Prospective study of phobic anxiety and risk of coronary heart disease in men

Long-term stress conditions and out-of-hospital cardiac arrest risk: a nested case-control study

OBJECTIVE

Patients with stress-related disorders and anxiety are at increased risk of developing cardiovascular disease. However, the risk of out-of-hospital cardiac arrest (OHCA) is scarcely investigated. We aimed to establish whether long-term stress (post-traumatic stress disorder, adjustment disorder) or anxiety is associated with OHCA in the general population.

METHODS

We conducted a nested case-control study in a nationwide cohort of individuals between 1 June 2001 and 31 December 2015 in Denmark. Cases were OHCA patients with presumed cardiac causes. Each case was matched by age, sex and date of OHCA with 10 non-OHCA controls from the general population. HRs for OHCA were derived from Cox models after controlling for common OHCA risk factors. Stratified analyses were performed according to sex, age and pre-existing cardiovascular disease.

RESULTS

We included 35 195 OHCAs and 351 950 matched controls (median age 72 years; 66.8% male). Long-term stress conditions were diagnosed in 324 (0.92%) OHCA cases and 1577 (0.45%) non-OHCA controls, and were associated with higher rate of OHCA (HR 1.44, 95% CI 1.27 to 1.64). Anxiety was diagnosed in 299 (0.85%) OHCA cases and 1298 (0.37%) controls, and was associated with increased rate of OHCA (HR 1.56, 95% CI1.37 to 1.79). We found no interaction with sex, age or history of cardiovascular diseases.

CONCLUSION

Patients with stress-related disorders or anxiety have an increased rate of OHCA. This association applies equally to men and women and is independent from the presence of cardiovascular disease. Awareness of the higher risks of OHCA in patients with stress-related disorders and anxiety is important when treating these patients.

The pursuit of health: A vitality based perspective

The larger number of adults who enter their senior years with a high burden of chronic diseases has led to new metrics designed to promote health pro-activity, such as the calculation of one's "healthspan". These efforts call for re-evaluation as to what is meant by "health". A large body of epidemiologic and clinical investigation identifies that good health is shaped by specific health behaviors (aerobic exercise, resistance training, sleep, and good diet quality) and four psychological determinants (positive emotions, positive mindsets, purposeful living, and social connectivity). In common, each of these determinants produce "vitality", which can be defined as having the pleasing sensation of feeling energetic. Having a strong sense of vitality produces a sense of agency, provides resilience, and serves as a leading indicator of good health. Importantly, vitality can be assessed as a single item "vital sign" in clinical practice and can be promoted by recommending simple steps to patients, such as suggesting that they initiate walking or other aerobic activities. Because health habits and psychological determinants of health are inter-related, such simple steps can initiate a "virtuous cycle" of health improvement. An emphasis on vitality can also encourage patients to become more cognizant of their level of energy and manage it through health-promoting behaviors rather than quick fix behaviors. Finally, vitality assessment and prescription can promote more successful aging. In sum, an updated and more clinically useful definition of health recognizes that it is a dynamic entity that is influenced at any time by one's engagement in physical and psychological practices that promote health. Accordingly, an updated definition of health is proposed: good health is characterized by physical and psychological well-being and is associated with vitality.

Personality, Preoperative Anxiety, and Postoperative Outcomes: A Review

Research has shown that personality is associated with anxiety levels in the general population. However, little is known about the relationship between personality and preoperative anxiety and the subsequent health outcomes in patients undergoing surgery. Therefore, this review aimed to identify studies that explored the relationship between personality traits and preoperative anxiety, as well as their association with postoperative outcomes. Existing literature shows that anxiety may play an intermediary role in the relationship between personality and postoperative outcomes. Severe anxiety may partially explain the adverse effects of certain personality traits, such as neuroticism, on postoperative outcomes. However, the relationship between personality traits, preoperative anxiety, and postoperative outcomes remains unclear. Interventions such as clinical evaluation, preoperative counseling, and management strategies can be of great value in identifying and resolving patients' anxiety and negative emotions to improve postoperative outcomes.

Anxiety Predicts Poor Prognosis in Patients With Hypertrophic Cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is the prevalent inherited cardiomyopathy and a major contributor to sudden death and heart failure in young adults. Although depression has been associated with poor prognosis in patients with cardiovascular disease, the relationship between anxiety and HCM clinical outcomes has not been addressed. We aimed to determine the prevalence of anxiety symptoms in patients with HCM and the association between anxiety and adverse prognosis in this population.

Methods

A total of 793 patients with HCM were prospectively enrolled and followed up for a mean of 4.1 years from March 2014 to January 2018. The primary endpoint was sudden cardiac death (SCD) events, and the secondary endpoint was HCM-related heart failure events. Anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS) during outpatient visits or hospital stays.

Results

Elevated scores on the HADS anxiety subscale (HADS-A ≥ 8) were defined as clinically significant anxiety. SCD and HCM-related heart failure events occurred in 76 and 149 patients, respectively, during the follow-up period. Kaplan–Meier survival curves demonstrated the significant association of anxiety with SCD events (log-rank P = 0.012) and HCM-related heart failure events (log-rank P = 0.001). Multivariable Cox regression analysis showed anxiety as a predictor of SCD events and HCM-related heart failure events (adjusted hazard ratio [HR] = 1.42, 95% confidence interval [CI] = 1.12–2.04, P = 0.03; adjusted HR = 2.9,2 95% CI = 1.73–4.03, P < 0.001), independent of conventional risk factors and depression. Besides, patients with comorbid anxiety and depression showed a fourfold higher risk of heart failure events and 3.5-fold higher risk of SCD versus those with neither (adjusted HR = 4.08, 95% CI = 2.76–5.91, P < 0.001; adjusted HR = 3.52, 95% CI = 2.24–4.67, P < 0.001, respectively).

Conclusions

Anxiety was prevalent among Chinese patients with HCM, and it was independently associated with a higher risk of SCD and HCM-related heart failure events, particularly when comorbid with depression. Psychological assessment and intervention should be considered to alleviate anxiety symptoms in this population.

Clinical Trial Registration

http://www.chictr.org.cn, identifier: ChiCTR2000040759.

Measurement of Noradrenaline and Serotonin Metabolites With Internal Jugular Vein Sampling: An Indicator of Brain Monoamine Turnover in Depressive Illness and Panic Disorder

In research spanning three decades we have estimated brain monoamine turnover (approximately equating with synthesis rate) with sampling from the internal jugular veins and measurement of trans-cerebral plasma monoamine metabolite concentration gradients. Here we report indices of brain noradrenaline and serotonin turnover in patients with major depressive illness (MDD) and panic disorder (PD). Brain noradrenaline turnover was assessed from the combined flux into the internal jugular veins of the metabolites dihydroxyphenylglycol (DHPG) and 3-hydroxy-4-methoxyphenylglycol (MHPG), and brain serotonin turnover from the overflow of the primary metabolite, 5-hydroxyindole acetic acid (5HIAA). Comparison was made with matched healthy research participants. In both MD and PD the estimate of brain noradrenaline turnover provided by metabolite overflow was unremarkable. In contrast, in both patient groups the estimate of brain serotonin turnover provided by 5HIAA overflow was increased 3-4-fold (P < 0.01). This neurotransmitter abnormality was normalized in MDD and PD in clinical remission, during selective serotonin reuptake blocker (SSRI) dosing. We cannot be sure if the brain serotonergic abnormality we find in MDD and PD is causal or a correlate. Measurements in PD were not made during a panic attack. The increased estimated serotonin turnover here may possibly be a substrate for panic attacks; serotonergic raphe nuclei participate in anxiety responses in experimental animals. It is puzzling that the findings were identical in MDD and PD, although it may be pertinent that these psychiatric diagnoses are commonly comorbid. It is unlikely that activation of brain serotonergic neurons is driving the sympathetic nervous activation present, which contributes to cardiovascular risk, persistent sympathetic activation in MDD and episodic activation in PD during panic attacks. We have previously demonstrated that the mechanism of activation of human central sympathetic outflow in other contexts (hypertension, heart failure) is activation of noradrenergic brainstem neurons projecting to the hypothalamus and amygdala.

