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Preoperative Anxiety as a Predictor of Mortality and Major Morbidity in Patients Aged >70 Years Undergoing Cardiac Surgery

      The present study examined the association between patient-reported anxiety and postcardiac surgery mortality and major morbidity. Frailty Assessment Before Cardiac Surgery was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals from 2008 to 2009. The patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale, a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was a high level of anxiety, defined by a Hospital Anxiety and Depression Scale score of ≥11. The main outcome measure was all-cause mortality or major morbidity (e.g., stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression analysis examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for the Society of Thoracic Surgeons predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the Hospital Anxiety and Depression Scale. High levels of preoperative anxiety were present in 7% of patients. No differences were found in the type of surgery and Society of Thoracic Surgeons predicted risk across the preoperative levels of anxiety. After adjusting for potential confounders, high preoperative anxiety was remained independently predictive of postoperative mortality or major morbidity (odds ratio 5.1, 95% confidence interval 1.3 to 20.2; p = 0.02). In conclusion, although high levels of anxiety were present in few patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.
      The importance of altered mood states in cardiovascular disease has been highlighted by several reports.
      • Frasure-Smith N.
      • Lesperance F.
      • Talajic M.
      Depression following myocardial infarction. Impact on 6-month survival.
      • Gullette E.C.
      • Blumenthal J.A.
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      • Jiang W.
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      • Frid D.J.
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      • Morris J.J.
      • Krantz D.S.
      Effects of mental stress on myocardial ischemia during daily life.
      • Arnold S.V.
      • Spertus J.A.
      • Ciechanowski P.S.
      • Soine L.A.
      • Jordan-Keith K.
      • Caldwell J.H.
      • Sullivan M.D.
      Psychosocial modulators of angina response to myocardial ischemia.
      • Martens E.J.
      • de Jonge P.
      • Na B.
      • Cohen B.E.
      • Lett H.
      • Whooley M.A.
      Scared to death? Generalized anxiety disorder and cardiovascular events in patients with stable coronary heart disease: the Heart and Soul Study.
      • Roest A.M.
      • Martens E.J.
      • Denollet J.
      • de Jonge P.
      Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis.
      • Dao T.K.
      • Chu D.
      • Springer J.
      • Gopaldas R.R.
      • Menefee D.S.
      • Anderson T.
      • Hiatt E.
      • Nguyen Q.
      Clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder as risk factors for in-hospital mortality after coronary artery bypass grafting surgery.
      With regard to surgical outcomes, depressive symptoms were evaluated in a cohort of patients undergoing coronary artery bypass graft surgery from 1989 to 1991, with Blumenthal et al
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      • Lett H.S.
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      • White W.
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      • Jones R.
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      • Newman M.F.
      • NORG Investigators
      Depression as a risk factor for mortality after coronary artery bypass surgery.
      discovering a significantly greater mortality among patients with preoperative depression. Despite the interrelation between the affective states of anxiety and depression,
      • Bankier B.
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      • Littman A.B.
      The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease.
      preoperative anxiety was not assessed. Prospective and simultaneous assessment of both anxiety and depression using a measure such as the Hospital Anxiety and Depression Scale (HADS) is necessary to understand and distinguish the role of these 2 affective states in postoperative outcomes.
      • Arnold S.V.
      • Spertus J.A.
      • Ciechanowski P.S.
      • Soine L.A.
      • Jordan-Keith K.
      • Caldwell J.H.
      • Sullivan M.D.
      Psychosocial modulators of angina response to myocardial ischemia.
      • Roest A.M.
      • Martens E.J.
      • Denollet J.
      • de Jonge P.
      Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis.
      As such, we administered the HADS to measure anxiety and depression prospectively in hospitalized elderly patients awaiting coronary artery bypass grafting and/or valve repair or replacement.

      Methods

      Consecutive patients were screened for study inclusion from 2008 to 2009 at 4 university-affiliated tertiary care centers in the United States and Canada as a part of the Frailty Assessment Before Cardiac Surgery (Frailty ABC'S) study.
      • Afilalo J.
      • Eisenberg M.J.
      • Morin J.F.
      • Bergman H.
      • Monette J.
      • Noiseux N.
      • Perrault L.P.
      • Alexander K.P.
      • Langlois Y.
      • Dendukuri N.
      • et al.
      Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery.
      Eligible patients were asked by the study personnel to complete a structured questionnaire that included the HADS and a brief battery of physical performance tests. Mini-mental state examinations were also administered, and patients were asked to grade their overall health status. Frailty criteria were determined according to the Cardiovascular Health Study (CHS) scale.
