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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

Anxiety and Heart Disease -- What's the Connection?

November 23, 2012

By Michael Craig Miller M.D.

Harvard Medical School

There is a well-known link between major depression and heart disease. People with heart disease are more likely to suffer from depression than otherwise healthy people. Angina and heart attacks are closely linked with depression.

However, much less is known about how anxiety affects the heart. Various studies have found that 3 out of 10 patients with heart disease have symptoms of anxiety. Moreover, severe anxiety, which may appear as a panic attack, can mimic a heart attack.

Panic attack

Heart attack

Sudden onset of fear or terror in conjunction with heart palpitations or chest pain
Gradual onset (over several minutes) of pain, pressure, and/or tightness in chest and upper body
Pain and discomfort tend to occur in the center of the chest
Pain may occur in center of chest but may also radiate to upper body (arms, shoulders, or jaw)
Chest pain and other symptoms subside after 5 to 30 minutes
Symptoms last at least 15 minutes and may continue for hours

If you have these symptoms, you should get immediate medical help.

One analysis of studies involving people admitted to emergency rooms for chest pain found that about one-fifth of those who underwent heart-disease testing had panic disorder rather than heart disease.

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A Look at the Evidence

Two well-designed studies followed large numbers of people over time to better examine the relationship between heart disease and generalized anxiety disorder. It is one of the most common anxiety disorders. People with this disorder have constant and pervasive anxiety, even about ordinary matters.

A particular strength of these studies is that they controlled for confounding factors, such as major depression (which often occurs along with anxiety) and demographic and lifestyle factors that affect heart disease risk. Both studies suggest that generalized anxiety disorder may indeed increase risk of heart attacks and other serious health events.

The ESCAPE study

In the Epidemiological Study of Acute Coronary Syndromes and the Pathophysiology of Emotions (ESCAPE) study, researchers followed 804 heart disease patients in Montreal for two years.

They tracked the participants' blood pressure and vital signs, and collected other data related to heart risk. They diagnosed major depression and generalized anxiety disorder using a structured clinical interview based on criteria from the standard manual for diagnosis in psychiatry (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).

During two years of follow-up, 115 of the participants had a heart attack, underwent an emergency heart procedure or died. When the researchers controlled for heart disease risk factors such as age, cigarette smoking, for example, they found that generalized anxiety disorder and major depression each significantly increased risk, to roughly the same degree, of heart attacks and other cardiac events.

The Heart and Soul study

The Heart and Sould study enrolled 1,015 outpatients with stable heart disease from 12 clinics in California. The researchers collected information on participants' heart health. They used a computerized interview based on established clinical criteria to diagnose generalized anxiety disorder and major depression in the patients. Then they followed participants for an average of nearly six years to track cases of stroke, heart failure, heart attack, transient ischemic attack or death.

During the follow-up period, 371 heart attacks and other cardiac problems occurred in participants. After the researchers adjusted for other factors that affect heart disease risk, such as age, gender, major depression, exercise capacity and cigarette smoking, participants with generalized anxiety disorder were still 74% more likely than others to have heart attacks or other heart-related events.

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What's Behind the Connection?

These studies were designed only to detect associations between anxiety and heart disease, rather than prove cause and effect. The researchers, therefore, can only guess about why generalized anxiety disorder might increase the risk of heart disease. Here are the possibilities:

  • Generalized anxiety disorder may cause surges of cortisol and other stress hormones — the same chemicals involved in the “fight or flight” response — that may trigger heart attacks and other heart events.
  • People with anxiety have low levels of heart-protective omega-3 fatty acids.
  • Although both studies controlled for major depression, this disorder has so many biological and psychological factors in common with generalized anxiety disorder that it is possible that depression rather than anxiety is contributing to heart risk.

Although many questions remain, the research does suggest that, at a minimum, if you are being treated for heart disease it's worth discussing symptoms of anxiety with your doctor. Likewise, if you have problems with anxiety, talk to your doctor about your general health. And put your heart into the discussion.

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Michael Craig Miller, M.D Michael Craig Miller, M.D., is Senior Editor of Mental Health Publishing at Harvard Health Publications. He is an assistant professor of psychiatry at Harvard Medical School. Dr. Miller is in clinical practice at Beth Israel Deaconess Medical Center, where he has been on staff for more than 25 years.

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