Pivotal role of the sympathetic nerves of the human heart in mental stress responses and triggered cardiovascular catastrophes

Mental stress can trigger cardiac catastrophes, explicitly evident during national disasters such as earthquakes. Activation of the cardiac sympathetic outflow and inhibition of the cardiac vagus are important mediating mechanisms. This manuscript describes efforts by the Human Neurotransmitters Research Laboratory of the Baker Institute in Melbourne to develop investigative methods to study the sympathetic nerves of the human heart, and to apply these in mental stress research. With laboratory mental stress, activation of the adrenal medulla was found to occur, accompanied by a regionalized sympathetic nervous response directed to the heart, but sparing the sympathetic outflow to the skeletal muscle vasculature. Patients with panic disorder are at increased cardiovascular risk. They exhibit high-level sympathetic activation during a panic attack, sometimes accompanied by coronary artery spasm. Patients with sudden ventricular arrhythmias causing collapse in the community were found to have as the predisposing substrate high baseline cardiac sympathetic activity, from previously unrecognized mild heart failure; it was surprising at the time that we did not find critical coronary artery stenosis as the substrate. In some the arrhythmia event had a behavioural trigger. In Takotsubo cardiomyopathy ("Broken Heart Syndrome") the myocardial stunning appears to represent a catecholamine cardiomyopathy, from astronomically high plasma adrenaline concentrations, rather than be caused by activation of the cardiac sympathetic nerves. Some diseases (essential hypertension, heart failure, panic disorder) have forms of sympathetic neural enhancement which contribute to cardiovascular risk: reuptake of noradrenaline by sympathetic nerves after release is faulty and single sympathetic fibres fire in multiple salvos within a single cardiac cycle. Paradoxically, obesity-hypertension does not share in this sympathetic neural augmentation, which is present only in normal-weight hypertensive patients, providing the possible basis for an observed "Obesity Paradox" (longer survival in obesity-hypertension than in normal weight hypertension). Community-wide specific prevention of cardiovascular triggering is not currently possible, due to there being no available simple screening tests which could be applied to the community at-large for the commonest substrates, silent coronary artery disease and mild heart failure. Standard medical preventive measures for coronary atherosclerosis will of course be helpful. Targeted prevention of triggering can be done in those with a detected predisposing substrate, such as genetic Long QT Syndrome, and in survivors of a serious triggered event, who need detailed, appropriate testing.

Stress, the autonomic nervous system, and sudden death

The existence of an important relationship between stress, the autonomic nervous system, and sudden cardiac death (SCD) has been long recognized. In the present essay we review the large number of conditions, acting at individual or at population level, that have been causally associated to SCD and discuss the mechanistic and translational value of the studies exploring such associations. These conditions include external stressors (earthquakes, wars) and internal stressors (anger, fear, loss of a loved one) and emotions of even opposite sign. Most situations confirm the time-honored view that increases in sympathetic activity are proarrhythmic whereas increases in vagal activity are protective; however, we will also show and discuss a condition in which the culprit appears to be the excess of vagal activity. The physiologic rationale underlying the most typical situations is on one hand the profibrillatory effect of the increase in the heterogeneity of repolarization secondary to the release of norepinephrine, and on the other the combined effect of acetylcholine to lower heart rate and to antagonize the cardiac effects of norepinephrine at ventricular level. An interesting facet of this potentially lethal relationship is that the elements involved are by no means always exceptional, and they can actually represent part of our everyday life.

Exposure and perception of PM2.5 pollution on the mental stress of pregnant women

Prenatal exposure to ambient PM_2.5 has been proved to be related to pregnant women's physical health and birth outcomes. However, the damage from air pollution on pregnant women's mental health has not been fully discussed. A case-control study was conducted to evaluate the effects of PM_2.5 exposure and risk perception on the mental stress of pregnant women. A total of 605 pregnant women, including 403 high symptoms of stress cases and 202 matched controls, were recruited from January 2018 to December 2018 in Nanjing, among which 313 high symptoms of stress cases and 144 matched controls were included in the analysis. Meaningfully high symptoms of anxiety were defined with a score of 6 points or greater on the phobic anxiety subscale of the Crown-Crisp index. We found that the PM_2.5 effect perceived by the case group was significantly higher than the control group, and the PM_2.5 exposure of the case group was also significantly higher than that of the control group. Binary logistic regression showed that for each increase in unit of PM_2.5 exposure, the risk of pregnant women suffering from high mental stress increased by 13.76% (95 %CI: 8.26-19.53%). Through path analysis modeling, we found that in the case group, perceived indoor attributions not only had a direct impact on mental stress (p < 0.001), but also played a key mediating role in the impact of average daily dose of PM_2.5 on mental stress (p < 0.001). The high level of mental stress is not only affected by objective exposure, but also by subjective perceptions in the case group. Considering the significant effect of PM_2.5 exposure on mental stress, pregnant women are recommended to spend appropriate amounts of time outdoors during clean air days. In addition, the mediating role of risk perception cannot be ignored. It is necessary to reassure pregnant women not to become overly concerned about the risk of PM_2.5 pollution and reduce their psychological burden.

Chronic Stress, Exercise and Cardiovascular Disease: Placing the Benefits and Risks of Physical Activity into Perspective

Chronic stress, which has been exacerbated worldwide by the lingering COVID pandemic, has been strongly linked to cardiovascular disease (CVD). In addition, autonomic dysregulation via sustained sympathetic activity has been shown to increase the risk of arrhythmias, platelet aggregation, acute coronary syndromes and heart failure. Fortunately, effective coping strategies have been shown to attenuate the magnitude of hyperarousal associated with the stress response, including moderate-to-vigorous lifestyle activity and/or structured exercise. A good-to-excellent level of cardiorespiratory fitness also appears to be highly cardioprotective. These beneficial effects have been substantiated by numerous studies that have evaluated the levels of stress reactivity and stress recovery in physically active individuals versus matched sedentary controls, as well as before and after exercise interventions. On the other hand, unaccustomed strenuous exercise in habitually sedentary persons with underlying CVD is associated with a disproportionate incidence of acute cardiac events. Moreover, extreme exercise regimens appear to increase coronary calcification and the likelihood of developing atrial fibrillation. This review summarizes these relations and more, with specific reference to placing the benefits and risks of physical activity into perspective.

Subclinical depression and anxiety as an additional risk factor for cardiovascular events in low- and moderate-risk patients: data from 10-year follow-up

Aim. To assess the contribution of anxiety (A) and depression (D) to the increased risk of cardiovascular events (CVEs) in patients with Systematic Coronary Risk Evaluation (SCORE) <5% according to 10-year follow-up.

Material and methods. The work included 190 patients with SCORErisk <5%, examined in 2009-2010. In addition to the standard examination, a questionnaire was carried out using Hospital Anxiety and Depression Scale (HADS). In 2019, we contacted participants by telephone to identify CVEs over the past time: death from cardiovascular diseases (CVDs), acute myocardial infarction (MI), unstable angina, stroke, revascularization. The response was 86,3%.

Results. CVEs occurred in 17 (10,2%) patients and included following outcomes: 3 deaths from CVDs, 6 acute MIs, 4 cases of unstable angina, 12 revascularizations. Patients with and without CVEs differed only in the depression level — 7 (5; 7) vs 5.0 (4; 5) points (p=0,0001). HADS-D score >6 increased the probability of CVEs — odds ratio (OR) 2,9 (1,1-7,7). In individuals with HADS-D score >6 and/or HADS-A score >7, the probability of CVEs increased — OR 4,9 (1,4-17,9). A combination of impaired two or more parameters of the lipid profile, systolic blood pressure >130 mm Hg and HADS-D score >6 and/or HADS-A score >7 increased the risk of CVE — OR 7,3 (2,48-21,36).

Conclusion. Depression, including subclinical depression, is associated with an increased risk of CVEs in patients with a SCORE risk <5%.

Inflammatory indicator levels in patients undergoing aortic valve replacement via median sternotomy with preoperative anxiety and postoperative complications: a prospective cohort study

OBJECTIVE

This study was performed to evaluate the association of preoperative anxiety with inflammatory indicators and postoperative complications in patients undergoing scheduled aortic valve replacement surgery.

METHODS

A prospective cohort study was performed. The Hamilton Anxiety Scale was used to assess preoperative anxiety. The serum white blood cell (WBC) count and concentrations of C-reactive protein, interleukin (IL)-6, and IL-8 were measured 1 day preoperatively and 3 and 7 days postoperatively. Postoperative complications were also recorded.

RESULTS

Seventy-three patients were included. The incidence of preoperative anxiety was 30.1% (22/73). The payment source was the only independent risk factor for preoperative anxiety. The incidence of postoperative complications was lowest in the mild anxiety group. The WBC count 3 days postoperatively was significantly lower in the mild than moderate-severe anxiety group. The IL-8 concentration 1 day preoperatively was highest in the no anxiety group.

