterpenes was measured at each site. STAI state questionnaires were administered before and after the sessions as a measure of anxiety. A propensity score matching analysis was then performed, considering an above-average exposure to inhalable air MTs as the treatment. The estimated effect was -1.28 STAI-S points (95% C.I. -2.51 to -0.06, p = 0.04), indicating that the average effect of exposure to high MT air concentrations during forest therapy sessions was to decrease anxiety symptoms.

Impact of mental disorders on clinical outcomes of physical diseases: an umbrella review assessing population attributable fraction and generalized impact fraction

Empirical evidence indicates a significant bidirectional association between mental disorders and physical diseases, but the prospective impact of men-tal disorders on clinical outcomes of physical diseases has not been comprehensively outlined. In this PRISMA- and COSMOS-E-compliant umbrella review, we searched PubMed, PsycINFO, Embase, and Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, up to March 15, 2022, to identify systematic reviews with meta-analysis that examined the prospective association between any mental disorder and clinical outcomes of physical diseases. Primary outcomes were disease-specific mortality and all-cause mortality. Secondary outcomes were disease-specific incidence, functioning and/or disability, symptom severity, quality of life, recurrence or progression, major cardiac events, and treatment-related outcomes. Additional inclusion criteria were further applied to primary studies. Random effect models were employed, along with I² statistic, 95% prediction intervals, small-study effects test, excess significance bias test, and risk of bias (ROBIS) assessment. Associations were classified into five credibility classes of evidence (I to IV and non-significant) according to established criteria, complemented by sensitivity and subgroup analyses to examine the robustness of the main analysis. Statistical analysis was performed using a new package for conducting umbrella reviews (https://metaumbrella.org). Population attributable fraction (PAF) and generalized impact fraction (GIF) were then calculated for class I-III associations. Forty-seven systematic reviews with meta-analysis, encompassing 251 non-overlapping primary studies and reporting 74 associations, were included (68% were at low risk of bias at the ROBIS assessment). Altogether, 43 primary outcomes (disease-specific mortality: n=17; all-cause mortality: n=26) and 31 secondary outcomes were investigated. Although 72% of associations were statistically significant (p<0.05), only two showed convincing (class I) evidence: that between depressive disorders and all-cause mortality in patients with heart failure (hazard ratio, HR=1.44, 95% CI: 1.26-1.65), and that between schizophrenia and cardiovascular mortality in patients with cardiovascular diseases (risk ratio, RR=1.54, 95% CI: 1.36-1.75). Six associations showed highly suggestive (class II) evidence: those between depressive disorders and all-cause mortality in patients with diabetes mellitus (HR=2.84, 95% CI: 2.00-4.03) and with kidney failure (HR=1.41, 95% CI: 1.31-1.51); that between depressive disorders and major cardiac events in patients with myocardial infarction (odds ratio, OR=1.52, 95% CI: 1.36-1.70); that between depressive disorders and dementia in patients with diabetes mellitus (HR=2.11, 95% CI: 1.77-2.52); that between alcohol use disorder and decompensated liver cirrhosis in patients with hepatitis C (RR=3.15, 95% CI: 2.87-3.46); and that between schizophrenia and cancer mortality in patients with cancer (standardized mean ratio, SMR=1.74, 95% CI: 1.41-2.15). Sensitivity/subgroup analyses confirmed these results. The largest PAFs were 30.56% (95% CI: 27.67-33.49) for alcohol use disorder and decompensated liver cirrhosis in patients with hepatitis C, 26.81% (95% CI: 16.61-37.67) for depressive disorders and all-cause mortality in patients with diabetes mellitus, 13.68% (95% CI: 9.87-17.58) for depressive disorders and major cardiac events in patients with myocardial infarction, 11.99% (95% CI: 8.29-15.84) for schizophrenia and cardiovascular mortality in patients with cardiovascular diseases, and 11.59% (95% CI: 9.09-14.14) for depressive disorders and all-cause mortality in patients with kidney failure. The GIFs confirmed the preventive capacity of these associations. This umbrella review demonstrates that mental disorders increase the risk of a poor clinical outcome in several physical diseases. Prevention targeting mental disorders - particularly alcohol use disorders, depressive disorders, and schizophrenia - can reduce the incidence of adverse clinical outcomes in people with physical diseases. These findings can inform clinical practice and trans-speciality preventive approaches cutting across psychiatric and somatic medicine.

