Study highlights:

• Anxiety and depression are associated with more frequent chest pain among coronary artery disease patients.
• Patients who had procedures to open arteries also had more chest pain.
• The findings suggest that future research should investigate strategies to reduce psychosocial distress.

News tip highlights:

• Elevated depression symptoms and being unmarried were associated with poor outcome in heart failure patients with atrial fibrillation.

DALLAS, June 29, 2009 — Anxiety and depression are associated with more frequent angina in coronary artery disease patients, researchers report in Circulation: Journal of the American Heart Association.

Angina is chest pain and can include jaw, shoulder, back and arm discomfort. Angina is caused by myocardial ischemia, an inadequate supply of blood-borne oxygen to the heart muscle.

Heart patients with at least moderate anxiety were more than four times likely to have chest pain, while patients with clinical depression were three times more likely to have frequent chest pain. Furthermore, patients with a history of coronary revascularization were twice as likely to have frequent angina.

“This study has identified a high-risk group for angina,” said Mark Sullivan, M.D., Ph.D., senior author of the study and a professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle, Wash. “Patients with daily or weekly angina are highly likely to have significant anxiety and depression.

“We are spending a lot of money on revascularization in these patients. There is a whole other domain that hasn’t received a lot of attention. Anxiety and depression should be assessed in people with frequent angina.”

The study included 191 patients who had established ischemia while undergoing stress testing with myocardial perfusion imaging between April 2004 and 2006 at two Seattle hospitals.

Researchers found:
• 36 percent reported no angina over the past month;
• 35 percent reported monthly symptoms;
• 30 percent had daily or weekly angina; and
• 44 percent who reported daily or weekly angina had significant anxiety; two-thirds had significant depression.

Average age of the study group was 63 years old, and patients with more frequent angina were more likely to be younger. Patients with more frequent chest pain were more likely to report exertional angina during treadmill testing.

Patients were given the Seattle Angina questionnaire to determine the frequency of angina before stress testing and were given psychosocial assessments including a self reported anxiety and depression questionnaire.

The frequency of angina was strongly linked with anxiety and depression, but the study didn’t establish cause, Sullivan said. “It is unclear whether these psychosocial factors are truly affecting the anginal response to ischemia or if the increased chest pain burden is causing an intensification in psychosocial distress.”

In the United States the primary goal in treating ischemia has been medication and revascularization procedures to reduce myocardial ischemia. In contrast, European physicians use a broader range of treatments for refractory angina, including cognitive-behavioral therapy, medication and rehabilitation programs similar to those used for chronic pain.

“Physicians need to assess patients with frequent angina for anxiety and depression,” Sullivan said. “It’s not all ischemia. There are other very important aspects to angina that can be diagnosed and treated either with psychotherapy or medication. Reducing anxiety and depression may be a cost-effective way to reduce angina.”

The researchers plan to conduct treatment trials in patients with confirmed ischemia who have frequent bouts of angina to determine whether psychotherapy and/or medication will help.

Co-authors are Suzanne V. Arnold, M.D., M.H.A.; John A. Spertus, M.D., M.P.H.; Paul S. Ciechanowski, M.D., M.P.H.; Laurie A. Soine, M.N, A.R.N.P.; Kier Jordan-Keith, A.R.N.P.; and James H. Caldwell, M.D.
The study was supported by a grant from the American Heart Association.

NR09 – 1076 (Circ/Arnold Sullivan)
 

Related News Tip: 

Depression, being single linked with poor outcomes among heart failure patients with atrial fibrillation
Elevated depression symptoms and being unmarried were associated with poor outcome in heart failure patients with atrial fibrillation, in a sub-study from the AF-CHF Trial of rate versus rhythm control.
Researchers investigated whether depression predicts long-term risk of cardiovascular death in patients who receive optimal medical care and have a left ventricular ejection fraction (LVEF, a measure of the heart’s function) of less than 35 percent, congestive heart failure symptoms and history of atrial fibrillation.

Researchers assessed depression in 974 participants (833 men), with 32 percent showing elevated scores. Over an average follow-up of 39 months, 246 cardiovascular deaths occurred (111 presumed to be related to irregular heartbeat; 302 all cause).

After adjusting for other factors (including age, marital status, heart failure causes, LVEF, previous atrial fibrillation hospitalization), researchers found elevated depression scores significantly predicted:
• 57 percent increased risk of cardiovascular death (primary outcome);
• 69 percent increased risk of arrhythmic death; and
• 38 percent increased risk of death from all causes.

Risks associated with depression and marital status increased further, with the highest risk in depressed patients who were unmarried.

The American Heart Association recently recommended depression screening in coronary artery disease patients to identify those who might benefit from additional evaluation or treatment.

“In the absence of clinical trials specifically addressing these psychosocial risks among congestive heart failure patients with atrial fibrillation, we believe that depression and lack of a marital partner should be considered as risk markers identifying patients who may require additional treatment efforts to manage their cardiac conditions and modify other known risks,” researchers said. “Knowledge of depression and marital status adds significantly to more established indicators’ ability to help identify patients at greatest risk.”

The AF-CHF trial was supported by a grant from the Canadian Institutes of Health Research.

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Statements and conclusions of study authors published in American Heart Association scientific journals are solely those of the study authors and do not necessarily reflect the association’s policy or position. The association makes no representation or guarantee as to their accuracy or reliability. The association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific association programs and events. The association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and device corporations are available at www.americanheart.org/corporatefunding.   

Additional Resources:

• Top Ten Things to Know -- Depression and CHD

• Depression and Coronary Heart Disease Recommendations for Screening, Referral, and Treatment: A Science Advisory From the American Heart Association Prevention Committee of the Council on   Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research
 

• Heart Attack and Angina Statistics