CONCLUSIONS

Mild preoperative anxiety might help to improve clinical outcomes. However, further investigations with more patients are warranted. Patients with different degrees of anxiety may have different levels of inflammatory cytokines.

The self in context: brain systems linking mental and physical health

Increasing evidence suggests that mental health and physical health are linked by neural systems that jointly regulate somatic physiology and high-level cognition. Key systems include the ventromedial prefrontal cortex and the related default-mode network. These systems help to construct models of the 'self-in-context', compressing information across time and sensory modalities into conceptions of the underlying causes of experience. Self-in-context models endow events with personal meaning and allow predictive control over behaviour and peripheral physiology, including autonomic, neuroendocrine and immune function. They guide learning from experience and the formation of narratives about the self and one's world. Disorders of mental and physical health, especially those with high co-occurrence and convergent alterations in the functionality of the ventromedial prefrontal cortex and the default-mode network, could benefit from interventions focused on understanding and shaping mindsets and beliefs about the self, illness and treatment.

Potential Role of Life Stress in Unexplained Sudden Cardiac Arrest

Background

The etiology of sudden cardiac arrest (SCA) in individuals without known cardiovascular heart disease remains elusive in nearly half of all patients after systematic testing. We investigated the relationship between stressful life events and SCA risk in cases of explained and unexplained SCA (USCA) events.

Methods

Individuals who previously experienced SCA were enrolled prospectively and divided into a USCA or explained SCA (ESCA) subgroup dependent on whether a diagnosis was ascribed after SCA. Participants completed either the 1997 Recent Life Changes Questionnaire, Student Stress Scale, or Social Re-adjustment Rating Scale for Non-Adults recalling events during the year preceding their SCA, depending on age at SCA presentation; all measure stress in life change units (LCUs). SCA group scores were compared with an age- and sex-matched control group.

Results

We compared 36 SCA group participants (22 USCA, 14 ESCA, age 47 ± 15 years, age at SCA 40 ± 14 years, 50% male) with 36 control participants (age 47 ± 15 years, 50% male). There was no significant difference in LCU score between the control group and the SCA group (248 ± 181 LCU vs 252 ± 227 LCU; P > .05). The ESCA subgroup had significantly lower mean LCU scores than the USCA subgroup (163 ± 183 LCU vs 308 ± 237 LCU; P = .030).

Conclusions

Stressful life events, especially those producing chronic stress, might predispose otherwise healthy individuals to lethal arrhythmias. Further investigation into the role of stress in SCA precipitation is warranted.

The Predictive Value of Health Anxiety for Cancer Incidence and All-Cause Mortality: A 44-Year Observational Population Study of Women

OBJECTIVE

Long-term data concerning mortality and serious illness as a function of health anxiety are scarce. We aimed to study health anxiety in relation to long-term mortality and cancer morbidity among women.

METHODS

A Swedish population sample of women (n = 770; ages, 38-54 years) took part in a general medical and psychiatric examination in 1968 to 1969 and were followed up until 2013 in national Swedish registries for all-cause mortality and first diagnosis of cancer. A modified version of the Whiteley Index questionnaire (maximum score, 12) was used to measure health anxiety. Scores were trichotomized based on quartiles as no (score 0, lowest quartile), mild-moderate (score 1-2, middle quartiles), and high (score ≥3, highest quartile) health anxiety. Risks of death and cancer were evaluated with Cox regression models.

RESULTS

Compared with women with mild-moderate health anxiety levels, women with no health anxiety had a higher risk of death (age-adjusted hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.00-1.49; fully adjusted for baseline sociodemographic, mental, and physical health variables: HR, 1.44, 95% CI = 1.17-1.76). Women with high health anxiety levels had a greater risk of death in age-adjusted analysis (HR = 1.26, 95% CI = 1.04-1.54; fully adjusted HR = 1.21, 95% CI = 0.98-1.49). For both groups, the mortality risk was time dependent and declined during follow-up. We observed no between-group differences in the risk of cancer.

CONCLUSIONS

In this population-based cohort of midlife women, health anxiety was moderately associated with mortality in a U-shaped fashion. Absence of health anxiety entailed the greatest risk when other factors were taken into account.

Anxiety, Mental Stress, and Sudden Cardiac Arrest: Epidemiology, Possible Mechanisms and Future Research

Sudden cardiac arrest (SCA) is a leading cause of mortality and morbidity in affluent societies, which underscores the need to identify persons at risk. The etiology of SCA is however complex, with predisposing and precipitating factors interacting. Although anxiety and mental stress have been linked to SCA for decades, their precise role and impact remain unclear and the biological underpinnings are insufficiently understood. In this paper, we systematically reviewed various types of observational studies (total n = 20) examining the association between anxiety or mental stress and SCA. Multiple methodological considerations challenged the summarizing and interpretation of the findings. For anxiety, the overall picture suggests that it predisposes for SCA in physically healthy populations (unadjusted OR = 2.44; 95% CI: 1.06-5.59; n = 3). However, in populations at risk for SCA (n = 4), associations were heterogeneous but not significant. Anxiety may partly predispose to SCA by contributing to other risk factors such as cardiovascular disease and diabetes mellitus via mechanisms such as unhealthy lifestyle and metabolic abnormalities. Mental stress appears to precipitate SCA, presumably by more directly impacting on the cardiac ion channels that control the heart's electrical properties. This may lead to ventricular fibrillation, the arrhythmia that underlies SCA. To advance this field of research, experimental studies that unravel the underlying biological mechanisms are deemed important, and most easily designed for mental stress as a precipitating factor because of the short timeframe. These proof-of-concept studies should examine the whole pathway from the brain to the autonomic nervous system, and eventually to cardiac ion channels. Ultimately, such studies may facilitate the identification of persons at risk and the development of novel preventive strategies.

The adrenal medulla in cardiovascular medicine: an untold story

Unlike noradrenaline, the sympathetic neurotransmitter which overflows to the circulation, adrenaline (ADR) is a secreted hormone, with a low plasma concentration, and plasma concentration for biological action a log order lower than that of noradrenaline. The venous drainage of the left adrenal medulla into the left renal vein does expose this vein to uniquely high plasma ADR concentrations and possible risk of thrombosis at high rates of ADR secretion. There is typically a different timeframe for adrenal medullary and sympathetic nervous system responses: ADR release is short term in contrast with sympathetic activation persisting for years in heart failure and hypertension. The historic view of Walter Cannon, subject to recent review, that the sympathoadrenal system is a unified biological system, was deconstructed further with demonstration of frequent mismatching of adrenal medullary and sympathetic nervous responses. Under gravity stimulation with standing, there is prompt sympathetic activation without ADR release. In many diseases, notably obesity, hypertension, heart failure and depressive illness, an activated sympathetic nervous system and silent adrenal medulla coexist. The therapeutic corollary of this is that ADR blockade is much less commonly needed clinically than pharmacological antagonism of the sympathetic nervous system.

Elevated homocysteine, as a biomarker of cardiac injury, in panic disorder patients due to oxidative stress

BACKGROUND AND OBJECTIVE

Patients with panic disorder (PD) suffer from elevated oxidative stress as a consequence of serotonin metabolism disorder. These patients have elevated serotonin concentration and catabolism of serotonin via monoamine oxidase. The aim of the present study was to evaluate serum homocysteine concentration and its relationship with oxidative stress level in PD patients, regarding homocysteine as a diagnostic biomarker of heart disease.

MATERIALS & METHOD

Sixty patients with PD according to the DSM-5 diagnostic criteria for a panic attack and 60 healthy individuals were included in the present study. Peripheral venous blood samples were taken from patients. Erythrocytes and serum were separated from blood, and RBC hemolysates were prepared to investigate oxidative stress indices including glutathione and glutathione peroxidase. Serum homocysteine and carbonyl groups concentrations were measured in all samples. Data were analyzed using ANOVA, and p < .05 was considered significant.

RESULTS

Results showed that serum carbonyl groups concentration was significantly higher in patients with PD than in healthy individuals (p < .001). The results also indicated decreased serum glutathione concentration and glutathione peroxidase activity in patients (p < .003). In addition, elevated homocysteine concentration in PD patients serum was observed during the present study (p < .003).

CONCLUSION

Our findings support that patients with PD experience higher levels of oxidative stress, due to impaired serotonin metabolism, which is related to the prognosis of heart disease in these patients.