Differential effects of anxiety on long-term outcomes of acute coronary syndrome and stroke according to their disease severities

This study investigated associations of anxiety at the acute phase with long-term outcomes of acute coronary syndrome (ACS) and stroke, and potential modifying effects of cardiovascular/cerebrovascular severity at onset. In 1152 ACS and 423 stroke patients with recent onset, long-term follow-up for cardio-cerebro-vascular outcomes was conducted. Acute-phase anxiety predicted long-term outcomes, but these associations were significant only in patients with great initial disease severities with significant interaction terms in both diseases after adjustment for relevant covariates. Clinical prediction of cardio-cerebro-vascular prognosis might be improved by screening for anxiety and disease severities in the acute phase of ACS and stroke.

The role of sense of coherence in reducing anxiety and depressive symptoms among patients at the first acute coronary event: A three-year longitudinal study

OBJECTIVE

Although several studies suggest an association between psychological distress and increased morbidity and mortality in various cardiac populations, little is known about positive psychological resources, like Sense of Coherence (SOC), that may reduce distress. This longitudinal observational study aimed to test the hypothesis that a strong SOC predicted a longitudinal decrease in anxiety and depression in a sample of patients after their first acute coronary event.

METHODS

A sample of 275 patients completed the Hospital Anxiety Depression Scale (HADS) and the SOC Scale at five time-points (at the baseline and after 6, 12, 24, and 36 months). Longitudinal trajectories of anxiety, depression, and SOC were examined through hierarchical (generalized) linear models, controlling for sociodemographic and clinical indicators.

RESULTS

38.6% of patients experienced clinically relevant anxiety symptoms soon after the cardiovascular event, whereas only 20.8% experienced clinically relevant depressive symptoms. Anxiety symptoms decreased over time, plateaued, and then slightly increased, whereas depressive symptoms tended to be stable; these variables were positively associated during all time points. The SOC did not change over time; a strong SOC at baseline predicted decreased anxiety and depression.

CONCLUSION

Findings showed a strong relationship between SOC and symptoms of anxiety and depression, and they suggested the importance of a salutogenic approach in clinical practice and the relevance of interventions aimed at increasing resilience resources like the SOC in patients with cardiovascular diseases.

The Association of Persistent Symptoms of Depression and Anxiety with Recurrent Acute Coronary Syndrome Events: A Prospective Observational Study

The purpose of this study was to examine the role of persistent symptoms of depression and anxiety in a second acute coronary syndrome (ACS) event. Data presented in this study were from an RCT study. A follow-up for 24 months after baseline to detect a second ACS event among 1162 patients from five hospitals. Hierarchal Cox regression analyses were used. The results showed that persistent depression only (HR 2.27; 95% CI: 1.35–3.81; p = 0.002), and comorbid persistent depression and anxiety (HR 2.03; 95% CI: 1.03–3.98; p = 0.040) were the significant predictors of a second ACS event. Secondary education level compared to primary educational level (HR 0.63; 95% CI: 0.43–0.93; p = 0.020) and college or more education level compared to primary educational level (HR 0.47; 95% CI: 0.27–0.84; p = 0.011) were the only demographic variables that were significant predictors of a second event. The study reveals that attention must be paid by healthcare providers to assess and manage persistent depression; particularly when it is co-morbid with anxiety.

Systematic screening for anxiety and depression in cardiac rehabilitation - are we there yet?

BACKGROUND

Anxiety and depression are prevalent in 20% of patients with acute coronary syndrome (ACS) and associated with poor outcomes. Guidelines recommend screening for these conditions in cardiac rehabilitation (CR) however, clinical practice is inconsistent. Sparse knowledge exists on determinants for screening.

