Cardiophobia: a critical analysis

Exploring pain experience and anxiety sensitivity among Latinx adults in a federally qualified health center

The Latinx population is the largest minority group in the United States (U.S.) and is expected to continue to grow through at least 2050. Although there is growing recognition of the importance of pain among Latinx individuals, few studies have examined individualized psychological processes governing pain severity and disability in Latinx populations. One psychological factor that has shown promise in relation to pain experience specifically and clinical conditions more generally is anxiety sensitivity. The present investigation sought to (1) characterize the severity of pain among an unselected sample of adult Latinx individuals attending a Federally Qualified Health Center (FQHC); (2) evaluate the severity of anxiety sensitivity as a function of pain severity; and (3) test the potential explanatory relevance of anxiety sensitivity as an individual difference factor for pain intensity, pain disability, psychological inflexibility for emotional distress, and global life impairment. Participants included 406 adult Spanish-speaking Latinx persons (87.2% female; M_age = 40.26 years, SD = 11.20, and 98.3% used Spanish as their first language) who attended an FQHC in Houston, Texas. Analyses revealed that 62.6% of the sample had at least some pain, and 21.9% of the same had high intensity, moderate interference, or severe interference chronic pain. Further, results provided evidence for anxiety sensitivity as a function of pain grade, such that individuals with grade 2 (high-intensity pain), grade 3 (moderate pain interference), and grade 4 (severe pain interference) chronic pain reported significantly higher levels of anxiety sensitivity than those with grade 0 pain (no chronic pain). Additionally, after controlling for age, gender, marital status, years of education, years living in the U.S., and generalized anxiety, anxiety sensitivity significantly accounted for significant variance in pain intensity, inflexibility in relation to emotional distress, and life impairment. Overall, the current study builds upon what is currently understood about anxiety sensitivity among the Latinx population and uniquely extends past work by linking individual differences in this construct to clinically relevant aspects of pain experience and life impairment among adults attending FQHC's. Additional clinical attention should be focused on anxiety sensitivity to offset pain disparities among this established health disparities group.

Heart-Focused Anxiety: An Evolutionary Concept Analysis

Although heart-focused anxiety is a common experience of patients following a myocardial infarction, it is one rarely addressed in nursing research. I used Rodger's evolutionary method of concept analysis to review uses of heart-focused anxiety in literature from several disciplines including nursing and synthesized a definition to guide future research. Heart-focused anxiety is an experience of avoidance, fear, and heart-focused attention that follows from cardiac diagnoses, somatic symptoms, and familial factors and results in adverse health outcomes, reassurance seeking, disruption of life, and recurrent chest pain. Although heart-focused anxiety is an evolving concept, the updated definition should help provide a foundation for future research. A Supplemental Digital Content video abstract is available at http://links.lww.com/ANS/A32.

Heart-Focused Anxiety Among Latinxs in Primary Care: Relations to Anxiety, Depression, Pain, and Functional Impairment

There is a public health need to better characterize the individual-based differences that may be involved in the expression and maintenance of psychological and related health problems among Latinx individuals. One individual difference factor that may be relevant to the nexus of psychological and physical concerns is heart-focused anxiety. The current study sought to evaluate the potential explanatory relevance of heart-focused anxiety as an important individual difference factor for anxiety, depression, pain experience, and functional impairment. Participants included 158 Latinx adults (Mage = 39.26, SD = 13.19; 85.4% female) from a primary health clinic. Results indicated that heart-focused anxiety was significantly related to anxious arousal, pain intensity, pain disability, and functional impairment. However, no significant effects were evident for depressive symptoms. These data indicate that heart-focused anxiety may be an underrecognized cognitive factor relevant to better understanding anxiety and pain among Latinx adults in primary care.

