**3. Anxiety**

#### **3.1. Anxiety and coronary heart disease**

Anxiety has been characterized as a future-oriented, negative affective state with a component of fear, resulting from the perception of threat and the individual's perceived inability to predict, control, or obtain the desired results in upcoming situations. Somatic manifestations are tachycardia, hyperventilation, sweating, psychological manifestations are feelings of apprehension, nervousness, restlessness, and may also cause changes in sleeping pattern [13]. Pathophysiological background by which anxiety influences outcome in ischemic heart disease is largely unknown. An increased incidence of ECG QT interval prolongation has been demonstrated among patients with anxiety, which increases the occurrence of ventricular arrhythmia [14]. Patients with anxiety have been shown consistently to have sympathetic nervous system upregulation, with excessive catecholamine production [15]. Furthermore, impaired vagal control, manifest as an impaired baroreflex response and a decrease in heart rate variability has been noted in patients with anxiety. Impairment of the baroreflex response and decreased heart rate variability are each thought to be sensitive markers for abnormalities in autonomic cardiovascular regulation and are independent risk factors for sudden cardiac death [16, 17, 18]. Patients with anxiety and CAD often show an exaggerated systemic response to stress, characterized by an abnormally increased production of catecholamines, which can result in increased myocardial oxygen demand due to elevations in heart rate, blood pressure, and the rate of ventricular contraction [19]. In addition to the biological risks of anxiety, the additive effects of adverse behavioural risk factors (e.g., excessive nicotine and perhaps caffeine) in anxious patients have also be taken into account [20]. Anxiety is very common in patients with myocardial infarction, with an inhospital occurrence rate of 30% to 40% [21]. Studies with coronary patients suggest that anxiety disorders may be associated with greater mortality, particularly sudden cardiac death, and greater cardiovascular morbidity. Higher levels of anxiety have been associated with poorer prognosis and greater recurrence of cardiac events after myocardial infarction [22]. In a cohort study the relative importance of depression, anxiety, anger, and social support in predicting 5-year cardiac-related mortality following a myocardial infarction was investigated. Higher level of anxiety predicted greater cardiacrelated mortality in a sample of nearly 900 patients with myocardial infarction, but this effect was non significant following adjustment for disease severity [23]. The first meta-analysis on the association of anxiety and coronary heart disease showed a consistent association between anxiety and impaired prognosis after myocardial infarction, with a 36% increased risk for mortality (cardiac and all-cause) and for cardiac events. Limitation of the result was the pooled odds ratios for cardiac death, because it was based on only four studies [21].

#### **3.2. Anxiety and CABG**

Tully PJ. The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery.

468 Artery Bypass

226 Hospital readmissions after coronary artery bypass graft surgery were assessed.

**Figure 1.** Figure showes significant difference in depression (BDI points) between survivors and non survivors preoper‐

Anxiety has been characterized as a future-oriented, negative affective state with a component of fear, resulting from the perception of threat and the individual's perceived inability to predict, control, or obtain the desired results in upcoming situations. Somatic manifestations are tachycardia, hyperventilation, sweating, psychological manifestations are feelings of apprehension, nervousness, restlessness, and may also cause changes in sleeping pattern [13].

**Table 1.** Some important studies about depression and CABG

atively, after discharge and in both intervals.

**3.1. Anxiety and coronary heart disease**

**3. Anxiety**

When analyzed as continuous variables in multivariable analyses, preoperative anxiety and

postoperative depression predicted readmissions independent of medical covariates. In multivariable analyses with dichotomized anxiety, depression and stress, more than two-fold increase in readmission risk was attributable to preoperative anxiety and postoperative depression, independent of

covariates.

