Anxiety Related to Heart Disease Identified by Questionnaire

After a cardiac event, many patients experience psychiatric symptoms, including depression, but more recent studies have paid attention to anxiety. These studies show that 30% to 40% of hospitalized patients experience significant anxiety after a myocardial infarction.^1-3

I was the lead author of a recent article in the International Journal of Psychiatry in Medicine about a questionnaire designed specifically to assess heart-focused anxiety, the Cardiac Anxiety Questionnaire (CAQ).

Because cardiac anxiety-the specific anxiety symptoms related to cardiac sensations-is a specific subtype of anxiety, it may be missed when clinicians look only at anxiety disorders that conform to current psychiatric classification systems.

The CAQ is useful instrument for detecting cardiac anxiety. In our study, its validity has been supported in a cardiac population.

Several studies have examined the relationship between psychiatric disease and cardiovascular disease. Meta-analyses of these studies have found that anxiety disorders are independent risk factors for myocardial infarction in otherwise healthy persons⁴ and that high anxiety after a myocardial infarction significantly worsens the prognosis of the cardiac disease.⁵

Anxiety disorders have many somatic signs that are equivalent to the symptoms of somatic disorders (eg, heart pounding and shortness of breath). As a result, many patients with anxiety disorders fear underlying heart disease. However, patients with cardiac disease may focus on their cardiac symptoms.

The CAQ is an 18-item self-report questionnaire designed to measure heart-focused anxiety, rated on a 5-point scale ranging from 0 (never) to 4 (always). The CAQ has 3 subscales: heart-related fear (“I worry that I may have an heart attack”), avoidance (“I take it easy as much as possible”), and attention (“I can feel my heart in my chest”).

The CAQ may be relevant to medical syndromes characterized by chest pain and psychological distress, including cardiac and noncardiac chest pain, as well as panic disorder.

My colleagues and I checked the validity of the CAQ in patients hospitalized for an acute coronary syndrome (ACS). We showed that the CAQ is a reliable and valid instrument for assessing cardiac anxiety in these patients.

We identified a fourth subscale, safety seeking behavior (“I like to be checked out by a doctor”). We found a significantly higher level of cardiac anxiety in inpatients with ACS than in inpatients with rheumatoid arthritis. This difference also remained after controlling for general distress level (depression and anxiety) associated with acute hospitalization. This shows that the CAQ indeed assesses cardiac anxiety specifically and not just general anxiety.

Cognitive-behavioral therapy is a generally effective treatment for patients with anxiety disorders. This approach often consists of a combination of psychoeducation, cognitive restructuring, and influencing avoidance behavior. These elements should be tailored to the patient’s cardiac status and individual needs.

The questionnaire may provide the primary care physician with insight into the individual patient’s level of anxiety as well as specific thoughts (cognitions) and accompanied behaviors. Cognitive or behavioral interventions and psychoeducation may be more targeted to the specific needs of a patient.

For example, a patient who scores positive on the item “I take it as easy as possible” should be told that gradually increasing exercise is much more beneficial for the heart than simply resting. A patient scoring high on “I worry that doctors do not believe my symptoms are real” is in need of more psychoeducation about anxiety and how anxiety can lead to physical symptoms.

The CAQ also is known to be a useful tool for assessing anxiety and response to treatment.⁶ On the basis of a recently conducted follow-up study in patients with a cardiac event, cardiac anxiety showed different trajectories in the year after the event. A specific subgroup of the patients continued to experience high levels of anxiety throughout the year, giving first clues for the clinician about which patients merit specific treatment.⁷References
1. Carinci F, Nicolucci A, Ciampi A, et al. Role of interactions between psychological and clinical factors in determining 6-month mortality among patients with acute myocardial infarction. Application of recursive partitioning techniques to the GISSI-2 database. Gruppo Italiano per lo Studio della Sopravvivenza nell' Infarto Miocardico. Eur Heart J. 1997;18:835-845.

2. Frasure-Smith N, Lesprance F, Juneau M, et al. Gender, depression and one-year prognosis after myocardial infarction. Psychosom Med. 1999;61:26-37.

3. Benninghoven D, Kaduk A, Wiegand U, et al. Influence of anxiety on the course of heart disease after acute myocardial infarction-risk factor or protective function? Psychother Psychosom. 2006;75:56-61.

4. Roest AM, Marten EJ, de Jonge P, Denollet J. Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol. 2010;56:38-46.

5. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med. 2010;72:563-569.

6. Spinhoven P, Van der Does AJ, Van Dijk E, Van Rood YR. Heart-focused anxiety as a mediating variable in the treatment of non-cardiac chest pain by cognitive-behavioral therapy and paroxetine. J Psychosom Res. 2010;69:227-235.

7. Van Beek MH, Mingels M, Voshaar RC, et al. One-year follow up of cardiac anxiety after a myocardial infarction: a latent class analysis. J Psychosom Res. 2012;73:362-368.