Burden of Non-cardiac Patients on the Emergency Room of a Rural Cardiac Center in Sindh, Pakistan

Introduction The number of cardiac patients increases on a daily basis, and emergency departments bear much of the burden of non-cardiac patients due to pathological fears of the aftermath of the disease. Therefore, this study aimed to determine the burden of non-cardiac patients on the emergency department of a cardiac center in a rural area of Sindh, Pakistan. Methods This cross-sectional study was conducted at the emergency department of Chandka Medical College Hospital in Larkana. Consecutive patients who presented with cardiac symptoms with no previous history of cardiac disease were included. After a brief history, physical examination, electrocardiogram, and a cardiac enzyme assessment, patients were categorized as cardiac or non-cardiac. Data were analyzed using IBM SPSS Statistics for Windows, Version 21.0. (IBM Corp., Armonk, NY, US) and p ≤0.05 was statistically significant. Results Of the 204 patients included, 112 (59.8%) were men, and the mean age was 47 ± 16 years. Most patients (n = 146; 71.6%) were diagnosed as non-cardiac. The non-cardiac diagnosis was significantly more common among patients without diabetes (n = 123, 77.4% vs. n = 23, 51.1%; p = 0.001), without chest pains (n = 93, 81.6% vs. n = 53, 58.9%; p< 0.001), and without shortness of breath (n = 107, 75.9% vs. n = 39, 61.9%; p = 0.041). Conclusion More than two-thirds of the patients were found to have a non-cardiac mechanism behind their symptoms. A major proportion of the emergency room's cardiology department is occupied by non-cardiac patients. Owing to its direct and indirect implication on an otherwise struggling health system, we suggest chest pain units should be developed to decrease the workload and provide better care to cardiac patients.

Non-cardiac Chest Pain: A Review for the Consultation-Liaison Psychiatrist

BACKGROUND

Patients presenting with chest pain to general practice or emergency providers represent a unique challenge, as the differential is broad and varies widely in acuity. Importantly, most cases of chest pain in both acute and general practice settings are ultimately found to be non-cardiac in origin, and a substantial proportion of patients experiencing non-cardiac chest pain (NCCP) suffer significant disability. In light of emerging evidence that mental health providers can serve a key role in the care of patients with NCCP, knowledge of the differential diagnosis, psychiatric co-morbidities, and therapeutic techniques for NCCP would be of great use to both consultation-liaison (C-L) psychiatrists and other mental health providers.

METHODS

We reviewed prior published work on (1) the appropriate medical workup of the acute presentation of chest pain, (2) the relevant medical and psychiatric differential diagnosis for chest pain determined to be non-cardiac in origin, (3) the management of related conditions in psychosomatic medicine, and (4) management strategies for patients with NCCP.

RESULTS

We identified key differential diagnostic and therapeutic considerations for psychosomatic medicine providers in 3 different clinical contexts: acute care in the emergency department, inpatient C-L psychiatry, and outpatient C-L psychiatry. We also identified several gaps in the literature surrounding the short-term and long-term management of NCCP in patients with psychiatric etiologies or co-morbid psychiatric conditions.

CONCLUSIONS

Though some approaches to the care of patients with NCCP have been developed, more work is needed to determine the most effective management techniques for this unique and high-morbidity population.

Prevalence and Overlap of Noncardiac Conditions in the Evaluation of Low-risk Acute Chest Pain Patients

BACKGROUND

When patients present to the emergency department with a complaint concerning for heart disease, this often becomes the primary focus of their evaluation. While patients with noncardiac causes of chest pain outnumber those with cardiac causes, noncardiac etiologies are frequently overlooked. We investigated symptoms and noncardiac conditions in a cohort of patients with chest pain at low risk of cardiac disease.

METHODS

We analyzed data from a prospective registry of patients who were evaluated in our chest pain evaluation center. Registry participants completed standardized and validated instruments for depression (by Patient Health Questionnaire PHQ-9), anxiety (by Generalized Anxiety Disorder GAD-7), and Gastroesophageal Reflux Disorder (GERD; by GERD Symptom Frequency Questionnaire). Chest pain characteristics were recorded; severity was reported on a 10-point scale.

RESULTS

A total of 195 patients were included in the investigation. Using the instruments noted above, the prevalence of depression was 34%, anxiety was 30%, and GERD was 44%, each of at least moderate severity. 32.5% of patients had 2 or more conditions. The median for the severity of angina was 7/10 and the number of episodes over the preceding week was 2, respectively. Severity of angina was associated with PHQ-9 (r = 0.238; P < 0.001) and GAD-7 (r = 0.283; P < 0.001) scores. The number of angina episodes over the prior week correlated with GERD Symptom Frequency Questionnaire (r = 0.256; P < 0.001) and PHQ-9 (r = 0.175; P = 0.019) scores. No correlation was observed between any of the scores and body mass index, smoking tobacco, diabetes mellitus, hypertension, or hyperlipidemia.

