Anxiety has been linked to onset of cardiovascular disease. This study examines the differential impact of types of anxiety (panic, phobia and worry) on 3-year onset of non-fatal cardiovascular disease (CVD). By investigating anxiety disorders as opposed to anxiety symptoms and by using a reliable diagnostic instrument to assess anxiety, limitations of previous studies are considered.
5149 persons at risk for CVD were interviewed using the Composite International Diagnostic Interview. The panic-type included panic disorder and panic attacks; the phobic-type included agoraphobia and social phobia, and the worry-type included generalized anxiety disorder. CVD was self-reported and required treatment or monitoring by a doctor. Analyses were adjusted for sociodemographics, behavioral variables, and comorbid somatic and psychiatric disorders. During follow-up, 62 persons (1.2%) developed CVD. Baseline generalized anxiety disorder was strongly associated with onset of CVD (adjusted OR: 3.39). Further research should replicate findings and focus on biological underpinnings of this association.
Anxiety has been found to increase the risk for the onset of cardiovascular disease (CVD) in a recent meta-analysis (Roest, Martens, de Jonge, & Denollet, 2010). This meta-analysis included 20 studies in which nonpsychiatric cohorts of initially healthy adults (total n = 249,846) were followed between 2 and 21 years. The presence of anxiety at baseline was associated with a 26% increase in risk of onset of coronary heart disease (95% CI: 1.15–1.38) and 48% increase in risk of cardiac death (95% CI: 1.14–1.92), controlling for demographic variables, biological risk factors and health behaviors ( Roest, Martens, de Jonge et al., 2010). These risk estimates implicate that reducing exposure to anxiety by increasing treatment for anxiety might contribute to the prevention of CVD. Any contribution to the prevention of CVD would be more than welcome given that cardiovascular disease is a leading cause of morbidity and mortality worldwide ( Mathers & Loncar, 2006) and has a huge economic impact ( Roger et al., 2012). Targeting anxiety to prevent the onset of CVD is moreover an appealing option because anxiety is common in the general population ( de Graaf et al., 2012 and Kessler et al., 2005), effective treatments for anxiety exist ( NIHCE, 2011) and given that only a minority of anxiety disorder patients receive treatment ( Wang et al., 2005), there is a large potential to increase treatment rates of anxiety.
A major limitation of previous studies assessing the impact of anxiety on onset of CVD concerns the assessment of anxiety. All except one study (i.e. Phillips et al., 2009) investigated anxiety on symptom-level; several studies assessed anxiety symptoms with a single question or by using a subscale with unknown psychometric properties; and most often assessment of anxiety was too global to differentiate between types of anxiety. Anxiety as a concept includes panic, phobias and worry. This distinction is reflected in the DSM-classification in which panic disorder represents panic, agoraphobia and social phobia represent the phobic-type, and generalized anxiety disorder represents the worry-type of anxiety (APA, 1994). The effects of panic, phobias and worry have not been investigated within a single study and many studies investigating one type of anxiety did not control for co-occurring other types of anxiety (see Roest, Martens, de Jonge et al., 2010), even though comorbidity among anxiety disorders is common (Hofmeijer-Sevink et al., 2012). Examining the unique contribution of types of anxiety on cardiovascular risk has been advocated (Laan et al., 2011 and Roest et al., 2010a) because it may well be that these types of anxiety have a differential impact on onset of CVD.
Using data of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), it was possible to take previous research one step further by taking the abovementioned limitations into account. We aim to examine the impact of the category of DSM-IV anxiety disorders, and of the panic-type, the phobic-type and the worry-type of anxiety on 3-year onset of non-fatal CVD. Specifying the types of anxiety impacting on cardiovascular function may clarify the association between anxiety and CVD, and may specify target groups for the prevention of CVD. This is utmost importance given the morbidity and mortality associated with CVD.
In the present study, a significant and strong association was found between GAD and onset of non-fatal CVD, taking multiple variables into account. Findings thus suggest that it is primarily the worry-type of anxiety that contributes to non-fatal CVD. Biologically, the link between GAD and onset of CVD seems plausible. Findings thus suggest that treating patients with GAD may contribute to the prevention of CVD and thereby impact on population health. Focusing on the underlying biological mechanisms by which GAD may cause CVD, and investigating the impact of regular treatments of GAD on these mechanisms seem fruitful areas for further research.