      • Fried L.P.
      • Tangen C.M.
      • Walston J.
      • Newman A.B.
      • Hirsch C.
      • Gottdiener J.
      • Seeman T.
      • Tracy R.
      • Kop W.J.
      • Burke G.
      • McBurnie M.A.
      Cardiovascular Health Study Collaborative Research Group
      Frailty in older adults: evidence for a phenotype.
      The inclusion criteria were age ≥70 years and scheduled to undergo coronary artery bypass grafting and/or valve replacement or repair through a traditional midline sternotomy. The exclusion criteria included any of the following: emergent surgery, defined as surgery for ongoing refractory cardiac compromise for which there should be no delay; clinical instability, defined as active coronary ischemia, decompensated heart failure, or any acute process causing significant symptoms or abnormal vital signs; a severe neuropsychiatric condition causing inability to cooperate with the study procedures; or cancellation of the patient's planned surgery. The treating physicians were unaware of the results of the HADS to not influence perioperative care.
      The present report was prepared in keeping with the standards set forth by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement.
      • von Elm E.
      • Altman D.G.
      • Egger M.
      • Pocock S.J.
      • Gotzsche P.C.
      • Vandenbroucke J.P.
      The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
      The institutional review board at each enrolling center approved the study before proceeding with patient enrollment or any data acquisition. All patients provided written informed consent to participate in the present study.
      The HADS is a brief, user-friendly, self-report questionnaire developed by Zigmond and Snaith
      • Zigmond A.S.
      • Snaith R.P.
      The Hospital Anxiety and Depression Scale.
      in 1983 to assess the levels of anxiety and depression among patients in nonpsychiatric hospitals. This self-report scale can be administered to patients in approximately ≤5 minutes and can be scored in approximately 1 minute. The HADS has been repeatedly validated and shown to perform well as a screening tool in assessing the presence and symptom severity of both anxiety disorders and depression.
      • Bjelland I.
      • Dahl A.A.
      • Haug T.T.
      • Neckelmann D.
      The validity of the Hospital Anxiety and Depression Scale: an updated literature review.
      • Osborne R.H.
      • Elsworth G.R.
      • Sprangers M.A.
      • Oort F.J.
      • Hopper J.L.
      The value of the Hospital Anxiety and Depression Scale (HADS) for comparing women with early onset breast cancer with population-based reference women.
      The HADS has been translated into many languages, with validation studies confirming the international applicability of the questionnaire.
      • Herrmann C.
      International experiences with the Hospital Anxiety and Depression Scale—a review of validation data and clinical results.
      In the present study, the HADS questionnaires were administered in English or French.
      The HADS questionnaire consists of 14 items, 7 for each of 2 subscales: anxiety (HADS-A) and depression (HADS-D). Each item is rated from 0 to 3 on a 4-point Likert scale, resulting in a potential range of scores from 0 to 21 for each subscale. A score of ≥11 on either subscale is considered to indicate cases of “significant psychological morbidity.” Scores of 8 to 10 represent “possible anxiety” and 0 to 7 represent “no anxiety.” Designed for use in the inpatient setting, the individual HADS items are formulated as symptoms referring to the previous 7 days and do not include physical indexes of psychological distress, which might be expected to result in false-positive results among hospitalized patients. The key phrases from the questions including the HADS-A subscale are listed in Table 1.
      Table 1Anxiety Questions from the Hospital Anxiety and Depression Scale
      The complete HADS is available in the original 1983 report by Zigmond and Snaith.12
      QuestionHow often in the past week did you… ?
      A1“feel tense or ‘wound up’”
      A2“get a sort of frightened feeling as if something awful is about to happen”
      A3“have worrying thoughts go through your mind”
      A4“sit at ease and feel relaxed”
      A5“get a sort of frightened feeling like ‘butterflies’ in the stomach”
      A6“feel restless as if I have to be on the move”
      A7“get sudden feelings of panic”
      The complete HADS is available in the original 1983 report by Zigmond and Snaith.
      • Zigmond A.S.
      • Snaith R.P.
      The Hospital Anxiety and Depression Scale.