The effect of PM2.5 exposure and risk perception on the mental stress of Nanjing citizens in China

The multidimensional characteristics and temporal dynamics of environmental risks have stimulated a social-scientific approach towards air pollution issues in recent decades. It's now widely acknowledged that air pollution has an ineligible influence on the psychological wellbeing of citizens beyond its well-established physical impact. We explored how fine particulate matter (PM_2.5), an essential air pollutant associated with morbidity and mortality, interacted with aspects of risk perception to influence citizen's mental stress level. Questionnaire data from 508 Nanjing citizens in China were collected across four seasons within an 18-month period. We found no evidence that mental stress was directly influenced by real-time PM_2.5 exposure. However, path analysis revealed that mental stress was subjected to the indirect influence of physical symptoms (β = 0.076, p = 0.11), by increasing perceived effect on health and increasing attribution to indoor pollution sources (β = 0.038, p = 0.005). Indoor attribution of PM_2.5 pollution was associated with perceived familiarity with risk (β = -0.095, p = 0.033), whereas outdoor attribution was associated with perceived control of risk (β = 0.091, p = 0.041). Public risk acceptable rate (PRAR) decreased as PM_2.5 concentration increased. In females, but not males, greater trust for government was associated with the increased acceptance of PM_2.5 (Year₂₀₁₇: β = -0.19, p = 0.003; Year₂₀₂₂: β = -0.21, p < 0.001). Using psychological statistical methods, our study implied that air pollution has a substantial association with psychological wellbeing in various ways, which might provide some references for public healthcare and risk communication.

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.

Anxiety and depression relationship with coronary slow flow

Background

Psychiatric disorders (depression / anxiety) are linked to coronary artery disease (CAD). Coronary slow flow (CSF) is a relatively common form of CAD with the same underlying mechanisms that are attributed to many anatomic and pathophysiologic factors. However, the relationship between psychiatric disorders and CSF is less well-established; and this is the aim of this study.

Methods

This cross-sectional observational study was conducted on the first 50 consecutive patients diagnosed with CSF by elective coronary angiography (CAG). They were compared with another 50 consecutive patients showing normal coronaries by CAG. Beck Anxiety Inventory and Beck Depression Inventory were used for assessment. CSF was diagnosed by coronary angiography “Thrombolysis In Myocardial Infarction” frame count. Lipid profile was obtained for all patients.

Results

Traditional risk factors (male gender, smoking, total cholesterol, low-density lipoproteins and triglycerides) were higher in the CSF group. Depression and anxiety scores were also higher in the CSF group. On multivariate analysis, male gender, depression and high triglycerides were the only significant independent predictors of CSF. A significant correlation existed between CSF and both anxiety and depression scores. Both scores were also significantly higher in multivessel vs single vessel affection.

Conclusion

Psychiatric depression, male gender and high triglycerides are highly associated with CSF in patients undergoing elective CAG. There is a significant correlation between CSF severity and the severity of both anxiety and depression. Further studies are warranted to explore the impact of psychological intervention on CSF and its long-term outcome.

Exercise Counteracts the Cardiotoxicity of Psychosocial Stress

Physical inactivity and psychosocial stress are prevalent in residents of the United States. The purpose of this article is to review the interaction between these 2 conditions and examine the effects of exercise on stress and cardiovascular (CV) health. A query of scientific references between 1974 to 2018 was performed using the PubMed search engine accessing the MEDLINE database using the search terms psychosocial stress, CV disease (CVD), physical activity, exercise, cardiac rehabilitation, and team sports. Psychosocial stress is a strong independent risk factor for adverse CV events. Conversely, people who experience CV events subsequently have drastically elevated rates of new-onset mental health disorders, including depression and anxiety. Psychosocial stress and CVD often trigger self-reinforcing feedback loops that can worsen mental health and cardiac prognosis. Exercise predictably improves CV health and prognosis and also is effective at lowering levels of psychosocial stress. Group exercise in particular seems to provide social support while at the same time boosting fitness levels and, thus, may be the single most important intervention for patients with concomitant CVD and emotional stress. Collaborative physical activity, such as group exercise, team sports, interactive physical play, and cardiac rehabilitation programs, have the potential to improve mental health and CV prognosis.

Different Clinical Expression of Anxiety Disorders in Children and Adolescents: Assessment and Treatment

BACKGROUND

Fearful and anxious behaviour is especially common in children, when they come across new situations and experiences. The difference between normal worry and an anxiety disorder is in the severity and in the interference with everyday life and normal developmental steps. Many longitudinal studies in children suggest that anxiety disorders are relatively stable over time and predict anxiety and depressive disorders in adolescence and adulthood. For this reason, the early diagnostic and treatment are needed. Researchers supposed that anxiety is a result of repeated stress. Additionally, some genetic, neurobiological, developmental factors are also involved in the aetiology.

METHODS AND SUBJECTS

The aim of this article is to summarize and to present our own results obtained with the assessment and treatment of different forms of anxiety disorders in children and adolescents such as: Posttraumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), Dental anxiety, General Anxiety Disorder (GAD), and Anxious-phobic syndrome. Some results are published separately in different journals. a) Post Traumatic Stress Disorder (PTSD) in 10 young children aged 9 ± 2, 05 y. is evaluated and discussed concerning the attachment quality. b) The group with OCD comprises 20 patients, mean age 14,5 ± 2,2 years, evaluated with Eysenck Personality Questionnaire (EPQ), Child behaviour Checklist (CBCL), K-SADS (Schedule for Affective Disorders and Schizophrenia for School age children), Beck Depression Inventory (BDI), SCWT (Stroop Colour Word task), WCST (Wisconsin Card Scoring test). c) Dental stress is evaluated in a group of 50 patients; mean age for girls 11,4 ± 2,4 years; for boys 10,7 ± 2,6 years, evaluated with (General Anxiety Scale (GASC), and Eysenck Personality Questionnaire (EPQ). d) Minnesota Multiphasic Personality Inventory (MMPI) profiles obtained for General Anxiety Disorder in 20 young females and 15 males aged 25,7± 5,35 years, and a group with Panic attack syndrome N=15 aged 19,3±4,9 years are presented and discussed by comparison of the results for healthy people. e) Heart Rate Variability (HRV) was applied for assessment and treatment in 15 anxious-phobic patients, mean age 12, 5±2,25 years and results are compared with other groups of mental disorder.

RESULTS

Children with PTSD showed a high level of anxiety and stress, somatization and behavioural problems (aggression, impulsivity, non-obedience and nightmares), complemented by hypersensitive and depressed mothers and misattachment in the early period of infancy. Consequently, the explanation of the early predisposition to PTSD was related to be the non-developed Right Orbital Cortex. The later resulted from insecure attachment confirmed in all examined children. The obtained neuropsychological profile of children with OCD confirmed a clear presence of obsessions and compulsions, average intellectual capacities, but the absence of depressive symptoms. Executive functions were investigated through Event Related Potentials on Go/NoGo tasks. Results showed that no significant clinical manifestations of cognitive dysfunction among children with OCD in the early stage of the disorder are present, but it could be expected to be appearing in the later stage of the disorder if it is no treated. In a study of 50 children randomly selected, two psychometric instruments were applied for measuring general anxiety and personal characteristics. It was confirmed that there was presence of significant anxiety level (evaluated with GASC) among children undergoing dental intervention. The difference in anxiety scores between girls and boys was also confirmed (girls having higher scores for anxiety). Results obtained with EPQ showed low psychopathological traits, moderate extraversion and neuroticism, but accentuated insincerity (L scale). L scales are lower by increasing of age, but P scores rise with age, which can be related to puberty. No correlation was found between personality traits and anxiety except for neuroticism, which is positively correlated with the level of anxiety. The obtained profiles for MMPI-201 in a group of patients with general anxiety are presented as a figure. Females showed only Hy peak, but in the normal range. However, statistics confirmed significant difference between scores in anxiety group and control (t= 2, 25164; p= 0, 038749). Males showed Hs-Hy-Pt peaks with higher (pathological) scores, related to hypersensitivity of the autonomic nervous system, as well as with manifested anxiety. Calculation confirmed significant difference between control and anxiety in men (t= 15.13, p=0.000). Additionally, MMPI profiles for patients with attack panic syndrome are also presented as a figure. Control scales for females showed typical V form (scales 1 and 3) related to conversing tendencies. In addition, females showed peaks on Pt-Sc scales, but in normal ranges. Pathological profile is obtained in males, with Hy-Sc peaks; this profile corresponds to persons with regressive characteristics, emotionally instable and with accentuated social withdraw. Heart rate variability (HRV) is a measure of the beat to beat variability in heart rate, related to the work of autonomic nervous system. It may serve as a psychophysiological indicator for arousal, emotional state and stress level. We used HRV in both, the assessment and biofeedback training, in a group of anxious-phobic and obsessive-compulsive school children. Results obtained with Eysenck Personality Questionnaire showed significantly higher psychopathological traits, higher neuroticism and lower lie scores. After 15 session HRV training very satisfying results for diminishing stress and anxiety were obtained.

