Anxiety, Depression Linked to Angina Frequency in Heart Patients

New research shows that ischemic heart disease patients who suffer significant anxiety have close to a 5-fold increased risk of experiencing frequent angina and those with depression have more than a 3-fold increased risk for these episodes.

This observed link between psychiatric symptoms and angina underlines the importance of treating anxiety and depression in cardiac patients, according to study coauthor Mark D. Sullivan, MD, PhD, from the department of psychiatry and behavioral sciences at the University of Washington School of Medicine, in Seattle.

Current cardiology care focuses almost exclusively on management of ischemia with medications and revascularization, said Dr. Sullivan. "We're saying that there's a very significant contribution of depression and anxiety to these symptoms." This is among the first studies to measure depression and anxiety in ischemic heart patients, he added.

The research is published online June 29 in the journal Circulation.

Significant Comorbidities

The study included patients with suspected ischemic heart disease who were scheduled for an outpatient stress test with myocardial perfusion imaging at 2 medical centers in Washington State between April 2004 and April 2006. Researchers focused on 191 patients with clearly established inducible ischemia on stress testing. The mean age of these subjects was 63 years. Many participants were middle-aged male veterans.

A significant portion of the study group had cardiac-related comorbidities. For example, 82% had hypertension, 81% had hyperlipidemia, 34% were smokers, and 14% had diabetes mellitus

Prior to the stress testing, patients completed the Seattle Angina Questionnaire. Researchers focused on the portion of this questionnaire that quantifies the frequency and burden of angina. Angina frequency was categorized as none, monthly, weekly, or daily; the last 2 frequencies were combined for the purposes of this analysis.

Angina pectoris was defined as discomfort, usually around the chest, jaw, shoulder, back, or arm, associated with atherosclerotic obstruction. Of the 191 patients with inducible ischemia on stress perfusion imaging, 68 (36%) reported no angina over the previous 4 weeks, 66 (35%) reported monthly symptoms, and 57 (30%) had weekly or daily angina.

Patients with more frequent baseline angina were much more likely to report chest pain during stress tests: 63% of patients with weekly or daily angina compared with 20% of patients with monthly angina and 11% of patients with no angina.

Psychosocial Factors

The researchers examined 5 psychosocial factors that might affect angina frequency: anxiety; depression; neuroticism (tendency to experience negative emotions such as sadness, anger, or guilt); alexithymia (impaired ability to express inner feelings); and somatosensory amplification (tendency to experience a somatic sensation as intense, noxious, and disturbing).

There was more anxiety and depression among patients with frequent angina. For instance, 22% of patients with no angina had clinically significant anxiety, defined as a score of 16 or greater on the Beck Anxiety Inventory scale, compared with 38% for patients with monthly angina and 64% for those with weekly or daily angina.

Other psychosocial factors were also increased among patients with more frequent angina. For example, 38% of patients with weekly or daily angina had a high level of alexithymia compared with 17% of patients with monthly angina and 14% of those without angina.

However, after adjustment for degree of myocardial ischemia, greater anxiety score (odds ratio, 1.39 per half–standard deviation increase in anxiety score) and greater depression score (OR, 1.51 per half–standard deviation increase in depression score) were the only psychosocial factors significantly associated with more frequent angina. As expected, previous coronary revascularization was also significantly associated with frequent angina.

Patients with at least moderate anxiety symptoms experienced a 4.7-fold increased risk of having more frequent angina (95% CI, 1.91 – 11.66; P = .001). Patients with clinically relevant depressive symptoms (16 or greater on the Center for Epidemiologic Studies Depression scale) had a 3.2-fold increased risk of experiencing more frequent angina (95% CI, 1.45 – 6.69; P = .004.)

Biological Factors

Not every patient with coronary artery disease develops angina. Up to 45% of these patients have asymptomatic ischemia. Several biological factors might explain the discrepancy between coronary artery disease and angina severity, according to the authors. For example, metabolic neuropathy or ischemic regional nerve injury may influence pain levels.

"Just as with other pain syndromes — for example, chronic back pain — the relationship between the injury or the disease severity and the pain severity is very loose," said Dr. Sullivan, who has an interest in chronic pain. "There are all sorts of things that modify it, but these have not been studied very much in angina. That's why we wanted to do this study."

While the study showed a link between psychosocial symptoms and angina frequency, there is no evidence yet that treating these symptoms would reduce angina, said Dr. Sullivan.

"In cardiology, we thought we knew exactly why people were having pain — because they've got plugged plumbing, and unplugging the plumbing was going to solve the problem," said Dr. Sullivan. And while revascularization often does relieve the pain, there is growing evidence that for stable angina, revascularization is not superior to medication, he noted.

Dr. Sullivan stressed that the study sample included heart patients, not psychiatric patients, and that most people with heart disease do not develop a clinical level of anxiety or depression. It is those who are vulnerable to begin with who are more susceptible to these psychological symptoms, said Dr. Sullivan.

Talk to Patients

Asked for his opinion, Gerald Fletcher, MD, professor of medicine and cardiology at the Mayo Clinic in Jacksonville, Florida, commended the authors for their innovative work.

The research underlines the need for doctors to talk to their patients more often to determine underlying psychological issues. "You can't determine sometimes if someone has anxiety, depression, or whatever without facing them in an exam room and talking to them."

Pursuing a healthy lifestyle, including exercising and not smoking, could make patients less prone to these psychological problems, he said. He added that psychotherapy and other treatment approaches may help to reduce stresses of everyday life.

Source : http://www.medscape.com/viewarticle/705085