Sandra K. Plach, PhD, RN

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. 

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, 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. 

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. 

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. 

In conclusion, the literature indicates that anxiety and depression are predictive of heart disease and death, and, less conclusively because of a dearth of studies, their effect may be even worse for women. Anxiety increases risk for cardiac events and complicates physical and psychosocial health outcomes in patients with heart disease. Early recognition and treatment of anxiety in women with heart disease may help to optimize women's role experiences and minimize risk for future cardiac events.

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