Relationship between major depressive disorder, generalized anxiety disorder and coronary artery disease in the US general population

OBJECTIVE

To evaluate whether the changes and persistence of major depressive disorder (MDD) and generalized anxiety disorder (GAD) affect the risk of incident coronary artery disease (CAD) in the US general population.

METHODS

Data was retrieved from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) conducted in 2001/2002 (Wave 1) and 2004/2005 (Wave 2). At both Wave 1 and one year before Wave 2, MDD and GAD were measured using the Alcohol Use Disorders and Associated Disabilities Interview Schedule IV. CAD was considered present at Wave 1 or Wave 2 based on the participants' self-reported physician diagnosis. Relationship between MDD, GAD and CAD was examined using generalized linear regression model.

RESULTS

The study included 32,345 participants without CAD at Wave 1, with 3.3% developing CAD at Wave 2. After adjustment, persistence of MDD/GAD and GAD predicted highest risk of developing CAD respectively (MDD/GAD: RR = 2.01, 95% CI: 1.54-2.64; GAD: RR = 2.09, 95% CI: 1.22-3.58), while positive changes predicted lowest risk (MDD/GAD: RR = 1.43, 95% CI: 1.15-1.78; GAD: RR = 1.68, 95% CI: 1.21-2.33). Negative change of MDD is associated with highest risk of developing CAD (RR = 2.07, 95% CI: 1.69-2.54), while positive changes predicted lowest risk (RR = 1.38, 95% CI: 1.11-1.73).

CONCLUSIONS

Existence of MDD/GAD, MDD, or GAD increase the risk of new-onset CAD. Positive change in MDD and GAD is associated with reduced risk of incident CAD, which highlights the importance of treating MDD and GAD in preventing the development of CAD.

Sex differences in major depression and comorbidity of cardiometabolic disorders: impact of prenatal stress and immune exposures

Major depressive disorder topped ischemic heart disease as the number one cause of disability worldwide in 2012, and women have twice the risk of men. Further, the comorbidity of depression and cardiometabolic disorders will be one of the primary causes of disability worldwide by 2020, with women at twice the risk. Thus, understanding the sex-dependent comorbidities has public health consequences worldwide. We propose here that sex differences in MDD-cardiometabolic comorbidity originate, in part, from pathogenic processes initiated in fetal development that involve sex differences in shared pathophysiology between the brain, the vascular system, the CNS control of the heart and associated hormonal, immune, and metabolic physiology. Pathways implicate neurotrophic and angiogenic growth factors, gonadal hormone receptors, and neurotransmitters such as gamma amino butyric acid (GABA) on neuronal and vascular development of HPA axis regions, such as the paraventricular nucleus (PVN), in addition to blood pressure, in part through the renin-angiotensin system, and insulin and glucose metabolism. We show that the same prenatal exposures have consequences for sex differences across multiple organ systems that, in part, share common pathophysiology. Thus, we believe that applying a sex differences lens to understanding shared biologic substrates underlying these comorbidities will provide novel insights into the development of sex-dependent therapeutics. Further, taking a lifespan perspective beginning in fetal development provides the opportunity to target abnormalities early in the natural history of these disorders in a sex-dependent way.

Gender differences in longitudinal relationships between depression and anxiety symptoms and inflammation in the health and retirement study

Depression and anxiety have been linked to elevated inflammation in cross-sectional and longitudinal studies. Yet, in terms of longitudinal studies, findings are inconsistent regarding whether depression predicts worsening inflammation or vice versa, and anxiety has been infrequently examined. Further, we know little about longitudinal relationships between inflammation and specific symptom profiles of depression and anxiety. The current study examined longitudinal associations between depression and anxiety symptoms and inflammation in 13,775 people (59% women, average age = 67) participating in the Health and Retirement Study - a population-based study focused on older adults. High sensitivity C-reactive protein and depression and anxiety symptoms were measured at two time-points separated by four years. We used cross-lagged panel models to examine bidirectional relationships, and tested interactions with gender. We found that depressive symptoms predicted increasing inflammation for men, but not for women, and inflammation predicted worsening depression for women, but not for men. These gender differences were driven by somatic symptoms. Specifically, somatic symptoms predicted increasing inflammation for men only and were predicted by inflammation for women only. Regardless of gender, inflammation predicted worsening dysphoric symptoms of depression, and lack of positive affect predicted increasing inflammation over time. Anxiety was not associated with inflammation longitudinally. These findings indicate bidirectional relationships between depressive symptoms and inflammation, but not between anxiety symptoms and inflammation, and that the direction of these effects may differ by gender and type of depressive symptom.

Is Mental Illness a Risk Factor for Hospital Readmission?

People with mental illnesses (MI) receive suboptimal care for medical comorbidities and their high risk for readmission may be addressed by adequate medication management and follow-up care. We examined the association between MI, medication changes, and post-discharge outpatient visits with 30-day readmission in 40,048 Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure or pneumonia. Beneficiaries with MI were more likely to be readmitted than those without MI (14 vs. 11%). Probability of readmission was 13 and 12% when medications were dropped or added, respectively, versus 11% when no change was made. Probability of readmission also increased with outpatient visits.

Abnormal Repolarization Duration During Everyday Emotional Arousal in Long QT Syndrome and Coronary Artery Disease

BACKGROUND

Rare, high-arousal negative emotions are known triggers of sudden death in individuals with preexisting heart disease. Whether everyday fluctuations in emotional arousal influence arrhythmia risk is unknown.

METHODS

We studied 160 patients with the congenital long QT syndrome, 199 patients with coronary artery disease, and 2 groups of matched healthy volunteers (n = 52 and 50, respectively). Three-day home visits including a 12-hour Holter recording each day were completed. Subjects engaged in typical daily activities and were paged 10 times per day. On each occasion, subjects rated the intensity of 16 different emotions during the 5 minutes preceding the page. Holter data over those 5-minute epochs were analyzed for heart rate and QT interval corrected for heart rate (QTc). Analyses focused on within-subject covariation of momentary emotion and QTc.

RESULTS

In patients with long QT syndrome, activated positive affect and activated negative affect were associated with QTc shortening, whereas low arousal positive affect (calm and relaxed) was associated with QTc lengthening, which at times exceeded 500 msec. Findings were not affected by beta-blocker status or observed in younger healthy subjects. Findings were 3 to 8 times stronger in the LQT2 genotype, known to be prone to emotion-induced events, relative to the LQT1 genotype. Findings in patients with long QT syndrome for activated positive affect and low arousal positive affect were replicated in patients with coronary artery disease relative to older healthy subjects.

CONCLUSION

These findings suggest that even subtle changes in emotional arousal may alter repolarization reserve and contribute to sudden death risk in vulnerable individuals.

Prefrontal hemodynamic after-effects caused by rebreathing may predict affective states - A multimodal functional near-infrared spectroscopy study

Brain activity has been shown to be influenced by respiratory behavior. Here, we evaluated whether respiration-induced hypo- or hypercapnia may support differentiation between physiological versus pathological respiratory behavior. In particular, we investigated whether systemic physiological measures could predict the brain's time-frequency hemodynamics after three respiratory challenges (i.e., breath-holding, rebreathing, and hyperventilation) compared to resting-state. Prefrontal hemodynamics were assessed in healthy subjects (N = 27) using functional near-infrared spectroscopy (fNIRS). Systemic physiological measures were assessed in form of heart rate, partial end-tidal carbon dioxide, respiration rate, and saturation of peripheral oxygen. Time-frequency dynamics were quantified using the wavelet transform coherence (i.e., defined here as cortical-systemic coherence). We found that the three respiratory challenges modulated cortical-systemic coherence differently: (1) After rebreathing, cortical-systemic coherence could be predicted from the amplitude of the heart rate (strong negative correlation). (2) After breath-holding, the same observation was made (moderate negative correlation). (3) After hyperventilation, no significant effect was observed. (4) These effects were found only in the frequency range of very low-frequency oscillations. The presented findings highlight a distinct role of rebreathing in predicting cortical-systemic coupling based on heart rate changes, which may represents a measure of affective states in the brain. The applied multimodal assessment of hemodynamic and systemic physiological measures during respiratory challenges may therefore have potential applications in the differentiation between physiological and pathological respiratory behavior.

