Heart-Focused Anxiety and Chest Pain: A Conceptual and Clinical Review

This article reviews the concept of heart-focused anxiety that may occur in response to cardiac-related stimuli and sensations. Our aim was to examine the relation between chest pain, panic, and heart-focused anxiety in persons with and without heart disease. We identify a preoccupation with the heart and its functioning based on the belief that it will lead to negative consequences (e.g., death, pain) as an important psychological variable in the production of anxious and fearful responding. We then discuss heart-focused anxiety in relation to other clinically relevant variables in anxiety-related problems such as hypochondriacal concerns, including physical symptoms, disease fear, disease conviction, and safety-seeking behavior. Finally, we briefly discuss the clinical importance of heart-focused anxiety in the assessment and treatment of certain anxiety and cardiac-related problems.     

Cardiac anxiety in patients self-referred for electron beam tomography

Studies have repeatedly shown that as many as 43% of patients undergoing coronary angiograms have no evidence of coronary heart disease (CHD). Fear of cardiac-related sensations has been posited as one explanation for complaints of chest pain in patients without CHD. The purpose of this study is to examine variables associated with cardiac anxiety in a sample of individuals self-referred for noninvasive coronary calcium screening. Nearly one quarter of the subjects screened experienced chest pain in the absence of coronary artery calcium (CAC). Individuals without evidence of CAC were more likely to report higher levels of heart-focused attention, even when subjects with any risk factors for CHD were excluded from the analyses. Men were more likely to have evidence of coronary calcium, although a greater proportion of women reported chest pain. Women generally endorsed higher levels of cardioprotective behavior, heart-focused attention, and fear of heart-related sensations. Findings are discussed in relation to treatment of cardiac anxiety and the prevention of unnecessary medical procedures.     

对难以解释的胸痛病人的心理评估与心理干预

目的 :分别对心内科冠心病心绞痛患者和难以解释的胸痛患者进行心理评估、心理干预 ,观察不同组患者的患病行为、对支持性心理治疗的反应。方法 :在心内科连续收集因胸闷、胸痛疑为冠心病而住院行心导管检查的患者 ,心导管检查阳性者为冠心病心绞痛组 ,阴性者为难以解释组。在心内科诊断明确前进行精神检查并对有精神障碍者做出诊断 (ICD -10标准 )。使用《患病行为问卷》评定患者的患病行为。以汉密尔顿焦虑量表和抑郁量表在入院和心导管手术前分别评定患者情绪状态 ,用以评估支持性心理治疗的效果。住院期间对难以解释胸痛的患者进行针对疾病观念的短期认知干预 ,并在一年后随访 ,与上一年住院而未加干预的难以解释胸痛的患者进行了疾病观念和就医行为方面的比较。结果 :在心内科共收集 46例 ,难以解释组 2 8例 ,其中存在明显心理健康问题的有 60 % (17/2 8) ,而冠心病组 (18例 )中这一比例只有11% (2 /18)。在患病行为上 ,难以解释组不良情绪较心绞痛组明显 ,同时 ,他们也更多地意识到自己的问题与心理有关。在疾病观念上 ,难以解释组中的心理障碍患者比没有心理障碍者病感强 ,疑病倾向重。而 1年后随访发现 ,短期认知干预对改善疾病观念和就医行为效果不显著。结论 :心内科患者中有相当部分其主诉难     

Heart-focused anxiety and chest pain in postangiography medical patients

The present cross-sectional study sought to examine the extent to which heart-focused anxiety is associated with the co-occurrence of coronary artery disease (CAD) and a history of regular smoking in a sample of 148 postangiography patients from a cardiology unit. Individuals with CAD who regularly smoked demonstrated significantly greater heart-focused attention, but no greater degree of avoidance and fear of heart-focused sensations, than did nonsmoking persons with CAD and smokers without CAD. We also found evidence that heart-focused attention and fear incrementally predicted (above and beyond demographic variables and body mass index) intensity of average chest pain. Overall, this study provides some of the first empirical evidence that the co-occurrence of regular smoking and CAD is associated with specific dimensions of health anxiety. We discuss these findings in relation to models of panic pathology and anxious responding to bodily sensations.     