      The primary outcome measure was the incidence of mortality or major morbidity occurring after cardiac surgery during the index hospitalization. The Society of Thoracic Surgeons (STS) database definitions were used for all outcomes. The outcomes were death (defined as mortality from any cause), stroke (central neurologic deficit persisting >72 hours), renal failure (a new dialysis requirement or increase in serum creatinine >2 mg/dl and more than twofold greater than the preoperative level), prolonged ventilation (need for mechanical ventilation >24 hours), deep sternal wound infection, and reoperation for any reason. The secondary outcome measures were discharge to a healthcare facility for ongoing medical care or rehabilitation, and prolonged postoperative length of stay, defined by the STS standard of >14 days after surgery. The physicians ascertaining outcomes from the medical records were unaware of the results of the HADS questionnaire.
      The demographic and operative characteristics were compared across the categories of HADS-A scores: 0 to 7 (no anxiety), 8 to 10 (possible anxiety), and ≥11 (anxiety). The categorical variables are presented as the percentages, and continuous variables are presented as the median and 25th and 75th percentiles. The comparisons of baseline variables were conducted using the nonparametric Wilcoxon rank sum test.
      Multivariable analyses were performed with logistic regression modeling and reported as odds ratios (ORs), with 95% confidence intervals (CIs). Because the number of risk factors in patients undergoing cardiac surgery is large,
      • Jones R.H.
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      • Tu J.V.
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      • Naylor C.D.
      Assessing the outcomes of coronary artery bypass graft surgery: how many risk factors are enough? Steering Committee of the Cardiac Care Network of Ontario.
      entering all possible covariates in the model would have resulted in model instability and overfitting. Therefore, we used the STS predicted risk of mortality or major morbidity (STS-PROMM) as a risk score to adjust for the surgical risk associated with traditional medical factors.
      • Shahian D.M.
      • O'Brien S.M.
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      • Rich J.B.
      • Normand S.L.
      • DeLong E.R.
      • Shewan C.M.
      • Dokholyan R.S.
      • Society of Thoracic Surgeons Quality Measurement Task Force
      • et al.
      The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3—valve plus coronary artery bypass grafting surgery.
      • O'Brien S.M.
      • Shahian D.M.
      • Filardo G.
      • Ferraris V.A.
      • Haan C.K.
      • Rich J.B.
      • Normand S.L.
      • DeLong E.R.
      • Shewan C.M.
      • Dokholyan R.S.
      • Society of Thoracic Surgeons Quality Measurement Task Force
      • et al.
      The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2—isolated valve surgery.
      • Shahian D.M.
      • O'Brien S.M.
      • Filardo G.
      • Ferraris V.A.
      • Haan C.K.
      • Rich J.B.
      • Normand S.L.
      • DeLong E.R.
      • Shewan C.M.
      • Dokholyan R.S.
      • Society of Thoracic Surgeons Quality Measurement Task Force
      • et al.
      The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1—coronary artery bypass grafting surgery.
      The STS-PROMM was selected among all available adult cardiac surgery risk scores, because this score was specifically designed to predict in-hospital mortality or major morbidity, the precise primary end point of the present study.
      A sensitivity analysis using a nonparsimonious model adjusted for additional covariates was performed to ensure that significant confounding had not been overlooked. The performance of the model was assessed before and after addition of the HADS-A score to determine its incremental value. Model discrimination, reflecting the ability to assign a greater predicted risk to those who will have the observed outcome, was measured with the area under the receiver operating characteristic curve c-statistic.
      • Hosmer D.
      • Lemeshow S.
      Applied Logistic Regression.
      Sensitivity analyses, with the HADS-A score represented as a continuous variable, were also performed. All analyses were performed with STATA, version 11 (StataCorp, College Station, Texas).

      Results

      The cohort for these analyses consisted of 148 patients who completed the HADS questionnaire and underwent cardiac surgery within the Frailty ABC'S study. The median interval from questionnaire completion to surgery was 2 days (interquartile range 1 to 3). No patients were lost to follow-up. Figure 1 displays the flow of patients through the present study. The baseline variables stratified by HADS-A score are listed in Table 2: 71% scored 0 to 7 (“no anxiety”); 22% scored 8 to 10 (“possible anxiety”); and 7% scored 11 to 21 (“anxiety” group). Age and gender were included individually, along with the STS risk score in the multivariable model. Patients with anxiety were less likely to have a university level education. The 3 HADS groups were not markedly different in procedure type. The median STS-PROMM was 17%, 16%, and 15% for the no anxiety, possible anxiety, and anxiety groups, respectively (Table 2).