Psychiatric comorbidities in acute coronary syndromes: Six-month follow-up study

INTRODUCTION

Acute coronary syndrome (ACS) caused by coronary atherosclerosis include ST-segment elevation myocardial infarction (STEMI), non-STEMI, and unstable angina. The relation between psychiatric disorders and coronary artery disease is a complex one which includes the effect of the psychosocial factors on heart and vice versa. Point prevalence studies have been reported, but there is paucity of follow-up studies from India.

MATERIALS AND METHODS

The study is a follow-up evaluation at discharge of 248 consecutive patients presented with ACS at JSS Hospital, Mysuru, Karnataka, over a period of 6 months to assess the psychiatric comorbidities. The patients were assessed on a structured and validated pro forma before discharge, at 3 months, and at 6 months. Screening of psychiatric disorders was done using Mini International Neuropsychiatric Interview PLUS 5.0.0 and assessment of depression was done using Hamilton Depression Rating Scale. ANOVA, Student's t-test, and SPSS 21 were used for statistical analysis.

RESULTS

The most common psychiatric comorbidities include major depressive disorder (44%), it persisted at the end of 3 (P < 0.001) and 6 (P < 0.001) months. A spectrum of anxiety disorders including panic disorder (12.10%), dysthymia (3.60%), agoraphobia (2.40%), social phobia (2%), obsessive-compulsive disorder (1.6%), specific phobia (1.2%), and posttraumatic stress disorder (0.8%) in descending order at the end of 6 months were found. Significant reduction in substance use of nicotine (66.1%) and alcohol (56.0%) was reported on follow-up.

CONCLUSION

Depression, anxiety, and substance use occur in patients with ACS which persist on follow-up. Early recognition at discharge and appropriate counseling on follow-up improve the clinical outcomes.

Differential Experimental Effects of a Short Bout of Walking, Meditation, or Combination of Walking and Meditation on State Anxiety Among Young Adults

INTRODUCTION

Single bouts of aerobic exercise and meditation have been shown to improve anxiety states. Yet to be evaluated in the literature, we sought to examine the effects of a single, short bout of aerobic exercise or meditation, as well as exercise and meditation combined on state anxiety among young adults.

DESIGN

Randomized controlled trial.

SETTING

University.

SUBJECTS

Participants (N = 110, mean age = 21.4 years) were randomly assigned to walk, meditate, walk then meditate, meditate then walk, or to sit (inactive control).

MEASURES

All walking and meditation bouts were 10 minutes in duration. Participants' state anxiety was monitored before and after the intervention using the State Trait Anxiety Inventory questionnaire.

RESULTS

Significant group × time interaction effects were observed ( P = .01). Post hoc paired t tests revealed that state anxiety significantly decreased from baseline to postintervention in the meditation ( P = .002), meditation then walk ( P = .002), and walk then meditation ( P = .03) groups but not the walk ( P = .75) or control ( P = .45) groups.

CONCLUSION

Meditation (vs a brisk walk) may be a preferred method of attenuating anxiety symptomology. Individuals desiring the health benefits associated with aerobic exercise may achieve additional anxiolytic benefits if they employ a brief meditation session before or after exercising.

Risk Factors of Delayed Onset Posttraumatic Stress Disorder in Chronically Critically Ill Patients

The main aim of this study was to investigate factors associated with a delayed-onset posttraumatic stress disorder (PTSD) after the intensive care unit (ICU) treatment of patients with a chronic critical illness (CCI). Patients (n = 97) with critical illness polyneuropathy or critical illness myopathy were interviewed via the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. The diagnosis of the acute stress disorder was assessed within 1 month (t1), the diagnosis of PTSD at 3 (t2) and 6 (t3) months after transfer from the acute care ICU to the post-acute ICU. Patients showing a delayed-onset or persistent course of PTSD were subsumed in one group; 24.7% (n = 24) showed a delayed-onset PTSD. Significant risk factors were as follows: the severity of the medical illness, the perceived fear of dying at the ICU, the number of traumatic memories from the ICU, and the presence of a coronary heart disease. Every fourth patient with CCI showed a delayed-onset PTSD up to 6 months after the ICU treatment. Markers for a delayed-onset PTSD should already be assessed at the time of discharge from the ICU.

Psychiatric Aspects of Heart Disease (and Cardiac Aspects of Psychiatric Disease) in Critical Care

Strong emotional reactions are common in patients admitted to cardiac critical care; only some are pathological. Cardiac critical care and associated technologies are associated with predictable psychiatric problems. Many occur as secondary complications of the medical status of the patient, which must be carefully assessed. Depression is common in patients with coronary disease and also for patients with heart failure; treatment is helpful, but persistent depression is associated with elevated morbidity and mortality. Preexisting psychiatric disorders may predispose to heart disease, and they and their treatment may affect critical care management.

Biological markers for anxiety disorders, OCD and PTSD: A consensus statement. Part II: Neurochemistry, neurophysiology and neurocognition

OBJECTIVE

Biomarkers are defined as anatomical, biochemical or physiological traits that are specific to certain disorders or syndromes. The objective of this paper is to summarise the current knowledge of biomarkers for anxiety disorders, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

METHODS

Findings in biomarker research were reviewed by a task force of international experts in the field, consisting of members of the World Federation of Societies for Biological Psychiatry Task Force on Biological Markers and of the European College of Neuropsychopharmacology Anxiety Disorders Research Network.

RESULTS

The present article (Part II) summarises findings on potential biomarkers in neurochemistry (neurotransmitters such as serotonin, norepinephrine, dopamine or GABA, neuropeptides such as cholecystokinin, neurokinins, atrial natriuretic peptide, or oxytocin, the HPA axis, neurotrophic factors such as NGF and BDNF, immunology and CO2 hypersensitivity), neurophysiology (EEG, heart rate variability) and neurocognition. The accompanying paper (Part I) focuses on neuroimaging and genetics.

CONCLUSIONS

Although at present, none of the putative biomarkers is sufficient and specific as a diagnostic tool, an abundance of high quality research has accumulated that should improve our understanding of the neurobiological causes of anxiety disorders, OCD and PTSD.

Prevalence of Fibromyalgia Syndrome and Its Correlations with Arrhythmia in Patients with Palpitations

OBJECTIVE

It is aimed to determine the prevalence of fibromyalgia syndrome (FMS) and its correlations with arrhythmia in patients with palpitations.

MATERIAL AND METHODS

Sixty-two patients who underwent electrophysiological study (EPS) due to palpitation complaints in Cardiology department and 40 healthy controls were included in the study. The precise diagnosis of arrhythmia was established using EPS. All participants were screened for FMS using American College of Rheumatology 2010 Fibromyalgia diagnostic criteria. Clinical assessments included measurement of severity of pain, fatigue and morning fatigue with visual analog scale (VAS), functional status with Fibromyalgia Impact Questionnaire (FIQ), and anxiety/depression with Hospital Anxiety and Depression Scale (HAD).

RESULTS

FMS was diagnosed in 22 of the 62 patients (36%), and 4 of the 40 healthy controls (10%) (p 0.05). EPS+ patients with FMS had higher fatigue levels, HAD and FIQ scores than EPS- patients, although statistically insignificant. HV durations were statistically longer in the EPS- subgroup (p < 0.05) but other EPS data were similar.

CONCLUSION

FMS frequency and HAD anxiety scores were found to be higher in patients with palpitation complaints. However, we found no association between arrhythmia, EPS parameters and FMS. In our clinical practice we should keep in mind to carry out assessments in terms of FMS in patients with palpitation.

Cardiovascular co-morbidity in cancer patients: the role of psychological distress

Due to aging of the population and cardiotoxic cancer treatment, there is an increasing group of patients with cancer and co-morbid cardiovascular disease (CVD). In order to find a balance between the risk of undertreating the malignancy on the one hand and inducing CVD on the other hand, CVD risk stratification at the time of cancer diagnosis and knowledge on the pathway for developing incident CVD in cancer patients is vital. In this paper, we propose an adapted multiple-hit hypothesis for developing CVD in cancer patients describing that patients with cancer are exposed to a series of sequential or concurrent events that together make them more vulnerable to reduced cardiovascular reserves, development of incident CVD and ultimately death. We highlight the possible impact of psychological distress secondary to a cancer diagnosis and/or treatment, which in turn may increase the risk of incident CVD in patients diagnosed with cancer. Furthermore, we discuss potential behavioral and pathophysiological mechanisms underlying the link between psychological distress and the pathophysiology of incident CVD. In addition, key unanswered questions for future research are posed. In the future, researching the adapted multiple-hit hypothesis for developing CVD among cancer patients will hopefully advance the care of cancer patients by finding some of the missing pieces of the puzzle. To do so, we need to focus on minimizing cardiovascular risk and promoting cardiovascular health in cancer patients by addressing the knowledge gaps formulated in this paper.