Anxiety and depressive symptoms and anxiety sensitivity in youngsters with noncardiac chest pain and benign heart murmurs

OBJECTIVE: Chest pain in children and adolescents is rarely associated with cardiac disease. We sought to examine psychological symptoms in youngsters with medically unexplained chest pain. We hypothesized that children and adolescents with medically unexplained chest pain would have high rates of anxiety and depressive symptoms. METHODS: We assessed 65 youngsters with noncardiac chest pain (NCCP) and 45 comparison youngsters with benign heart murmurs using self-report measures of anxiety and depressive symptoms and anxiety sensitivity. RESULTS: Compared with the asymptomatic benign-murmur group, youngsters with NCCP had higher levels of some anxiety symptoms and anxiety sensitivity. Differences on depressive symptoms were not significant. CONCLUSIONS: Though preliminary, results suggest that youngsters with chest pain may experience increased levels of some psychological symptoms. Future studies of noncardiac chest pain in youngsters should include larger samples and comprehensive diagnostic assessments as well as long-term follow-up evaluations.     

Chest pain admissions: characteristics of black, Latino, and white patients in low- and mid-socioeconomic strata.

To assess the potential impact of socioeconomic status (SES) factors on health-care seeking behavior for suspected acute coronary artery disease symptoms, equal numbers of black, Latino, and white patients seeking care for chest pain at two large hospital emergency rooms were studied. Differences between low and middle SES groups with respect to pre-attack health, health history, ethnicity, gender, and modes of transportation to the hospital were explored. Highly significant self-reported differences between low SES and middle SES patients were found as follows: low SES subjects were more likely to describe themselves as being in fair to poor general health (68% versus 18%), had more frequent chest pain, reported other types of heart disease, were more often current smokers, more likely to be black or Latino, and to be younger. Members of the low SES group also were less [corrected] likely to have known cholesterol levels, to have used estrogen, to have had a prior ECG or cardiac surgery, to be nonsmokers, to have had a stress test, and to have typical angina. Middle SES subjects more often described typical angina, prior use of estrogen (females), congenital, rheumatic, or family history of heart disease, prior knowledge of high cholesterol, were more likely to be of the male gender, and to be older than the low SES cohort. The data reveal that low SES subjects, with markedly less health-care resources compared with middle SES subjects, have a worse general health and cardiac risk profile despite the fact that they were significantly younger (mean age 53.4 versus 60.7, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of Factors Associated with Atypical Symptoms in Younger and Older Patients with Acute Coronary Syndromes

Patients with acute coronary syndromes (ACS) who are accompanied by atypical symptoms are frequently misdiagnosed and under-treated. This study was conducted to examine and compare the factors associated with atypical symptoms other than chest pain in younger (<70 yr) and older (≥70 yr) patients with first-time ACS. Data were obtained from the electronic medical records of the patients (n=931) who were newly diagnosed as ACS and hospitalized from 2005 to 2006. The 7.8% (n=49) of the younger patients and 13.4% (n=41) of the older patients were found to have atypical symptoms. Older patients were more likely to complain of indigestion or abdominal discomfort (P=0.019), nausea and/or vomiting (P=0.040), and dyspnea (P<0.001), and less likely to have chest pain (P=0.007) and pains in the arm and shoulder (P=0.018). A logistic regression analysis showed that after adjustment made for the gender and ACS type, diabetes and hyperlipidemia significantly predicted atypical symptoms in the younger patients. In the older patients, the co-morbid conditions such as stroke or chronic obstructive pulmonary disease were positive predictors. Health care providers need to have an increased awareness of possible presence of ACS in younger persons with diabetes and older persons with chronic concomitant diseases when evaluating patients with no chest pain.     