      Table 2Baseline variables stratified by Hospital Anxiety and Depression Scale–Anxiety (HADS-A) score
      VariableNo Anxiety (HADS-A 0–7; n = 105)Possible Anxiety (HADS-A 8–10; n = 32)Anxiety HADS-A (11–21; n = 11)
      Age (yrs)75 (72, 79)76 (73, 80)76 (71, 79)
      Women29 (28%)17 (53%)4 (36%)
      Living alone30 (29%)9 (28%)4 (36%)
      University-level education34 (32%)8 (25%)1 (9%)
      General perception of health
       Very good29 (28%)4 (13%)0 (0%)
       Good47 (45%)12 (38%)5 (45%)
       Fair27 (26%)10 (31%)4 (36%)
       Poor2 (2%)6 (19%)1 (18%)
      Body mass index (kg/m2)26 (24, 29)27 (23, 30)27 (26, 30)
      Diabetes mellitus39 (37%)13 (41%)4 (36%)
      Hypertension75 (71%)26 (81%)8 (73%)
      Dyslipidemia67 (64%)22 (69%)9 (82%)
      Current or past smoker59 (56%)20 (62%)5 (45%)
      Chronic heart failure30 (29%)9 (28%)2 (18%)
      Left ventricular ejection fraction (%)55 (45, 60)60 (54, 65)55 (35, 65)
      Atrial fibrillation17 (16%)4 (13%)3 (27%)
      Chronic renal failure19 (18%)6 (19%)2 (18%)
      Stroke12 (11%)3 (9%)1 (9%)
      History of anxiety6 (6%)2 (6%)0 (0%)
      History of depression5 (5%)2 (6%)1 (9%)
      Hospital Anxiety and Depression Scale depression score (/11)2 (1, 4)4 (2, 7)8 (6, 10)
      Mini-mental state examination score (/30)27 (23, 29)28 (26, 29)27 (25, 29)
      Frailty (Cardiovascular Health Study scale)16 (15)9 (28)5 (45)
      Surgery type
       Isolated coronary artery bypass grafting64 (61%)18 (56%)8 (73%)
       Valve procedure with or without coronary artery bypass grafting41 (39%)14 (44%)3 (27%)
      Urgent surgery56 (53%)20 (63%)5 (45%)
      Society of Thoracic Surgeons predicted risk of mortality or major morbidity (%)17 (11, 26)16 (13, 21)15 (10, 23)
      Society of Thoracic Surgeons predicted risk of mortality (%)3 (1, 4)2 (2, 3)2 (1, 4)
      Logistic EuroSCORE7 (4, 12)8 (5, 14)6 (4, 9)
      Data are presented as n (%) or value (quartile 1, quartile 3).
      The median mini-mental state examination score was 27 of 30 (normal range), without differences across the 3 HADS-A groups. An existing diagnosis of depression was more often present in patients with anxiety, and the median HADS-D score was 2, 4, and 8 for the no anxiety, possible anxiety, and anxiety groups, respectively (Table 2).
      The clinical outcomes according to the HADS-A score are listed in Table 3. The composite end point of mortality or major morbidity occurred in 22% of the no anxiety group, 25% of the possible anxiety group, and 55% of the anxiety group. In-hospital mortality across the 3 HADS-A score groups (no anxiety, possible anxiety, and anxiety group) was 4%, 6%, and 9%, respectively. Discharge to a healthcare facility (nursing home or convalescence or rehabilitation facility) was also increased with increasing anxiety.
      Table 3In-hospital outcomes by anxiety groups
      OutcomesNo Anxiety (HADS-A 0–7; n = 105)Possible Anxiety (HADS-A 8–10; n = 32)Anxiety (HADS-A 11–21; n = 11)
      Mortality or major morbidity23 (22%)8 (25%)6 (55%)
      Mortality4 (4%)2 (6%)1 (9%)
      Prolonged length of stay >14 days25 (24%)12 (38%)3 (28%)
      Discharge to healthcare facility28 (28%)14 (47%)5 (50%)
      The relation between the measured HADS-A score and adverse events demonstrated a threshold effect rather than a graded linear response. A receiver operating characteristic analysis was performed to identify the optimal threshold cutoff and showed that a HADS-A score of ≥11 was most predictive of mortality or major morbidity in our cohort of elderly patients undergoing cardiac surgery (76% of patients were correctly classified). This cutoff is in keeping with the established norms recommended for categorizing the HADS-A score (0 to 7 for no anxiety, 8 to 10 for possible anxiety, and ≥11 for anxiety). On univariate logistic regression analysis with the HADS-A score considered as a dichotomous variable (score ≥11 signifying anxiety vs score <11 signifying possible or no anxiety), the unadjusted OR for mortality or major morbidity was 4.1 (95% CI 1.2 to 14.4; p = 0.027).
