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"Patients with heart disease who experience high anxiety during the stressors of everyday life may benefit from treatments designed to reduce anxiety, such as medications targeting anxiety or stress management," said lead researcher Lana Watkins, an associate professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.
Previous studies have shown that depression is about three times more common in heart attack patients than in others. But few studies have looked at anxiety's effect or the combination of the two on heart disease patients.
One expert, Dr. Gregg Fonarow, a spokesman for the American Heart Association and a professor of cardiology at the University of California, Los Angeles, agreed anxiety and depression are most lethal when they co-exist.
"Depression and anxiety have both been individually associated with a higher risk of developing cardiovascular disease, and in patients with cardiovascular disease [they are] associated with higher risk of recurrent cardiovascular events and death," Fonarow said.
This new study finds that anxiety, particularly when accompanying depression, independently increased risk of dying, he added.
The report was published March 19 in the Journal of the American Heart Association.
Anxiety is a common mental health problem, with about one-third of U.S. adults experiencing an anxiety disorder in their lifetime, the researchers noted. And heart disease is the leading cause of death in the United States.
For the study, more than 900 heart disease patients, average age 62, answered a questionnaire measuring their level of anxiety and depression right before or just after coronary angiography, which can be a stressful cardiac procedure. The test uses special X-rays and dyes to view the coronary arteries.
The investigators found that 90 patients had anxiety, 65 had depression and 99 suffered from both.
Of the 133 patients who died over the three years of follow-up, 55 suffered from anxiety, depression or both, the researchers reported. Most of these deaths (93) were related to heart disease, they noted.
Patients who are highly anxious during a stressful life experience, such as a cardiac hospitalization, are at an increased risk of dying, and this risk is independent of the severity of their heart disease and also of depression, Watkins said.
According to the researchers, anxiety can increase inflammation and blood pressure. Fatigue or feelings of worthlessness associated with depression may cause people to ignore their treatment for heart disease.
Simon Rego, director of psychology training at Montefiore Medical Center and Albert Einstein College of Medicine in New York City, said these findings show how mental health issues can complicate medical problems.
"These findings lend further support to the serious impact that psychological disorders can have on medical outcomes, and suggest that patients presenting with medical conditions and/or for medical procedures should be routinely assessed for both anxiety and depression," Rego said.
Patients with anxiety and/or depression should, at a minimum, have their symptoms closely monitored on a regular basis, and ideally get referred to a psychologist with expertise in treatments for anxiety and depression, such as cognitive behavioral therapy, Rego said. Cognitive behavioral therapy is a treatment that helps patients try to change their thoughts, feelings and behaviors.
Whether treating anxiety and depression in these patients will reduce the risk of dying isn't clear, however, Fonarow said.
"Further studies are needed to determine if effective treatment of anxiety and depression can reduce cardiovascular risk," he said.
The authors acknowledge that one limitation of the study is that it did not account for substance use and abuse, which tends to be high in people with depression and anxiety disorders.
While the study found an association between an increased risk of death from all causes and having heart disease accompanied by anxiety and depression, it did not prove a cause-and-effect relationship.
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