Meta-Analysis of Anxiety as a Risk Factor for Cardiovascular Disease

doi:10.1016/j.amjcard.2016.05.041

The American Journal of Cardiology

Volume 118, Issue 4, 15 August 2016, Pages 511-519

https://doi.org/10.1016/j.amjcard.2016.05.041 Get rights and content

Whether anxiety is a risk factor for a range of cardiovascular diseases is unclear. We aimed to determine the association between anxiety and a range of cardiovascular diseases. MEDLINE and EMBASE were searched for cohort studies that included participants with and without anxiety, including subjects with anxiety, worry, posttraumatic stress disorder, phobic anxiety, and panic disorder. We examined the association of anxiety with cardiovascular mortality, major cardiovascular events (defined as the composite of cardiovascular death, stroke, coronary heart disease, and heart failure), stroke, coronary heart disease, heart failure, and atrial fibrillation. We identified 46 cohort studies containing 2,017,276 participants and 222,253 subjects with anxiety. Anxiety was associated with a significantly elevated risk of cardiovascular mortality (relative risk [RR] 1.41, CI 1.13 to 1.76), coronary heart disease (RR 1.41, CI 1.23 to 1.61), stroke (RR 1.71, CI 1.18 to 2.50), and heart failure (RR 1.35, CI 1.11 to 1.64). Anxiety was not significantly associated with major cardiovascular events or atrial fibrillation although CIs were wide. Phobic anxiety was associated with a higher risk of coronary heart disease than other anxiety disorders, and posttraumatic stress disorder was associated with a higher risk of stroke. Results were broadly consistent in sensitivity analyses. Anxiety disorders are associated with an elevated risk of a range of different cardiovascular events, including stroke, coronary heart disease, heart failure, and cardiovascular death. Whether these associations are causal is unclear.

Section snippets

Methods

Cohort studies or case-control studies nested within cohort studies were eligible for inclusion. Studies were required to contain adults with and without anxiety and were required to have a minimum of 3-month follow-up. Anxiety was defined as anxiety symptoms, generalized anxiety disorder, panic, phobia, posttraumatic stress disorder (PTSD), and worry, consistent with previous studies.² Only studies that were conducted in a general population were eligible for inclusion; studies conducted on

Results

A total of 1,804 studies were identified in the search, and 1,564 studies excluded in the abstract screen (Figure 1). After excluding an additional 194 studies in the full-text screen, 46 studies were included in the meta-analysis. These 46 studies included 2,017,126 participants, in total, and 222,253 participants with anxiety. Although we included chronic kidney disease as an outcome of interest in our protocol, no studies were identified that examined the association between anxiety and

Discussion

In this meta-analysis, anxiety was associated with a 41% higher risk of cardiovascular mortality, a 41% higher risk of coronary heart disease, a 71% higher risk of stroke, and a 35% higher risk of heart failure. Although anxiety was not significantly associated with atrial fibrillation and major cardiovascular events, CIs were wide and point estimates similar to other outcomes. Estimates were broadly similar in sensitivity analyses although phobic anxiety was associated with a higher risk of

Disclosures

The authors have no conflicts of interest to disclose.

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: Dr. Emdin had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr. Emdin conceived of the study, acquired, analyzed and interpreted the data, and drafted and critically revised the report. Drs. Odutayo, Tran, Hunn, Hsiao, Wong acquired, analyzed and interpreted the data, and critically revised the report.

: Drs. Emdin, Odutayo, Tran, and Hunn are supported by the Rhodes Trust, Oxford, United Kingdom. Dr. Wong is supported by the Rhodes Trust, Oxford, United Kingdom and by a Neil Hamilton Fairly Fellowship from the National Health and Medical Research Council, Canberra, Australia. Dr. Hsiao is supported by a National Science Foundation Graduate Research Fellowship.

: No funders or sponsors were involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

: See page 518 for disclosure information.

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Preventative CardiologyMeta-Analysis of Anxiety as a Risk Factor for Cardiovascular Disease

Section snippets

Methods

Results

Discussion

Disclosures

J Am Coll Cardiol

J Clin Epidemiol

Int J Cardiol

J Affect Disord

J Am Coll Cardiol

J Affect Disord

J Clin Epidemiol

Am Heart J

J Psychosom Res

Ann Epidemiol

J Anxiety Disord

Ann Epidemiol

J Am Coll Cardiol

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