METHODS

This observational study used data from the National Audit of Cardiac Rehabilitation from January 2016-December 2019. A multivariate logistic regression model was performed to analyze patient- and provider level determinants for screening for anxiety and depression among patients with ACS.

RESULTS

The population consisted of 138,018 patients, where 82,507 (59.8%) were screened and 55,511 (40.2%) were not. Younger age, non-white ethnicity, living in areas of social deprivation, current smoking, body mass index>30, and physical activity<150 min per week were negatively correlated with patients being screened. Compared to patients having a percutaneous coronary intervention, patients undergoing coronary artery bypass grafting or medical treatment were less likely to be screened. History of anxiety, depression, osteoporosis, chronic back problems, and asthma were positively correlated with screening, while chronic obstructive pulmonary disease, diabetes, hypertension, and stroke were negatively correlated with screening. Regarding provider level, certification of CR centers was positively associated with screening, while looking over time data showed an incremental negative trend in screening from 2016 to 2019.

CONCLUSION

We found both patient and provider level determinants of screening for anxiety and depression. Clinical practice is still inconsistent especially for high-risk groups. We recommend systematic screening to enable tailored interventions which in turn may mitigate inequity in health outcomes.

Anxiety is associated with higher recurrence of atrial fibrillation after catheter ablation: A meta‐analysis

Previous studies that evaluated the influence of anxiety on recurrence of atrial fibrillation (AF) after catheter ablation showed inconsistent results. We performed a meta‐analysis of cohort study to systematically evaluate the association between anxiety and AF recurrence after catheter ablation. Electronic databases of PubMed, Embase, and Web of Science were searched for relevant cohort studies from inception to January 20, 2021. We applied the random‐effect model to combine the results to incorporate the potential influence of heterogeneity among studies. Five cohort studies were eligible for the meta‐analysis, which included 549 patients with AF that received catheter ablation. No significant heterogeneity was observed among the included studies (I² = 7%, P for Cochrane's Q test = 0.37). During a mean follow‐up of 9.7 months, 216 (39.3%) cases of recurrent AF occurred. Results of the meta‐analysis showed that anxiety was independently associated with an increased risk of AF recurrence after catheter ablation (adjusted relative risk: 2.36, 95% confidence interval: 1.71–3.26; p < .001). Subgroup analyses did not show that differences in study characteristics including study design, ethnicity of the patients, sample size, AF type, anxiety evaluation method, follow‐up duration, or adjustment of LAD may significantly affect the association between anxiety and AF recurrence (p for subgroup difference all > .10). Anxiety may be an independent risk factor for AF recurrence after catheter ablation. Whether alleviating anxiety mood could reduce the risk of AF recurrence after catheter ablation should also be investigated.

[The Role of Heart-Focused Anxiety in the Need for Psychological Support and Self-Assessment of Early Retirement - Indications from Cardiac Inpatient Rehabilitation]

OBJECTIVE

The psychosocial care of cardiac patients is becoming increasingly important. In inpatient cardiac rehabilitation, patients should be ideally screened for psychosocial risk factors and given psychological support. Heart-focused anxiety can significantly impair quality of life and subsequently influence prognosis of the course of the disease as well as social and occupational participation. Due to the difference between reported prevalence of heart-focused anxiety and the observed lower rate of patients expressing need for psychological support, the authors assumed that some patients do not express their need for psychological support. Therefore, aim of the study was to identify these patients through a simple screening instrument in order to offer them appropriate psychological support and consequently to maintain rehabilitation goals, including ability to work.

METHODS

We conducted a cross-sectional study at an inpatient cardiac rehabilitation center, Roderbirken, Leichlingen, Germany. Patients completed a standardised questionnaire, consisting of the Cardiac Anxiety Questionnaire, the Hospital Anxiety and Depression Scale and Scale I of the Screening Instrument Work and Occupation. Data were analyzed using descriptive statistics and logistic regression analysis. Ethical approval was obtained.