Mental stress and human cardiovascular disease

The London physician and neuroanatomist Thomas Willis in the 17th century correctly attributed the source of emotions to the brain, not the heart as believed in antiquity. Contemporary research documents the phenomenon of "triggered" heart disease, when the autonomic nervous system control of the heart by the brain goes awry, producing heart disease of sudden onset, precipitated by acute emotional upheaval. This can take the form of, variously, cardiac arrhythmias, myocardial infarction, Takotsubo cardiomyopathy and sudden death. Chronic psychological distress also can have adverse cardiovascular consequences, in the causal linkage of depressive illness to heart disease, and in the probable causation of atherosclerosis and hypertension by chronic mental stress. In patients with essential hypertension, stress biomarkers are present. The sympathetic nervous system is the usual mediator between these acute and chronic psychological substrates and cardiovascular disease.

The association between comorbid anxiety disorders and the risk of stroke among patients with diabetes: An 11-year population-based retrospective cohort study

BACKGROUND

Diabetes and anxiety disorders are independent risk factors for stroke. However, it remains unclear whether the risk of stroke is higher among diabetic patients with comorbid anxiety than without comorbid anxiety. Therefore, the purpose of this study was to investigate the association between comorbid anxiety and the risk of stroke among patients with diabetes.

METHODS

This is a retrospective cohort study. We used the National Health Insurance Research Database in Taiwan to identify a diabetes cohort with a new diagnosis of an anxiety disorder but without a history of stroke. The enrollment period was 2001-2006 with up to 11 years of follow-up data. Comorbid anxiety was defined by both a clinical diagnosis of the DSM-IV (ICD-9-CM) and prescriptions for anxiolytic medications. Propensity score matching was performed to balance the selected confounders between the anxiety-exposed group and anxiety non-exposed group. Cox-propositional hazard regression models were used to evaluate the association between comorbid anxiety and the risk of stroke.

RESULTS

Among patients with diabetes (N=40,846), an estimated 5.8% (N=2374) of patients had comorbid anxiety disorders. Diabetic patients with comorbid anxiety were significantly associated with a higher risk of stroke compared to patients without comorbid anxiety (hazard ratio: 1.33, 95% confidence interval: 1.02-1.72).

LIMITATIONS

The severity of anxiety or diabetes could not be measured from the claims data. Residual confounding may still exist.

CONCLUSION

A significantly elevated risk of stroke was observed in association with comorbid anxiety among patients with diabetes. Psychiatrists should consider routine screening for anxiety disorders to prevent a stroke event among patients with diabetes.

Pain and Anxiety in Rural Acute Coronary Syndrome Patients Awaiting Diagnostic Cardiac Catheterization

CONTEXT

In rural areas of Canada, people with acute coronary syndromes (ACS) can wait up to 32 hours for transfer for diagnostic cardiac catheterization (CATH). While awaiting CATH, it is critical that pain and anxiety management be optimal to preserve myocardial muscle and minimize the risk of further deterioration.

OBJECTIVES

The aim of this study was to examine the relationship between clinical management, cardiac pain intensity, and state anxiety for rural ACS patients awaiting diagnostic CATH.

METHODS

In a prospective, descriptive-correlational repeated-measures design involving 121 ACS rural patients, we examined the associations of analgesic and nitroglycerin administration with cardiac pain intensity (numeric rating scale) and state anxiety (Spielberger State Anxiety Inventory) and also nurses' pain knowledge and attitudes (Toronto Pain Management Inventory-ACS Version and Knowledge and Attitudes Survey Regarding Pain) using linear mixed models.

RESULTS

The mean age of patients was 67.6 ± 13, 50% were men, and 60% had unstable angina and the remainder had non-ST-elevated myocardial infarction. During follow-up, cardiac pain intensity scores remained in the mild range from 1.1 ± 2.2 to 2.4 ± 2.7. State anxiety ranged from 44.0 ± 7.2 to 46.2 ± 6.6. Cumulative analgesic dose was associated with a reduction in cardiac pain by 1.0 points (numeric rating scale, 0-10) (t108 = -2.5; SE, -0.25; confidence interval, -0.45 to -0.06; P = .013). Analgesic administration was not associated with state anxiety. Over the course of follow-up, ACS patients reported consistently high anxiety scores.

CONCLUSIONS

Whereas cardiac pain declines in most patients in the early hours after admission, many patients experience a persistent anxious state up to 8 hours later, which suggest that development and testing of protocols for anxiety reduction may be needed. More urgently, the development and examination of a treatment intervention, early on in the ACS trajectory, are warranted that targets pain and anxiety for those for whom immediate angioplasty is not possible and who continue to experience cardiac pain and persistent high levels of anxiety. Moreover, a larger prognostic study is required to determine whether high levels of anxiety in rural ACS patients are predictive of major adverse cardiac events.

Meta-Analysis of Anxiety as a Risk Factor for Cardiovascular Disease

Whether anxiety is a risk factor for a range of cardiovascular diseases is unclear. We aimed to determine the association between anxiety and a range of cardiovascular diseases. MEDLINE and EMBASE were searched for cohort studies that included participants with and without anxiety, including subjects with anxiety, worry, posttraumatic stress disorder, phobic anxiety, and panic disorder. We examined the association of anxiety with cardiovascular mortality, major cardiovascular events (defined as the composite of cardiovascular death, stroke, coronary heart disease, and heart failure), stroke, coronary heart disease, heart failure, and atrial fibrillation. We identified 46 cohort studies containing 2,017,276 participants and 222,253 subjects with anxiety. Anxiety was associated with a significantly elevated risk of cardiovascular mortality (relative risk [RR] 1.41, CI 1.13 to 1.76), coronary heart disease (RR 1.41, CI 1.23 to 1.61), stroke (RR 1.71, CI 1.18 to 2.50), and heart failure (RR 1.35, CI 1.11 to 1.64). Anxiety was not significantly associated with major cardiovascular events or atrial fibrillation although CIs were wide. Phobic anxiety was associated with a higher risk of coronary heart disease than other anxiety disorders, and posttraumatic stress disorder was associated with a higher risk of stroke. Results were broadly consistent in sensitivity analyses. Anxiety disorders are associated with an elevated risk of a range of different cardiovascular events, including stroke, coronary heart disease, heart failure, and cardiovascular death. Whether these associations are causal is unclear.

Development and validation of parallel short forms PaSA-cardio for the assessment of general anxiety in cardiovascular rehabilitation patients using Rasch analysis

OBJECTIVE

To develop and validate parallel short forms for the assessment of general anxiety in cardiovascular rehabilitation patients, that facilitate repeated measurement over time without contamination from residual practice effect variance.

DESIGN

Development of the parallel short forms using Rasch analysis. Validation study.

SETTING

Cardiac rehabilitation centres in Germany.

SUBJECTS

Cardiovascular rehabilitation patients.

INTERVENTIONS

Not applicable.

MAIN MEASURES

Parallel short forms PaSA-cardio, Hospital Anxiety and Depression Scale, Short Form Health Survey SF-12 and Structured Clinical Interview for DSM-IV Axis I Disorders.

RESULTS

Each version of the parallel short forms (PaSA-cardio-I and PaSA-cardio-II) comprises ten items. The two forms fitted to the Rasch model with a non-significant item-trait interaction (PaSA-cardio-I: chi-square = 39.49, degrees of freedom = 30, probability = 0.12; PaSA-cardio-II: chi-square = 26.56, degrees of freedom = 30, probability = 0.65). Person-separation reliability was 0.75/0.76. Unidimensionality could be verified. Correlation between the two models was 0.94 and 0.95, and correlations with the underlying item bank were 0.95 and 0.93. Validity could be confirmed. The area under the curve was between 0.88 and 0.97 for PaSA-cardio-I and between 0.92 and 0.95 for PaSA-cardio-II.

CONCLUSIONS

Assessment of general anxiety in cardiovascular rehabilitation patients with the PaSA-cardio was valid, economical and accurate. The two forms of the PaSA-cardio are equivalent and allow retest without contamination from residual practice effect variance.