CONCLUSION

In our cohort of low-risk acute chest pain patients, depression, anxiety, and GERD were common, substantial overlap was observed. The severity of these noncardiac causes of chest pain causes correlated with the self-reported severity and frequency of angina, but weakly. These conditions should be part of a comprehensive plan of care for chest pain management.

Illness perceptions, negative emotions, and pain in patients with noncardiac chest pain

Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and pain-related life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development.

Heart-Focused Anxiety in Patients With Noncardiac Chest Pain: Structure and Validity

Heart-focused anxiety (HFA) is a fear of cardiac sensations driven by worries of physical health catastrophe. HFA is impairing and distressing and has been shown to disproportionately affect individuals with noncardiac chest pain (NCCP), chest pain that persists in the absence of an identifiable source. The Cardiac Anxiety Questionnaire (CAQ) is a measure designed to assess HFA. The aim of this study was to evaluate the psychometric properties and factor structure of the CAQ in a sample of 229 adults diagnosed with NCCP. Results demonstrated that the CAQ is a useful measure of HFA in patients with NCCP and that a four-factor model including fear of cardiac sensations, avoidance of activities that elicit cardiac sensations, heart-focused attention, and reassurance seeking was the best fit for the data. Additionally, associations between CAQ subscales and two measures of health-related behaviors-pain-related interference and health care utilization-provided evidence of concurrent validity. Treatment implications are also discussed.

Brazilian Portuguese validated version of the Cardiac Anxiety Questionnaire

Background

Cardiac Anxiety (CA) is the fear of cardiac sensations, characterized by recurrent anxiety symptoms, in patients with or without cardiovascular disease. The Cardiac Anxiety Questionnaire (CAQ) is a tool to assess CA, already adapted but not validated to Portuguese.

Objective

This paper presents the three phases of the validation studies of the Brazilian CAQ.

Methods

To extract the factor structure and assess the reliability of the CAQ (phase 1), 98 patients with coronary artery disease were recruited. The aim of phase 2 was to explore the convergent and divergent validity. Fifty-six patients completed the CAQ, along with the Body Sensations Questionnaire (BSQ) and the Social Phobia Inventory (SPIN). To determine the discriminative validity (phase 3), we compared the CAQ scores of two subgroups formed with patients from phase 1 (n = 98), according to the diagnoses of panic disorder and agoraphobia, obtained with the MINI - Mini International Neuropsychiatric Interview.

Results

A 2-factor solution was the most interpretable (46.4% of the variance). Subscales were named "Fear and Hypervigilance" (n = 9; alpha = 0.88), and "Avoidance", (n = 5; alpha = 0.82). Significant correlation was found between factor 1 and the BSQ total score (p < 0.01), but not with factor 2. SPIN factors showed significant correlations with CAQ subscales (p < 0.01). In phase 3, "Cardiac with panic" patients scored significantly higher in CAQ factor 1 (t = -3.42; p < 0.01, CI = -1.02 to -0.27), and higher, but not significantly different, in factor 2 (t = -1.98; p = 0.51, CI = -0.87 to 0.00).

Conclusions

These results provide a definite Brazilian validated version of the CAQ, adequate to clinical and research settings.

Psychometric properties and factor structure of the Greek version of the Cardiac Anxiety Questionnaire (CAQ)

The present study assesses the psychometric properties and factor structure of the Greek version of the Cardiac Anxiety Questionnaire (CAQ). The questionnaire was administered to 598 healthy individuals from 15 different regions of Greece with a measure of socioeconomic characteristics and the Symptom Checklist-90-Revised (SCL-90-R). The sample was split into two random halves, and exploratory factor analysis indicated a three-factor solution. This solution was tested using a confirmatory factor analysis on the second half of the sample. In terms of latent dimensions, the Greek version retains the three-factor structure as proposed by the initial authors. However, adequate fit was achieved only after omitting eight items. The shorter (10-item) version was submitted to further analysis. The shorter version provided satisfactory internal reliability and evidence indicating the validity of the scale with respect to SCL-90-R subscales. The stability of the questionnaire was verified by a high test-retest reliability over a 3-mo. period (r = .86). Sex and age differences were assessed. The 10-item version appears to be a practical, brief tool for clinical use.