Anxiety is especially high for CABG patients while they are on the waiting list with an unknown surgery date [24]. The patients have fear of dying before, rather than during surgery, and this fear influenced strongly their level of anxiety. Anxiety also manifests as an activator of sympathetic and parasympathetic nervous systems and cardiovascular excitation that can exacerbate CAD symptoms. After surgery, while anxiety may decrease to below pre-operative level, the severity of anxiety does not necessarily remit to below sub-clinical levels and may warrant intervention [25]. In the Post-CABG Trial the presence of anxiety symptoms was significantly associated with a higher incidence rate of death or myocardial infarction after a median follow-up time of 4.3 years following CABG. After controlling for the presence of depressive symptoms and other covariates (age, gender, race, treatment assignment and years since CABG surgery), a significant dose-response relationship persisted between anxiety and mortality. The observed dose-response relationship between level of anxiety and risk of death or myocardial infarction underlines the importance of even lower levels of anxiety. The risk of death or myocardial infarction in those with both depressive and anxiety symptoms was what would be expected from the combination of the independent effects [26]. In a study of our workgroup trait anxiety was associated with increased mortality and cardiovascular morbidity. In our population trait anxiety remained an independent predictor for postdischarge cardiovascular events and 4 year mortality. Moreover, post-discharge 6th month trait anxiety scores were more predictive for cardiovascular events compared to the preoper‐ ative values. Although anxiety and depression were positively and highly correlated in these patients, only anxiety was associated with increased mortality and morbidity. In addition trait anxiety was significantly higher in patients hospitalized with arrhythmia, congestive heart failure or myocardial infarction during a 4 year period after cardiac (CABG and valve) surgery [27]. In another study of our workgroup depression, anxiety, education, social isolation and mortality together were investigated 7.5 years after cardiac surgery. Our results have suggest‐ ed that the assessment of psychosocial factors, particularly anxiety and education may help identify patients at an increased risk for long-term mortality after cardiac surgery (Figure 2.) [13]. Anxiety was also reported to be associated with twofold risk for fatal CHD and more than fourfold risk for sudden death [28]. In a retrospective study 17,885 discharge records of patients after primary CABG surgery were identified. In the sample of rural patients the prevalence of anxiety disorder was 27%. Anxiety was a significant independent predictor of both length of hospital stay and non routine discharge [29]. In a prospective study on cardiac-related readmission within 6 months of CABG postoperative anxiety was identified as both a uni‐ variate risk factor and a multivariate risk factor for CHD and surgery-related readmission both with and without adjustment for covariates [30].

Frasure-Smith N. Depression and other psychological risks following myocardial

Koivula M. Fear and anxiety in patients at different timepoints in the coronary artery

Rosenbloom JI. Self-reported anxiety and the risk of clinical events and atherosclerotic progression among patients with Coronary Artery Bypass

Székely A. Anxiety predicts mortality and morbidity after coronary artery and valve surgery--a 4-year follow-up

study.

bypass process.

Grafts (CABG).

896 Beck Depression Inventory, state scale of

myocardial infarction.

171 CABG patients completed questionnaires

Anxiety Inventory.

1317 CABG patients were randomized to either

Anxiety Inventory (STAI)

180 Patients who underwent cardiac surgery

using cardiopulmonary bypass were prospectively studied and followed up for 4 years. Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI), living alone, and education level along with clinical risk factors and

while awaiting surgery at home, in hospital the evening before surgery and 3 months later. The Bypass Grafting Fear scale was developed to measure fear. Anxiety was measured using State-Trait-

aggressive or moderate lipid lowering and to either warfarin or placebo. Patients were followed up for clinical end points and coronary angiography was conducted at enrollment and after a median followup of 4.3 years. Anxiety symptoms were assessed at enrollment using the state portion of the Spielberger State-Trait

version of the General Health Questionnaire, Modified Somatic Perception Questionnaire, Anger Expression Scale, Perceived Social Support Scale, number of close friends and relatives, and visual analog scales of anger and stress were assessed to predict 5-year cardiac-related mortality following a

the State-Trait Anxiety Inventory, 20-item

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

The Beck Depression Inventory (P<0.001), the State-Trait Anxiety Inventory (P =0.04), and the 20-item version of the General Health Questionnaire (P = 0.048) were related to outcome, but only depression remained significant after adjustment for cardiac disease severity (hazards ratio per SD, 1.46; 95% confidence interval, 1.18-1.79) (P<0.001). There was also a covariate-adjusted trend between negative affectivity scores and outcome (P = 0.08). Furthermore, residual depression scores (P =0.001) and negative affectivity scores (P = 0.05) were linked to cardiac-related mortality after adjustment for each other and cardiac covariates.

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The highest levels of fear and anxiety were measured in the waiting period to coronary CABG. Compared with the waiting period, fear and anxiety levels dropped in hospital and 3 months later. Female gender was related to change in

STAI score "/> or =40 was positively associated with risk of death or myocardial infarction (MI) (OR 1.55, 95% CI 1.01-2.36, P =0.044). This association was attenuated slightly when depressive symptoms were included in the model, but lost statistical significance (P = 0.11). There was a dose-response relationship between STAI score and risk of death or myocardial infarction. There was no association between self-reported anxiety and atherosclerotic progression of grafts.

