Association of anxiety and recurrent cardiovascular events: investigating different aspects of anxiety

AIMS: While elevated levels of anxiety are associated with worse prognosis of cardiovascular disease (CVD), this association may vary between different aspects of anxiety. The aim of this study was to analyse self-reported behavioural, physiological, affective, and cognitive aspects of anxiety and their relation to the risk of recurrent CV events. METHODS AND RESULTS: This prospective cohort study utilized data from the U-CARE Heart trial. Participants (N = 935, post myocardial infarction) answered the Hospital Anxiety and Depression Scale (HADS: Anxiety subscale) and the Cardiac Anxiety Questionnaire (CAQ: Fear, Avoidance & Attention subscales). HADS Anxiety reflected physiological aspects, CAQ Fear reflected cognitive and affective aspects, CAQ Avoidance reflected behavioural aspects, and CAQ Attention reflected cognitive aspects of anxiety. Cox regression was used to estimate the risk between anxiety and recurrent major adverse cardiac event (MACE). During the follow-up period (mean 2.9 years), 124 individuals (13%) experienced a specified MACE endpoint. HADS Anxiety and CAQ Total were both associated with increased risk of MACE [hazard ratio (HR) = 1.52, 95% confidence interval (CI): 1.15-2.02 and HR = 1.30, 95% CI: 1.04-1.64, respectively]. Among the CAQ subscales, there was support for an association between Avoidance and risk of MACE (HR = 1.37, 95% CI 1.15-1.64), but not for Attention and Fear. CONCLUSION: The results support that anxiety is associated with an increased risk of recurrent MACE in post-myocardial infarction patients. The association between anxiety and risk was strong for the aspects of anxiety relating to behaviour and physiology, while the support for an association with cognitive and affective aspects was lacking.