Mitral valve prolapse and psychiatric disorders

The authors report the prevalence of anxiety and depressive disorders in three groups of cardiac outpatients. The first group had mitral valve prolapse syndrome; the second group had been referred with chest complaints but were proven to have no cardiac disease; and the third group had been referred with innocent murmurs and were found to have no chest complaints and no cardiac disease. There was a somewhat higher prevalence of symptoms and diagnoses of depression in the chest complaint group. The findings did not support the often reported association between mitral valve prolapse syndrome and anxiety disorders.     

Prospective examination of anxiety persistence and its relationship to cardiac symptoms and recurrent cardiac events

BACKGROUND: The current study builds on previous research demonstrating a link between anxiety and inhospital recurrent ischemic and arrhythmic events, by examining the effects of persistent anxiety on recurrent events 1 year later. METHODS: 913 patients with unstable angina (UA) and myocardial infarction (MI) from 12 coronary care units were recruited, and follow-up data were collected at 6 and 12 months after the event. Measures included cardiac symptomatology, healthcare utilization, the anxiety subscale of the Primary Care Evaluation of Mental Disorders , the phobic anxiety subscale of the Middlesex Hospital Questionnaire, and the Beck Depression Inventory. RESULTS: Over one third of participants with UA and MI experienced elevated anxiety at the time of the ischemic event, and these symptoms persisted for 1 year in 50% of anxious participants. Although participants with anxiety reported more atypical cardiac symptomatology, the prevalence of typical cardiac symptoms such as chest pain did not differ based on anxiety. After controlling for the severity of the coronary event, family income, sex, diabetes, and smoking, the following variables were significantly predictive of self-reported recurrent cardiac events at 6 months or 1 year: older age, family history of cardiovascular disease, greater depressive symptomatology at baseline, and anxiety at 6 months. Only 38% of anxious patients were asked about such symptoms, indicating underutilization of effective psychotherapeutic treatment. CONCLUSIONS: Over and above the effects of depressive symptomatology (among other confounding variables), nonphobic anxiety appears to have a negative effect on self-reported outcome following an ischemic coronary event. Anxiety symptomatology is underrecognized and undertreated, and examination of effects of treatment on secondary prevention must be pursued.     

Pediatric pain: prevalence,assessment, and management in a teaching hospital

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients'' pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child''s pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.     

Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity

Ninety-nine patients with chest pain and a presumptive diagnosis of coronary heart disease were assessed blindly within 24 hours of angiography, using standardized psychiatric and social interviews and a personality inventory. Thirty-one patients had normal coronary arteries (NCA), 15 had slight disease and 53 had significant coronary obstruction. Twenty-eight (61%) of the 46 patients with insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity. Associations between the overall severity of psychiatric morbidity and measures of social maladjustment were strongest in the patients with normal coronary arteries. The 26 men with insignificant coronary artery disease had higher scores of neuroticism and extraversion than the 41 with important coronary occlusions. No differences were observed when the same comparisons were made for the women. The findings indicate that approximately two thirds of patients with normal and near-normal coronary arteries have predominantly psychiatric rather than cardiac disorders: the symptoms in these patients are more likely to represent the somatic manifestations of anxiety and overbreathing than the consequences of underlying cardiac disease. Physicians should be aware of the ways in which neurotic illness may present with symptoms mimicking cardiac disease, especially when cardiovascular symptoms are accompanied by phobic symptoms and unexplained shortness of breath.     

