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Alzheimer's, Dementia & Mental Health

Study is First Linking Stroke Directly to Anxiety; Earlier Study Finds It Deadly for Heart Patients

In older adults, anxiety disorders often occur at the same time as depression, heart disease, diabetes, and other medical problems

Dec. 27, 2013 – Congratulations, you have survived the period of peak anxiety during this holiday season. The greater your anxiety level, the higher your risk of having a stroke, according to new research published in the American Heart Association journal Stroke. And, heart disease patients who suffer anxiety have twice the risk of dying.

Heart patients with both anxiety and depression have triple the risk of dying, researchers said, in the Journal of the American Heart Association published earlier this year.

The stroke study is reported to be the first in which researchers linked anxiety and stroke independent of other factors such as depression. Anxiety disorders are one of the most prevalent mental health problems. Symptoms include feeling unusually worried, stressed, nervous or tense.

 

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Over a 22 year period, researchers studied a nationally representative group of 6,019 people 25-74 years old in the first National Health and Nutrition Examination Survey (NHANES I).

Participants underwent an interview and took blood tests, medical examinations and completed psychological questionnaires to gauge anxiety and depression levels.

 Researchers tracked strokes through hospital or nursing home reports and death certificates. After accounting for other factors, they found that even modest increases in anxiety were associated with greater stroke risk.

People in the highest third of anxiety symptoms had a 33 percent higher stroke risk than those with the lowest levels.

“Everyone has some anxiety now and then. But when it’s elevated and/or chronic, it may have an effect on your vasculature years down the road,” said Maya Lambiase, Ph.D., study author and   cardiovascular behavioral medicine researcher in the Department of Psychiatry at the University of Pittsburgh School of Medicine, in Pittsburgh, Penn.

Anxiety Disorders and Senior Citizens

Doctors and older adults tend to view anxiety and fear as normal given the circumstances of aging. But developing an anxiety disorder late in life is not a normal part of aging, according to NIH Senior Health.

Studies estimate that anxiety disorders affect between 3 and 14 percent of older adults in a given year. More women than men experience anxiety disorders. They tend to be less common among older adults than younger adults.

Anxiety caused by stressful events like moving or losing a job is a normal part of life. But anxiety disorders are different. An anxiety disorder lasts a long time and can get worse if it is not treated.

Anxiety disorders commonly occur at the same time as other illnesses. In older adults, anxiety disorders often occur at the same time as depression, heart disease, diabetes, and other medical problems.

In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.

The National Institute of Mental Health says you may feel anxious before you take a test or walk down a dark street. This kind of anxiety is useful - it can make you more alert or careful. It usually ends soon after you are out of the situation that caused it.

But for millions of people in the United States, the anxiety does not go away, and gets worse over time. They may have chest pains or nightmares. They may even be afraid to leave home. These people have anxiety disorders. Types include:

   • Panic disorder
   • Obsessive-compulsive disorder
   • Post-traumatic stress disorder
   • Phobias
   • Generalized anxiety disorder

People with high anxiety levels are more likely to smoke and be physically inactive, possibly explaining part of the anxiety-stroke link. Higher stress hormone levels, heart rate or blood pressure could also be factors, Lambiase said.

In earlier work, researchers found that depression was linked to greater risk of stroke. In contrast to anxiety, depression is a persistent feeling of hopelessness, dejection, and lack of energy, among other symptoms.

Stroke is the No. 4 killer and a leading cause of disability in the United States, according to this study funded by the National Heart, Lung, and Blood Institute and the National Institute of Mental Health.

Anxiety, depression identify heart disease patients at increased risk of dying

“Many studies have linked depression to an increased risk of death in heart disease patients,” said Lana Watkins, Ph.D., lead author of the study and an associate professor in Psychiatry and Behavioral Sciences at Duke University Medical Center in Durham, N.C.  “However, anxiety hasn’t received as much attention.”

Studies show that depression is about three times more common in heart attack patients.  The American Heart Association recommends that heart patients be screened for depression and treated if necessary.

Depressed heart disease patients often also have anxiety, suggesting it may underlie the risk previously attributed solely to depression, Watkins said. “It’s now time for anxiety to be considered as important as depression, and for it to be examined carefully.”

In the study, 934 heart disease patients, average age 62, completed a questionnaire measuring their level of anxiety and depression immediately before or after a cardiac catheterization procedure at Duke University Medical Center. Patients had anxiety if they scored 8 or higher on a scale composed of seven common characteristics of anxiety, with each item rated from 0 to 3 (range of possible scores: 0-21).  Depression was measured using a similar scale composed of seven symptoms of depression.

Researchers, after accounting for age, congestive heart failure, kidney disease and other factors that affect death risk, found:

   • 90 of the 934 patients experienced anxiety only, 65 experienced depression only and 99 suffered anxiety and depression.

   • Among 133 patients who died during three years of follow-up, 55 had anxiety, depression or both. The majority of deaths (93 of 133) were heart-related.

Researchers measured anxiety and depression during cardiac catheterization because levels better reflected how patients normally handle stressful situations.

Anxiety and depression each influence risk of death in unique ways. Anxiety, for example, increases activity of the sympathetic (adrenaline-producing) nervous system that controls blood pressure.

“People who worry a lot are more likely to have difficulty sleeping and to develop high blood pressure,” Watkins said.

The link between depression and mortality is more related to behavioral risk factors, she said. “Depression results in lack of adherence to medical advice and treatments, along with behaviors like smoking and being sedentary.”

Future studies should test strategies to manage anxiety alone and with depression in heart disease patients, Watkins said.

“Anxiety reducing medications combined with stress management could improve outcome for patients with just anxiety, whereas patients with anxiety and depression may need a stronger intervention involving more frequent outpatient monitoring and incentives to improve adherence,” she said.

Co-authors are: Gary G. Koch, Ph.D.; Andrew Sherwood, Ph.D.; James A. Blumenthal, Ph.D.; Jonathan R.T. Davidson, M.D.; Christopher O’Connor, M.D.; and Michael H. Sketch Jr., M.D. Author disclosures are on the manuscript.

The National Institutes of Health funded this study.

>>For more information about the role anxiety and depression play in heart disease, visit depression screening in heart patients.

>> For the latest heart and stroke news, follow us on Twitter: @HeartNews.

>>For stroke science, follow the Stroke journal at @StrokeAHA_ASA.

 

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