Average preoperative STAI-T score was 44.6 +/- 10. Kaplan-Meier analysis showed a significant effect of preoperative STAI-T "/>45 points (p =0.008) on mortality. In multivariate models, postoperative congestive heart failure (OR: 10.8; 95% confidence interval [CI]: 2.9-40.1; p =0 .009) and preoperative

fear and anxiety.

infarction


of death or myocardial infarction in those with both depressive and anxiety symptoms was what would be expected from the combination of the independent effects [26]. In a study of our workgroup trait anxiety was associated with increased mortality and cardiovascular morbidity. In our population trait anxiety remained an independent predictor for postdischarge cardiovascular events and 4 year mortality. Moreover, post-discharge 6th month trait anxiety scores were more predictive for cardiovascular events compared to the preoper‐ ative values. Although anxiety and depression were positively and highly correlated in these patients, only anxiety was associated with increased mortality and morbidity. In addition trait anxiety was significantly higher in patients hospitalized with arrhythmia, congestive heart failure or myocardial infarction during a 4 year period after cardiac (CABG and valve) surgery [27]. In another study of our workgroup depression, anxiety, education, social isolation and mortality together were investigated 7.5 years after cardiac surgery. Our results have suggest‐ ed that the assessment of psychosocial factors, particularly anxiety and education may help identify patients at an increased risk for long-term mortality after cardiac surgery (Figure 2.) [13]. Anxiety was also reported to be associated with twofold risk for fatal CHD and more than fourfold risk for sudden death [28]. In a retrospective study 17,885 discharge records of patients after primary CABG surgery were identified. In the sample of rural patients the prevalence of anxiety disorder was 27%. Anxiety was a significant independent predictor of both length of hospital stay and non routine discharge [29]. In a prospective study on cardiac-related readmission within 6 months of CABG postoperative anxiety was identified as both a uni‐ variate risk factor and a multivariate risk factor for CHD and surgery-related readmission both

Methods Results

During a median follow-up of 7.6 years (25th to 75th percentile, 7.4 to 8.1 years), the mortality rate was 23.6% (95% confidence interval [CI] 17.3-29.9; 42 deaths). In a Cox regression model, the risk factors associated with an increased risk of mortality were a higher EUROSCORE (points; Adjusted Hazard Ratio (AHR):1.30, 95%CI:1.07-1.58)), a higher preoperative STAI-T score (points; AHR:1.06, 95%CI 1.02-1.09), lower education level (school years; AHR:0.86, 95%CI:0.74-0.98), and the occurrence of major adverse cardiac and cerebral events during follow up (AHR:7.24, 95%CI: 2.65-19.7). In the postdischarge model, the same risk factors remained.

180 Anxiety (Spielberger State-Trait Anxiety

patients.

Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI) and the number and reason for rehospitalizations were assessed each year in cardiac surgery

with and without adjustment for covariates [30].

patients

First author and title Number of

Cserep Z. The impact of preoperative anxiety and education level on long-term mortality after cardiac

surgery.

470 Artery Bypass



**Figure 2.** Figure showes significant difference in STAI-T (State-Trait Anxiety Inventory) between survivors and non sur‐

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

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473

Self-rated health (SRH) is measured with a simple question "How do you rate your health in general?" There are five possible responses: very good, good, fair, poor and very poor [31]. Self rated health has been shown to be a potent predictor of mortality and morbidity, functional decline, disability and utilization of health care even after controlling for several sociodemo‐ graphic and health indicators The association can be explained by three ways: (1) SRH is a more comprehensive and sensitive measure of health status than the other psychosocial covariates in the analyses; (2) SRH measures individual optimistic or pessimistic disposition, that as such, may be associated with survival; or (3) SRH also measures characteristics other than health status itself, such as family history, health behaviour, and social and psychological resources [32]. In a review SRH was described as an active cognitive process that is independ‐ ent from formal definitions of health. Self rated health covers bodily sensations that are directly available only to the individuals. These sensations may reflect important physiological dysregulations, such as inflammatory processes. SRH is an individual and subjective concep‐ tion that is related to death, and builds a connection from the social world and psychological to the biological world. Therefore the answer to the SRH question may summarize the dimensions of health that are most important and determinant to each individual [33]. SRH has been described as one of the most important health outcomes available and recommended as a tool for disease risk screening, as an outcome indicator in the primary care, and standard part of clinical trials [34]. Several studies in different field confirmed the importance of SRH, one of them described that good self health 3 months after PCI predicted good clinical outcome

vivors preoperatively, after discharge and in both intervals.

**4. Self rated health**

**Table 2.** Some important studies about anxiety and CABG

**Figure 2.** Figure showes significant difference in STAI-T (State-Trait Anxiety Inventory) between survivors and non sur‐ vivors preoperatively, after discharge and in both intervals.