Anger rumination,social support,and cardiac symptoms in patients undergoing angiography

Objectives . Socially isolated individuals report more cardiac symptoms, suffer increased cardiovascular morbidity and mortality, and experience higher levels of stress and anxiety than those with more effective support resources. However, the complex interactions of psychosocial factors implicated in the disease process remain to be fully elucidated. We sought to explore these relationships, with the addition of a novel psychosocial variable, anger rumination, which could be associated with increased cardiovascular risk. Design . We examined the association of psychological stress, social support, and anger rumination, with surgical anxiety, self‐reported cardiac symptoms, and angiographically documented coronary artery disease, using a correlational ex post facto design. Methods . One hundred and one patients scheduled for elective coronary angiography completed questionnaires during the week prior to angiography. Disease severity was objectively assessed using the Gensini scoring system. Results . Self‐reported cardiac symptom severity was significantly correlated with higher perceived stress, less social support, and higher anger rumination, but none of the psychosocial variables predicted Gensini score. Social support partially mediated the relationship between anger rumination and surgical anxiety. Perceived stress mediated the relationship between anger rumination and cardiac symptoms. Conclusions . For patients awaiting angiography, stress, and lack of social support are important predictors of self‐reported cardiac symptoms, irrespective of actual disease severity. Intervention could focus on reducing perceived stress by encouraging reappraisal and a support seeking, rather than a ruminative, anger coping style.     

Cardiac Exposure History as a Determinant of Symptoms and Emergency Department Utilization in Noncardiac Chest Pain Patients

Although comparative studies differentiate noncardiac chest pain (NCCP), panic disorder, and coronary artery disease (CAD), little research has examined the defining features of NCCP, such as cardiac complaints, medical utilization, and learning history. We administered self-report measures to 80 Emergency Department (ED) patients with a primary complaint of chest pain who were subsequently found to not have CAD. Forty-eight percent of the ED utilization variance was accounted for by NCCP duration, age, cardiac distress symptoms, and prior exposure to both siblings' and friends' cardiac distress symptoms. In turn, 67% of the variance in cardiac distress symptoms was explained by education, age, NCCP duration, number of illnesses, noncardiac panic symptoms, prior exposure (friends), and prior observation of others' cardiac distress. No effects emerged for gender, ethnicity, avoidance, or depression. Results suggest that beyond the effects of age and distress intensity, prior exposure to other people's cardiac distress may influence NCCP.     

静息心电图、胸痛症状与冠脉CTA筛查冠心病的临床价值

目的 探讨静息心电图、胸痛症状与256层螺旋CT冠脉成像筛查冠心病的诊断价值。方法 收集入院后接受静息心电图、256层螺旋CTA检查共计68例非急症胸痛疑似冠心病患者的相关资料,所有患者30 d内均进行CAG检查。以CAG诊断为标准,采用ROC曲线分析静息心电图、胸痛症状与冠脉CTA筛查冠心病的诊断价值。结果 256层螺旋CTA诊断冠心病的ROC曲线下面积为0.73（P＜0.05）,其诊断敏感性为96.55%,特异性为50.00%,诊断价值大于静息心电图（AUC=0.50,P＞0.05）和胸痛症状（AUC=0.51,P＞0.05）。结论 256层螺旋CTA筛查冠心病有较高的诊断价值;静息心电图、胸痛症状对冠心病的筛查存在明显的局限性。     

Aberrant parasympathetic and hemodynamic function distinguishes a subgroup of psychologically distressed individuals with asymptomatic type-I diabetes mellitus