      When adjusting for STS-PROMM, age, gender, and HADS-D score, the adjusted OR for mortality or major morbidity was 5.1 (95% CI 1.3 to 20.2; p = 0.02; Table 4). Figure 2 demonstrates that for a given STS-PROMM (STS risk score), the predicted risk according to our regression model was greater for patients with anxiety (HADS-A score ≥11) compared to patients with no anxiety or possible anxiety (HADS-A score <11).
      Table 4Multivariable model to predict mortality or major morbidity
      OR (95% CI)p Value
      Society of Thoracic Surgeons predicted risk of mortality or major morbidity1.06 (1.01–1.10)0.01
      Age1.02 (0.93–1.12)0.62
      Female gender3.49 (1.52–7.99)0.003
      Depression (Hospital Anxiety and Depression Scale–Depression score ≥11)1.28 (0.25–6.59)0.77
      Anxiety (Hospital Anxiety and Depression Scale–Anxiety score ≥11)5.1 (1.27–20.2)0.02
      CI = confidence interval; OR = odds ratio.
      Figure thumbnail gr2
      Figure 2Projected risk of mortality or major morbidity according to anxiety or no anxiety by HADS-A score for any STS predicted risk.
      Sensitivity analyses with the HADS-A score represented as a continuous variable confirmed results similar to those presented in Table 4. Additional sensitivity analysis was performed using a nonparsimonious model adjusted for frailty and education level. This did not suggest any evidence of residual confounding, with the OR for anxiety unchanged after the additional variables were added to the model.

      Discussion

      In the present prospective multicenter study, significant levels of patient-reported preoperative anxiety independently predicted a greater risk of in-hospital mortality or major morbidity in elderly patients undergoing cardiac surgery. This increased hazard persisted even after adjustment for surgical risk (STS risk score) related to traditional risk factors and depressive symptoms. The majority of patients with high levels of anxiety were unlikely to have a clinical diagnosis of general anxiety disorder. Importantly, because high levels of anxiety are potentially modifiable, identifying these patients could provide an opportunity to increase psychological comfort and improve the clinical outcomes in this high-risk group.
      The relationship between pre-existing anxiety and outcomes after cardiac surgery has not been clearly defined. This is likely owing, in part, to the small size of previous studies, variations in anxiety definitions (i.e., anxiety disorder, symptoms, or trait anxiety), and failure to consider depression and anxiety simultaneously.
      • Hoen P.W.
      • Whooley M.A.
      • Martens E.J.
      • Na B.
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      Differential associations between specific depressive symptoms and cardiovascular prognosis in patients with stable coronary heart disease.
      • Rothenbacher D.
      • Hahmann H.
      • Wusten B.
      • Koenig W.
      • Brenner H.
      Symptoms of anxiety and depression in patients with stable coronary heart disease: prognostic value and consideration of pathogenetic links.
      We found anxiety in the days preceding surgery among hospitalized elderly patients to be associated with a greater risk of mortality or major morbidity after adjusting for, not only the STS risk score, but also symptoms of preoperative depression as measured by the HADS-D questionnaire. This is particularly relevant, given that most previous studies did not explicitly test for coexisting anxiety.
      • Blumenthal J.A.
      • Lett H.S.
      • Babyak M.A.
      • White W.
      • Smith P.K.
      • Mark D.B.
      • Jones R.
      • Mathew J.P.
      • Newman M.F.
      • NORG Investigators
      Depression as a risk factor for mortality after coronary artery bypass surgery.
      Depression, and to a lesser extent, anxiety are known risk factors for progressive cardiovascular disease among medically managed outpatients.
      • Gullette E.C.
      • Blumenthal J.A.
      • Babyak M.
      • Jiang W.
      • Waugh R.A.
      • Frid D.J.
      • O'Connor C.M.
      • Morris J.J.
      • Krantz D.S.
      Effects of mental stress on myocardial ischemia during daily life.
      • Greillier L.
      • Thomas P.
      • Loundou A.
      • Doddoli C.
      • Badier M.
      • Auquier P.
      • Barlési F.
      The prediction of cardiac surgery outcome based upon preoperative psychological factors.
      In a study of 1,054 patients with stable coronary artery disease completing the HADS questionnaire, Rothenbacher et al
      • Rothenbacher D.