RESULTS

Finally, 507 patients were included in the analysis (82.6% men, mean age 54.4±7.1 years). Of these, 40.0% expressed need for psychological support. Prevalence of heart-focused anxiety was 15.7%; among them significantly more patients expressed need for psychological support (59.0 vs. 41.0%; p<0.05). Also patients with mental disorders expressed need for psychological support (57.6 vs. 0.7%; p<0.05). Subjective assessment of early retirement was associated with heart-focused anxiety and with depressive symptoms (both p<0.001) as well as education and employment status.

DISCUSSION

Based on the results of the self-assessment instruments as well as the socioeconomic and clinical patient characteristics, possible indicators of subjective occupational prognosis can be derived.

CONCLUSION

An screening through Hospital Anxiety and Depression Scale can facilitate target achievement of return to work in cardiac rehabilitation.

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.

Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE Risk Model

AIMS

Most patients with established atherosclerotic cardiovascular disease (CVD) are at very high risk for developing recurrent events. Since this risk varies a lot between patients there is a need to identify those in whom an even more intensive secondary prevention strategy should be envisaged. Using data from the EUROASPIRE IV and V cohorts of coronary heart disease (CHD) patients from 27 European countries, we aimed at developing and internally and externally validating a risk model predicting recurrent CVD events in patients aged < 75 years.

METHODS AND RESULTS

Prospective data were available for 12 484 patients after a median follow-up time of 1.7 years. The primary endpoint, a composite of fatal CVD or new hospitalizations for non-fatal myocardial infarction (MI), stroke, heart failure, coronary artery bypass graft, or percutaneous coronary intervention (PCI), occurred in 1424 patients. The model was developed based on data from 8000 randomly selected patients in whom the association between potential risk factors and the incidence of the primary endpoint was investigated. This model was then validated in the remaining 4484 patients. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, a previous hospitalization for stroke, heart failure or PCI, a previous diagnosis of peripheral artery disease, self-reported diabetes and its glycaemic control, higher non-high-density lipoprotein cholesterol, reduced renal function, symptoms of depression and anxiety and living in a higher risk country. The model demonstrated excellent internal validity and proved very adequate in the validation cohort. Regarding external validity, the model demonstrated good discriminative ability in 20 148 MI patients participating in the SWEDEHEART register. Finally, we developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CHD.

CONCLUSION

In patients with CHD, fatal and non-fatal rates of recurrent CVD events are high. However, there are still opportunities to optimize their management in order to prevent further disease or death. The EUROASPIRE Risk Calculator may be of help to reach this goal.

Treatment of Heart Failure Patients with Anxiolytics Is Associated with Adverse Outcomes, with and without Depression

BACKGROUND

Few studies have evaluated the effect of pharmacologic treatment of anxiety on outcomes in heart failure (HF) patients. This study examined the impact of treatment with anxiolytics on clinical outcomes in a real-world sample of HF patients with and without depression.

METHODS

Patients diagnosed with HF were retrieved from a large HMO database. Patients prescribed anxiolytic medication and patients diagnosed with depression and/or prescribed anti-depressant medication were followed for cardiac-related hospitalizations and death.

RESULTS

The study cohort included 6293 HF patients. Treatment with anxiolytics was associated with decreased one-year survival compared to untreated individuals, with a greater reduction in survival seen in patients diagnosed with depression and/or treated with anti-depressants. Multi-variable analysis adjusting for age, sex, NYHA class, cardiac risk factors and laboratory parameters found that treatment with anxiolytics remained a predictor of mortality even when adjusting for depression. Depression combined with anxiolytic treatment was predictive of increased mortality, and treatment with anxiolytics alone, depression alone and anxiolytic treatment together with depression were each associated with an increased hazard ratio for a composite outcome of death and hospitalization.

CONCLUSIONS

In this real-world study of HF patients, both treatment with anxiolytics and depression were associated with increased mortality, and anxiolytic therapy remained a predictor of mortality when adjusting for depression. Treatment of anxiety together with depression was associated with the highest risk of mortality. Safe and effective treatment for anxiety and depression is warranted to alleviate the detrimental impact of these disorders on quality and of life and adverse events.