In a previous study, a subgroup of asymptomatic insulin-dependent diabetic individuals (termed IDDM-2) were identified on the basis of diminished parasympathetic cardiac input and elevated heart rate at rest. When compared to another group of asymptomatic IDDM participants (termed IDDM-1), and a nondiabetic healthy control group, the IDDM-2 group displayed elevated blood pressure, supported by elevated total peripheral resistance. Measures of psychological regulation were also taken in this study, and form the basis of this article, which examined whether these IDDM-2 patients differed from the other two groups on these measures. The possible role of glycemic control, IDDM duration, and number of somatic complaints among group differences in psychological regulation was also examined. The IDDM-2 group reported increased psychological distress, as reflected by increased dysphoric or depressive symptoms, trait anxiety, perceived stress, and cynical hostility, as well as decreased optimism and interpersonal, but not family, social support. Glycemic control did not account for any of the group differences in psychological regulation. However, group differences in dysphoria and anxiety were accounted for by differences in somatic complaints, whereas differences in interpersonal social support were accounted for by IDDM duration. Moreover, none of the variables investigated accounted for the diminished optimism of the IDDM-2 group. Therefore, in individuals with IDDM, who would otherwise be considered, after medical examination, as no different from other asymptomatic IDDM individuals, the combination of diminished parasympathetic cardiac input and elevated heart rate was associated with aberrant alterations of both hemodynamic and psychological functioning; the increased psychological distress in these individuals may be influenced, in part, by increased diabetes duration and number of somatic symptoms.     

Cognitive and somatic item response pattern of pain patients, psychiatric patients, and hospital employees

Standard psychological tests generally provide a single global score that reflects multidimensional constructs, such as depression and anxiety. This single score, however, integrates a range of item contents, including cognitive/affective, somatic, and behavioral characteristics of these multidimensional constructs. The present study was designed to compare the pattern of item endorsement among chronic pain patients (N = 50), psychiatric inpatients (N = 50), and hospital employees (N = 50) on the SCL-90-R (Derogatis, Rickels, & Rock, 1976). Pain patients reported the highest SCL-90 scale level of Somatization, while the psychiatric inpatients reported the highest level of Anxiety and Depression. Additionally, the within-scale pattern of item responses on the Anxiety and Depression scales differed among groups. Although psychiatric inpatients endorsed equivalent levels of somatic and cognitive items, the pain patients' reports of psychological distress were limited primarily to somatic signs of anxiety and depression. Thus, the interpretation of pain patients' psychological profiles and subsequent treatment recommendations may be inappropriate if based on normative data obtained from psychiatric and/or normal populations.     

Oesophageal symptoms and manometry in valvular heart disease

A possible relationship between heart disease, oesophageal dysfunction (OD) and symptomatology was studied in 47 patients with valvular heart disease. They were investigated with oesophageal manometry and oesophageal acid perfusion test. OD was found in 32 percent of the patients. A local pressure increase in the middle part of the oesophagus, probably an effect of cardiac enlargement and compression of the oesophagus, was found at manometry in 38 percent. The incidence of OD and of oesophageal symptoms was the same in patients with and without oesophageal compression. We did not find any indications that valvular disease in itself provokes OD, nor that symptoms of chest pain and cough in patients with valvular heart disease are due to OD.     

Predicting panic disorder among patients with chest pain: an analysis of the literature

As many as 25% of patients with chest pain who come to hospital emergency departments have panic disorder. Rates of panic disorder are even higher among those who present for outpatient evaluation of their chest pain. Unfortunately, panic disorder remains largely undiagnosed and untreated in these settings. The authors reviewed studies published between 1970 and 2001 that addressed the prevalence of panic disorder among persons who seek treatment for chest pain in an emergency department or outpatient cardiology clinic. A meta-analysis of the findings revealed five variables that appear to correlate with higher rates of panic disorder among persons who present with chest pain: 1). absence of coronary artery disease, 2). atypical quality of chest pain, 3). female sex, 4). younger age, and 5). a high level of self-reported anxiety. Further studies of these and other variables associated with panic disorder should aid in the detection of this disabling but treatable cause of chest pain.     

Parental Overprotection and Heart-Focused Anxiety in Adults with Congenital Heart Disease

Background  

The care of adult patients with congenital heart disease (CHD) is challenging from a mental health perspective, as these patients continue to face a variety of biopsychosocial issues that may impact emotional functioning. Despite these issues, there are limited data on the psychosocial functioning of adults with CHD, and there are no data on the impact of parental overprotection on heart-focused anxiety in this patient population.