      • Hahmann H.
      • Wusten B.
      • Koenig W.
      • Brenner H.
      Symptoms of anxiety and depression in patients with stable coronary heart disease: prognostic value and consideration of pathogenetic links.
      simultaneously considered anxiety and depressive symptom scores in relation to adverse cardiovascular events during 3-year follow-up. Similar to our study, anxiety was associated with an increased risk of cardiovascular events (hazard ratio 3.3, 95% CI 1.3 to 8.3), and depressive symptoms were associated with a nonsignificant risk (hazard ratio 0.62, 95% CI 0.20 to 1.87) among the patients not undergoing surgical treatment.
      • Rothenbacher D.
      • Hahmann H.
      • Wusten B.
      • Koenig W.
      • Brenner H.
      Symptoms of anxiety and depression in patients with stable coronary heart disease: prognostic value and consideration of pathogenetic links.
      Several pathophysiologic processes have been proposed to explain the negative relation between anxiety and adverse events, including hypercortisolemia with insulin resistance, sympathetic and vagal disturbance, and lifestyle risk factors, including cigarette smoking.
      • Tully P.J.
      • Baker R.A.
      • Knight J.L.
      Anxiety and depression as risk factors for mortality after coronary artery bypass surgery.
      • Carney R.M.
      • Freedland K.E.
      • Miller G.E.
      • Jaffe A.S.
      Depression as a risk factor for cardiac mortality and morbidity—a review of potential mechanisms.
      • Cohen B.E.
      • Marmar C.
      • Ren L.
      • Bertenthal D.
      • Seal K.H.
      Association of cardiovascular risk factors with mental health diagnoses in Iraq and Afghanistan war veterans using VA health care.
      Increased anxiety could stem from low health literacy or lower educational status, which results in unfamiliarity with the healthcare environment. In such cases, patients who feel anxious or ill-at-ease are more likely to be unable to adhere to the postprocedural plan of care, resulting in adverse events. This explanation would represent a potentially modifiable process.
      The results of the present study have relevance for clinical care. Administration of the simple HADS questionnaire might warrant additional study for use in rapid bedside diagnostic orientation. A quick evaluation of anxiety symptoms as a part of the preoperative workup might allow identification of high-risk patients for whom pharmacologic or psychotherapeutic interventions could be instituted. Moreover, stress management and educational intervention services are offered at many hospitals, and these resources could be used for appropriately identified cardiac surgical inpatients.
      Recent published studies have suggested that cardiovascular procedures after myocardial infarction might be underused in patients with mental health disorders.
      • Druss B.G.
      • Bradford D.W.
      • Rosenheck R.A.
      • Radford M.J.
      • Krumholz H.M.
      Mental disorders and use of cardiovascular procedures after myocardial infarction.
      We caution readers not to interpret these findings as a barrier to delivery of evidence-based care. Instead, our observations should encourage the recognition of preoperative anxiety among elderly patients before cardiac surgery and promote collaboration among cardiovascular physicians with psychiatric services to reduce emotional tension and perhaps improve postcardiac surgery outcomes.
      The present study had several important limitations. First, it was an observational study for which causality cannot be inferred and the effects of unknown confounders on the observed associations cannot be excluded. Second, patients with high levels of anxiety reported slightly lower overall health status, suggesting that something about their health might not have been captured in the clinical variables (including the STS risk score). Thus, anxiety symptoms might act as a surrogate for more sick or vulnerable patients not captured by the STS risk score. Third, although we adjusted for depression symptoms as a co-morbid state using the HADS-D, the severity of depression was not considered. Fourth, previous or current use of antidepressants, anxiolytics, or psychiatric services was not assessed. Finally, although ours was a multi-institutional and multinational study, the findings remain to be validated in a larger external data set, particularly for younger patients.

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      Linked Article

      • Anxiety and Depression as Predictors of Cardiovascular Outcomes After Cardiac Surgery
        American Journal of CardiologyVol. 111Issue 7
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          We read the article by Williams et al,1 who curiously suggest that the relation between pre-existing anxiety and cardiac surgery outcomes has not been clearly defined, in fact referring to a past “failure to consider depression and anxiety simultaneously.” Putting the alleged “past failure” in appropriate context, several studies published during the past 6 years have elucidated the simultaneous role of anxiety and depression with respect to various cardiac surgery outcomes.2–10 Overlooking previous studies would not be so conspicuous had Williams et al1 used a questionnaire other than the Hospital Anxiety and Depression Scale (HADS).
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