Among patients with heart disease, anxiety disorders appear to be associated with a higher risk of stroke, heart attack, heart failure and death, according to a report in the July issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

As many as 24 percent to 31 percent of patients with heart disease also have symptoms of anxiety, according to background information in the article. "Compared with the extensive literature on depression in patients with coronary heart disease, relatively few studies have examined the role of anxiety," the authors write. "Several studies have found that anxiety symptoms are predictive of disability, increased physical symptoms and worse functional status and quality of life in patients with coronary heart disease. However, studies examining anxiety as a risk factor for future coronary heart disease have yielded conflicting results."

Elisabeth J. Martens, Ph.D., of Tilburg University, Tilburg, the Netherlands, and colleagues assessed 1,015 outpatients with stable coronary heart disease. The baseline examination consisted of interviews, blood and urine sample testing, exercise testing and electrocardiography. The presence of generalized anxiety disorder and of depressive disorder was determined using the computerized version of the Diagnostic Interview Schedule.

After an average follow-up time of 5.6 years, a total of 371 cardiovascular events occurred. After adjusting for age, the yearly rate of cardiovascular events was 9.6 percent in the 106 participants with general anxiety disorder and 6.6 percent in the 909 participants without. After further adjustments for potentially confounding variables-including sex, co-occurring conditions, heart disease severity and medication use-generalized anxiety disorder was associated with a 74 percent increased risk of cardiovascular events.

"This leaves the question of why generalized anxiety disorder is associated with adverse outcomes in patients with coronary heart disease," the authors write. Anxiety may be associated with surges in catecholamines, "fight or flight" hormones that may be related to heart risks, they suggest. Alternatively, patients with anxiety may be more likely to seek care when they have symptoms and therefore be more likely to receive a diagnosis of stroke or heart attack, although this would not explain the increased risk of death. It is also possible that a common underlying factor predisposes individuals to both anxiety and heart events.

"These findings have implications for clinical practice and research," they conclude. "Generalized anxiety disorder may be considered a prognostic factor in patients with coronary heart disease and could be used in risk stratification. Evaluation and treatment of anxiety may also be considered as part of the comprehensive management of patients with coronary heart disease. Research programs designed to advance our understanding of the impact of generalized anxiety disorders on medical prognosis and biobehavioral mechanisms that link anxiety to mortality in the context of coronary heart disease are needed to develop evidence-based approaches to improving patient care."