Heart-focused anxiety in the general population

OBJECTIVE

Heart-focused anxiety is a common phenomenon that is related to psychological disorders and cardiac diseases. We investigated heart-focused anxiety in the general population and provided standard values using the Cardiac Anxiety Questionnaire (CAQ). Furthermore, we assessed the reliability of the CAQ and investigated the influence of social variables on heart-focused anxiety.

METHODS AND RESULTS

The questionnaire was applied to 2,396 individuals (age range: 18-92; mean age 49 ± 17, 50% male). Three aspects of heart-focused anxiety (fear, attention, and avoidance) were captured by the CAQ. To test the influence of age, gender, and social factors, we performed analyses of variance, correlative statistics, and regression analyses. Heart-focused anxiety showed a linear increase with age (P < 0.001). No gender differences were observed. The degree of anxiety was affected by relationship (P < 0.001), level of education (P < 0.001), employment (P < 0.001), and income (P < 0.001).

CONCLUSION

We evaluated heart-focused anxiety in the general population and validated the CAQ. Using percentiles based on a normative sample allows screening for heart-focused anxiety in patients with or without cardiac diseases and the measurement of therapy success after psychotherapeutic or pharmacological intervention.

Anxiety, panic disorder and coronary artery disease: issues concerning physical exercise and cognitive behavioral therapy

Psychological factors such as stress and depression have already been established as primary and secondary cardiovascular risk factors. More recently, the role of anxiety in increasing cardiac risk has also been studied. The underlying mechanisms of increased cardiac risk in panic disorder patients seem to reflect the direct and indirect effects of autonomic dysfunction, as well as behavioral risk factors associated with an unhealthy lifestyle. Implications of the comorbidity between panic and cardiovascular disease include higher morbidity, functional deficits, increased cardiovascular risk, and poor adherence to cardiac rehabilitation or exercise programs. This article probes the most recent evidence on the association between coronary artery disease, anxiety and panic disorder, and discusses the potential role of incorporating regular physical exercise and cognitive behavioral therapy in the treatment of this condition.

Treinamento físico intervalado como ferramenta na terapia cognitivo-comportamental do transtorno de pânico

Este trabalho consiste no relato da utilização de um programa de exercícios físicos aeró-bicos intervalados no contexto da terapia cognitivo-comportamental em um caso de transtorno de pânico e agorafobia. São descritos os procedimentos utilizados, bem como os resultados positivos obtidos na redução da ansiedade cardíaca e na ansiedade cotidiana em relação a situações que exigem esforço físico.

Ataques de pânico são realmente inofensivos? O impacto cardiovascular do transtorno de pânico

OBJETIVO: Estresse e depressão já são considerados fatores de risco para o desenvolvimento e o agravamento de doenças cardiovasculares. Os transtornos de ansiedade têm sido fortemente associados às cardiopatias nos últimos anos. O transtorno de pânico em cardiopatas representa um desafio em termos de diagnóstico e tratamento. Atualizar o leitor quanto ao status da associação entre transtornos de ansiedade, especialmente transtorno de pânico, e cardiopatias. MÉTODO: Foi realizada uma busca nas bases de dados ISI e Medline, com as palavras-chave: "heart disease", "coronary disease", "anxiety", "panic disorder" e "autonomic function". Foram selecionados os artigos publicados a partir de 1998. DISCUSSÃO: O padrão autonômico encontrado em pacientes com transtorno de pânico, em particular a redução da variabilidade cardíaca, é apontado como o provável fator mediador do impacto cardiovascular do transtorno de pânico. CONCLUSÕES: Apesar de a associação entre transtornos de ansiedade e doenças cardiovasculares estar atualmente bastante estabelecida, existem ainda diversas lacunas no estado atual do conhecimento. São recomendadas a terapia cognitivo-comportamental e a prática de exercícios físicos supervisionados como potenciais coadjuvantes na intervenção terapêutica.