Heart Disease and Secondhand Smoke, Anxiety

Contact: Amanda Jekowsky, ajekowsk@acc.org, 202-375-6645

In addition to alleviating emotional suffering, keeping one’s anxiety in check may also be good for the heart. While doctors are well aware of the temporary effects anxiety can have on blood pressure, heart palpitations and chest pains, two new studies suggest that symptoms of anxiety may also increase a person’s risk of developing heart disease decades into the future. Data from both studies are published in the June 29, 2010, special prevention and outcomes focus issue of the Journal of the American College of Cardiology.

Also reported in this issue are findings from a study that shows over a two-fold increased risk of cardiovascular death in people with high exposure to second hand smoke who have never smoked. This study, for the first time, also assesses the role markers of inflammation and hemostasis might play in mediating the association between second hand smoke and cardiovascular deaths.

Anxiety’s Toxic Effects on Long-Term Heart Health

“The studies in this issue of the Journal suggest that, by the time patients with symptoms of coronary heart disease present themselves to a cardiologist, early life anxiety might have already taken its toll,” states Joel Dimsdale, M.D., professor of psychiatry, University of California, San Diego, CA, and author of the accompanying editorial.

One of the studies—the first meta-analysis to examine the association of anxiety and subsequent development of heart disease among initially health people—found anxiety to be an independent risk factor for developing heart disease and related death. In fact, anxiety was associated with a 26 percent increased risk of coronary heart disease on average 11 years into the future. People who are anxious also had a 48 percent increased risk of heart-related death down the line. The association between anxiety and future cardiac risk remained significant even after adjusting for demographics and other traditional risk-promoting behaviors (e.g., smoking, sedentary behavior).

The analysis combined reports from 20 prospective studies reporting on incident cardiac events and included nearly 250,000 people. Compared to previous studies, authors noted that anxiety appears to be more strongly associated with developing heart disease than anger and hostility (19 percent increased risk), but somewhat less than depression (46 percent increased risk).

A second study confirmed the role of anxiety as a strong predictor of future cardiac events. This 37-year follow-up of approximately 50,000 young Swedish men, who were medically examined for military service and 18 to 20 years of age at the time, found that anxiety, but not depression, was a major risk factor for cardiac events later in life.

Anxiety disorders remained significantly predictive of subsequent heart disease even after controlling for baseline differences in blood pressure, smoking, and other potential risk factors for heart disease. Strengths of this study include diagnosis by a psychiatrist rather than through self-report, completeness of Swedish health registries, and studying a young population whose emotional symptoms are unlikely influenced by subclinical or clinical heart disease (called reverse causation). Major cardiovascular risk factors were recorded including smoking status, alcohol consumption, body mass index, family history of heart disease, diabetes, blood pressure and physical activity.

Findings from both studies reinforce the need to assess patients’ emotional health in addition to asking about physical symptoms, especially as nearly three in 10 people will suffer from anxiety at some point in their lives. Dr. Dimsdale encourages cardiologists and others to take advantage of assessment tools like the Prime-MD, which include easy-to-ask questions such as “have you been bothered a lot by ‘nerves’ or feeling anxious or on edge?”

“Physicians are frequently timid about assessing emotional symptoms. It is odd that we thread catheters, ablate lesions, and give rectal exams but are uncomfortable asking our patients about their lives,” he states.

Authors agree future research studies should investigate whether treating anxiety disorders through medications, psychotherapy, stress reduction andor lifestyle changes might have long-term heart benefits as well as reducing emotional suffering and improving quality of life. New studies should also examine the interplay of anxiety and other psychological factors (e.g., depression and anger), and uncover the mechanisms by which anxiety might affect the onset and progression of heart disease. “That emotional factors affect the heart is obvious. How they do so and how to mitigate these effects remains to be discovered,” writes Dr. Dimsdale.

Exposure to Second Hand Smoke Spells Trouble for Heart, Inflammation Plays Role

People who have never smoked, but have high exposure to second hand smoke (SHS)—as determined by measuring salivary levels of cotinine (a reliable biochemical marker of nicotine exposure)—appear to have over a two-fold increased risk of cardiovascular death after adjusting for other risk factors, according to a new study.

This study—the first to assess the role of inflammatory and hemostatic markers in relation to SHS exposure—also showed that otherwise healthy people exposed to SHS had higher levels of low grade inflammation in their blood, which is thought to be involved with processes in the blood vessels that lead to heart disease. In particular, authors found that high SHS exposure was associated with elevated C-reactive protein (CRP), which explained nearly half (48 percent) of the association between smoke exposure and heart-related deaths.

Researchers collected cotinine from the saliva of 13,443 British adults. Of these, 20.8 percent had high SHS exposure, which was associated with all-cause and cardiac deaths during an average 8-year follow up. During this period, there were 1,221 all-cause deaths and 364 cardiovascular deaths. Compared to those with lower SHS exposure, both smokers and participants with high SHS were younger, more likely to be male, come from lower social status groups, and be less physically active.

Interestingly, there was no association between high SHS exposure and cardiovascular disease in former smokers. Cigarette smoking was related to elevated levels of fibrinogen, CRP and lower HDL cholesterol.

About the American College of Cardiology

The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 39,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at www.cardiosource.org.

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