The additive effect of psychological distress on people who experience a major cardiac health disruption is becoming an area of increasing concern. While researchers have focused substantial attention on psychological outcomes in men after a cardiac event, less is known about the anxiety experience for women with heart disease. Although it is well-documented that women are more vulnerable to anxiety and depression than men (National Institute of Mental Health [NIMH], 2001; Young et al., 2001), relatively few researchers have focused on psychological outcomes for women with heart disease. This paper is a review of research findings related to this issue, with a primary focus on anxiety.
Anxiety as a Predictor
Substantial epidemiological evidence implicates anxiety in the development of heart disease, as well as the occurrence of sudden cardiac death for both men and women. Findings from a meta-analysis of articles concerning anxiety and the pathogenesis leading to heart disease published between 1980 and 1998 concluded that evidence related to the relationship of stress-induced atherosclerosis and endothelial dysfunction strongly supports the role of anxiety in the onset of coronary heart disease (Kubzansky and Kawachi, 2000). Researchers exploring the link between anxiety and sudden cardiac death suggested that individuals with anxiety disorders have reduced heart-rate variability and thus may have a pathological alteration in cardiac immune tone (Kawachi et al., 1995). This alteration could lead to sympathetic stimulation, hypertension, and consequent ventricular arrhythmias and sudden death, or impaired vagal control, which has also been linked to cardiac mortality (Rich et al., 1988; Sloan et al., 1999). Findings from retrospective epidemiological studies suggested that about one-fourth of individuals who died suddenly had experienced substantial emotional distress in the period immediately preceding their deaths (Lown, 1990). Epidemiological evidence about the influence of acute stress on a large number of sudden deaths suggested that acute emotional stress may precipitate cardiac events in people who are already predisposed to them (Leor et al., 1996).
Anxiety With Heart Disease
Anxiety, which has a higher incidence in women in general, is problematic when superimposed on heart disease for a number of reasons. Higher levels of anxiety adversely affect physical functioning, interfere with role performance and role fulfillment, and increase risk for heart disease sequelae and progression. Furthermore, anxiety is a significant predictor of depression in both men and women with heart disease (Burker et al., 1995).
A major cardiac event evokes feelings of anxiety, with initial concerns about diagnosis and treatment and later concerns about the impact of impaired health on roles and relationships (Friedman, 1993). Women and men with heart disease who perceive themselves as disabled and unable to perform their usual activities are three times more likely to report anxiety (Nickel et al., 1990). In a one-year prospective study of individuals with heart disease, Sullivan and colleagues (1997) explored associations of anxiety with self-reported physical function and activity interference. Findings indicated that those who report higher levels of anxiety also report higher levels of physical disability. High levels of anxiety affect functional status after heart surgery as well. In a randomized clinical trial with 156 participants, greater perceived tension/anxiety level at four weeks predicted decreased self-reported activity for both men and women (Ruiz et al., 1992). Relationships between anxiety and quality of life have also been empirically examined. Anxiety related to decreased functional ability after myocardial infarction has been found to substantially reduce quality of life among survivors and their families (Lane et al., 2001; Mayou et al., 2000).
Relatively few studies have explored women's psychological or social responses to a cardiac health disruption. One study used a developmental approach to examine relationships among role experiences and anxiety in a cross-sectional study of 155 women seven months after heart surgery (Plach et al., 2001). Early middle-age women (40 years to 55 years) had more anxiety than midlife women (56 years to 65 years) and elderly women (66 years and older). Early middle-age women reported a lower balance between role rewards and concerns and more incongruence between ideal and actual function than their older counterparts. Varvaro (1993) reported that midlife women (38 years to 64 years) experienced greater anxiety related to problems with role performance and family responsibilities than women ages 65 and older.
