As women move though the age trajectory from early middle-age to elderly, role responsibilities may decrease over time as family-based role obligations change. It might be that older women are more accustomed to changes in their health status because of the aging process in general, and experiencing heart disease may be considered just one more aspect of growing old. On the other hand, a cardiac event occurring in early middle-age may be less expected and more problematic for women in terms of family and career responsibilities and, thus, elicit more anxiety (Plach et al., 2001).
To date, the majority of participants in studies concerning heart disease and psychological outcomes have been men. Much of what is currently known about women and heart disease is based on research concerning gender comparisons, and in most of these studies, women were underrepresented and older, as compared with men (Beery, 1995; Lee et al., 2001). Research findings regarding gender differences in the anxiety experience for women and men are mixed.
Compared to men, women have higher levels of anxiety prior to a cardiac intervention (Czajkowski et al., 1997). One year after heart surgery, women reported more anxiety, depression and sleep disturbances than men (Holahan et al., 1995; Moore, 1994; Wiklund et al., 1993). Women have significantly higher trait and state anxiety throughout both the preoperative and postoperative cardiac surgery phases (Duits et al., 1998; McCrone et al., 2001). During the early hospitalization phase for acute myocardial infarction, women report higher anxiety levels than men (Kim et al., 2000). Even eight to nine years after a cardiac event, anxiety was significantly higher for younger women (less than 58 years) than for older women or men (Nickel et al., 1990). In contrast, Rankin (1990) reported that during the six weeks after cardiac surgery, women had significantly fewer mood disturbances (anxiety and depression) and higher levels of satisfaction with family life than did men.
In a study comparing the anxiety experience by age in both men and women recovering from cardiac surgery, McCrone et al. (2001) noted that younger age for both men and women was a stronger predictor than gender for increased anxiety. After examining short- and long-term outcomes of a home-based psychosocial intervention post-myocardial infarction, Cossette et al. (2001) reported that women were less likely than men to report reduced anxiety after the two-visit intervention. However, women who experienced successful short-term outcomes similar to men were just as likely as men to report less psychological distress and fewer cardiac events at one-year intervention.
Women's increased anxiety after a cardiac event may very well be related to changes and stressors in their social roles. They return to household tasks sooner than men, frequently as early as one-week post-discharge (Hamilton and Seidman, 1993), but return to paid work later than men, if at all (Covinsky et al., 2000). Because of home and family responsibilities, women are less likely than men to enroll in cardiac rehabilitation programs, and those women who do enroll have higher dropout rates (Oldridge et al., 1992; Schuster and Waldron, 1991). In focus group studies, older women reported that the burden of caring for others, such as spouses, adult children, grandchildren, other family members or friends, interfered with managing their own cardiac condition (Clark et al., 1994; Thomas, 1994). Women who had been hospitalized with ischemic heart disease reported that despite decreased physical capacity, they retained the social roles that were important to them by modifying the accompanying role responsibilities (MacKenzie, 1993). On the other hand, Plach and Heidrich (2001) found that after heart surgery and angioplasty, women reported high role quality despite functional health impairment.
Depression and Heart Disease
Anxiety has been shown to predict depression in both men and women with heart disease (Burker et al., 1995). Depression is associated with higher incidence of cardiac disease morbidity and mortality and is considered a predictor of poor long-term treatment outcomes (Carney et al., 1999). Depression is associated with increased sympathetic and decreased parasympathetic tone and subsequent increased catecholamine concentrations, tachycardia, and decreased heart-rate variability, all of which adversely affect cardiac reactivity and function (Musselman et al., 1998). In a series of clinical studies, using a large sample of men and women post-myocardial infarction, Frasure-Smith et al. (1999; 1995; 1993) explored the effect of in-hospital depression on future cardiac events. Results indicated that at six, 12 and 18 months, depression was a significant predictor of mortality. Female patients were more likely than males to exhibit depression. Kaufmann et al. (1999) followed 331 myocardial infarction survivors and reported depression to be a significant predictor of mortality at 12 months but not at six months. Barefoot et al. (1996) found that, even after 10 or more years following a cardiac event, depressed patients have a 72% greater risk of cardiac death as compared to non-depressed patients. They also found that depression may be persistent or frequently recurring in heart disease patients and is associated with progression of heart disease and triggering of acute events.
Depression has been found to be closely linked with atherosclerotic risk factors, thus effectively increasing women's risk of developing heart disease and undermining the prognosis for women with existing disease (Rutledge et al., 2001). In a large clinical study with an exclusively female cohort, these researchers found high depression scores were associated with a threefold risk of smoking, and women reporting higher depression symptoms were four times more likely to describe themselves in the lowest category of functional capacity.