Associations of specific phobia and its subtypes with physical diseases: an adult community study

BACKGROUND

Specific phobia is the most prevalent anxiety disorder in the community and is associated with substantial impairment. Comorbidity with physical diseases is assumed and has important implications for etiology, treatment, or prevention of the comorbid conditions. However, due to methodological issues data are limited and subtypes of specific phobia have not been investigated yet. We examined the association of specific phobia and its subtypes with physical diseases in a representative community sample with physician-diagnosed physical diseases and diagnostic criteria of specific phobia.

METHODS

Data of the German Mental Health Survey from 4181 subjects aged 18-65 years were used. Specific phobia was diagnosed using M-CIDI/DIA-X interview; physical diseases were assessed through a self-report questionnaire and a medical interview. Logistic regression analyses adjusted for sex were calculated.

RESULTS

Specific phobia was associated with cardiac diseases, gastrointestinal diseases, respiratory diseases, arthritic conditions, migraine, and thyroid diseases (odds ratios between 1.49 and 2.53). Among the subtypes, different patterns of associations with physical diseases were established. The findings were partially replicated in the Swiss PsyCoLaus Study.

CONCLUSIONS

Our analyses show that subjects with specific phobia have an increased probability for specific physical diseases. From these analyses etiological mechanisms of specific phobia and physical disease can be deduced. As subtypes differed in their patterns of associations with physical diseases, different etiological mechanisms may play a role. The findings are highly relevant for public health in terms of prevention and therapy of the comorbid conditions.

Sound mind vs sound heart

Depressive and anxiety disorders have both have been associated with an increased risk of cardiovascular disease. This article highlights the multifactorial and bidirectional interaction between cardiovascular diseases, depression and anxiety, and the need for early assessment, diagnosis and intervention.

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

BACKGROUND

Anxiety has been associated with new-onset cardiovascular disease (CVD), but the quality of this relationship is unclear. Only if anxiety is a causal, independent cardiovascular risk factor might it be a target for CVD prevention.

AIMS

To determine and examine the independent association and causality between anxiety and incident CVD.

METHOD

PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A review of Hill's criteria for causality and random effects meta-analysis were conducted of prospective, population-based studies examining anxiety and incident CVD in people free from CVD at baseline.

RESULTS

The meta-analysis comprised 37 papers (n = 1 565 699). The follow-up ranged from 1 to 24 years. Anxiety was associated with a 52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36-1.71). The risk seemed independent of traditional risk factors and depression. The evaluation of Hill's criteria largely argued in favour of causality.

CONCLUSIONS

Anxiety may be of interest for CVD prevention. Future research should examine biological and behavioural underpinnings of the association in order to identify targets for intervention.

Increased arterial stiffness parameters in panic disorder patients in long term treatment period

BACKGROUND

The relationship between mental stress and cardiovascular disease has been shown in several studies. Panic disorder (PD) is also associated with cardiovascular disease due to increased risk of myocardial infarction. The aim of this study is to evaluate the association between arterial stiffness parameters and depression/anxiety scores in patients with PD.

METHODS

The study population consisted of 25 patients with PD and 25 age-sex-matched healthy controls. Depression and anxiety levels were evaluated by Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI), respectively. Determination of arterial stiffness parameters was conducted using a Mobil-O-Graph arteriograph system that detected signals from the brachial artery.

RESULTS

While baseline characteristics were similar between two groups, BDI and BAI scores were significantly higher in patients with PD (p < 0.005). The pulse wave velocity (PWV) and Augmentation Index (AIx) were also significantly higher in patients with PD (p = 0.001, p = 0.006). There was a moderate correlation between PWV and AIx with BAI scores (r = 0.442, p = 0.001, r = 0.441, p = 0.001). AIx was also positively correlated with BDI scores (r = 0.415, p = 0.03).

CONCLUSION

We demonstrated a significant relationship between arterial stiffness parameters and anxiety/depression scores in patients with PD who receive antidepressant treatment.

Panic disorder and incident coronary heart disease: a systematic review and meta-regression in 1131612 persons and 58111 cardiac events

BACKGROUND

Substantial healthcare resources are devoted to panic disorder (PD) and coronary heart disease (CHD); however, the association between these conditions remains controversial. Our objective was to conduct a systematic review of studies assessing the association between PD, related syndromes, and incident CHD.

METHOD

Relevant studies were retrieved from Medline, EMBASE, SCOPUS and PsycINFO without restrictions from inception to January 2015 supplemented with hand-searching. We included studies that reported hazard ratios (HR) or sufficient data to calculate the risk ratio and 95% confidence interval (CI) which were pooled using a random-effects model. Studies utilizing self-reported CHD were ineligible. Twelve studies were included comprising 1 131 612 persons and 58 111 incident CHD cases.

RESULTS

PD was associated with the primary incident CHD endpoint [adjusted HR (aHR) 1.47, 95% CI 1.24-1.74, p < 0.00001] even after excluding angina (aHR 1.49, 95% CI 1.22-1.81, p < 0.00001). High to moderate quality evidence suggested an association with incident major adverse cardiac events (MACE; aHR 1.40, 95% CI 1.16-1.69, p = 0.0004) and myocardial infarction (aHR 1.36, 95% CI 1.12-1.66, p = 0.002). The risk for CHD was significant after excluding depression (aHR 1.64, 95% CI 1.45-1.85) and after depression adjustment (aHR 1.38, 95% CI 1.03-1.87). Age, sex, length of follow-up, socioeconomic status and diabetes were sources of heterogeneity in the primary endpoint.

CONCLUSIONS

Meta-analysis showed that PD was independently associated with incident CHD, myocardial infarction and MACE; however, reverse causality cannot be ruled out and there was evidence of heterogeneity.

Comparison of heart rate variability between resting state and external-cuff-inflation-and-deflation state: a pilot study

Heart rate variability (HRV) has been widely used in clinical research to provide an insight into the autonomic control of the cardiovascular system. Measurement of HRV is generally performed under a relaxed resting state. The effects of other conditions on HRV measurement, such as running, mountaineering, head-up tilt, etc, have also been investigated. This study aimed to explore whether an inflation-and-deflation process applied to a unilateral upper arm cuff would influence the HRV measurement. Fifty healthy young volunteers aged between 21 and 30 were enrolled in this study. Electrocardiogram (ECG) signals were recorded for each subject over a five minute resting state followed by a five minute external-cuff-inflation-and-deflation state (ECID state). A one minute gap was scheduled between the two measurements. Consecutive RR intervals in the ECG were extracted automatically to form the HRV data for each of the two states. Time domain (SDNN, RMSSD and PNN50), frequency domain (LFn, HFn and LF/HF) and nonlinear (VLI, VAI and SampEn) HRV indices were analyzed and compared between the two states. In addition, the effects of mean artery pressure (MAP) and heart rate (HR) on the aforementioned HRV indices were assessed for the two states, respectively, by Pearson correlation analysis. The results showed no significant difference in all aforementioned HRV indices between the resting and the ECID states (all p  >  0.05). The corresponding HRV indices had significant positive correlation (all p  <  0.01) between the two states. None of the indices showed MAP-related change (all p  >  0.05) for either state. Besides, none of the indices showed HR-related change (all p  >  0.05) for either state except the index of VLI in the resting state. To conclude, this pilot study suggested that the applied ECID process hardly influenced those commonly used HRV indices. It would thus be applicable to simultaneously measure both blood pressure and HRV indices in clinical practice.

The spectrum of epidemiology underlying sudden cardiac death

Sudden cardiac death (SCD) from cardiac arrest is a major international public health problem accounting for an estimated 15%-20% of all deaths. Although resuscitation rates are generally improving throughout the world, the majority of individuals who experience a sudden cardiac arrest will not survive. SCD most often develops in older adults with acquired structural heart disease, but it also rarely occurs in the young, where it is more commonly because of inherited disorders. Coronary heart disease is known to be the most common pathology underlying SCD, followed by cardiomyopathies, inherited arrhythmia syndromes, and valvular heart disease. During the past 3 decades, declines in SCD rates have not been as steep as for other causes of coronary heart disease deaths, and there is a growing fraction of SCDs not due to coronary heart disease and ventricular arrhythmias, particularly among certain subsets of the population. The growing heterogeneity of the pathologies and mechanisms underlying SCD present major challenges for SCD prevention, which are magnified further by a frequent lack of recognition of the underlying cardiac condition before death. Multifaceted preventative approaches, which address risk factors in seemingly low-risk and known high-risk populations, will be required to decrease the burden of SCD. In this Compendium, we review the wide-ranging spectrum of epidemiology underlying SCD within both the general population and in high-risk subsets with established cardiac disease placing an emphasis on recent global trends, remaining uncertainties, and potential targeted preventive strategies.