STRESS & ANXIETY

By the year 2020, cardiovascular disease is thought to be the number one cause of death
in the entire world.

WHAT IS ANXIETY?
Anxiety is a negative state which results from a persons inability to predict or control
perceived threats in any situations (Konstam, Moser & De Jong, 2005). A study by Moser
(2007) stresses the importance of a clinicians role in identifying and addressing a patients
stress and anxiety. Because anxiety is so common, it is often passed over without realising
the potential consequences. As a result , it is infrequently assessed and often managed
inappropriately.

WHAT IS STRESS?
Stress is when you face a situation you think you cant manage. According to Dimsdale
(2008), it is important to pay attention when cardiac patients report stress due to the
connection between the heart and the brain. Stress has always been suspected of having
a powerful and adverse effect on the heart. While stress may not directly cause heart
disease, it has been suggested that it make the heart vulnerable. Stress can be functional
up to a point, but if you stress for long periods of time, there can be negative effects on the
heart (Dimsdale, 2008).

Konstam, Moser & De Jong (2005) reports that patients with heart failure have either the
same or higher anxiety levels when compared to patients with cancer or lung disease.
However, it also highlighted that there are many studies which, combined, have very
inconsistent findings 4 separate studies have found that increased anxiety predicted
subsequent CHD (coronary heart disease), while 3 other reports found NO correlation
between anxiety and CHD disorders> this study suggests that these inconstancies are a
result of the different definitions and measures of anxiety.

Up to 40% of heart failure patients can suffer from major anxiety overall, anxiety levels
are 60% higher than those seen in healthy elders (Moser et al., 2010). Long term stress
such as work-related and marital stress have consistently been associated with increased
cardiovascular risk (Richardson et al., 2012).

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NON-PHARMACOLOGIC INTERVENTIONS
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Konstam, Moser & De Jong (2005) reports heart failure as having a massive psychologic
effect on both the patient and their support systems. Patients and their spouses/ support
should meet with psychologists/ social workers to help improve anxiety levels.

People with higher levels of perceived self- efficacy (belief in their ability to have control
over their motivations and behaviour) were able to better manage their heart failure, which
can lead to improvement in their functional status which can then lead to a decrease in
anxiety/ depression (Tsay & Chao, 2002). Therefore, it is important to work with patients
and be optimistic.

Rohrbaugh et al. (2002) assess the psychological distress and marital quality in couples
where one partner had congestive heart failure. 57% of patients and 40% of their spouses
reported being distressed, and it also found that the patients distress related to the
severity of the illness.

A meta-analysis by Roest, Martens, de Jonge & Denollet (2010) found that anxiety
increased the CHD (coronary heart disease) diagnosis by 26%. In particularly, anxiety was
associated with cardiac mortality and an anxious person had a 48% increased risk of
cardiac death.
Moser (2007) outlines the consequences of persistent or severe anxiety. Additionally,
70-80% of patients who have already experienced an acute cardiac event experience
anxiety.
> Higher anxiety can result in a decrease in quality of life for patients with cardiovascular
disease. More importantly, cardiac patients who are anxious often have difficulties
following medication, activity and diet prescriptions (Moser et al., 2010).
The study by Shibeshi, Young-Xu & Blatt (2007) shows that high levels of anxiety predicted
nonfatal myocardial infarction (MI) or death in patients with stable CAD (coronary artery
disease). Furthermore, mental stress has been linked to atherosclerosis, development of
atherothrombosis and increased risk of arrhythmias (Schwartz et al. 2003).
Moser et al. (2010) identified negative emotions to be more common amongst cardiac
patients compared to healthy individuals. It also deals with whether or not age is linked to
cardiac disease. The study concluded that emotional distress in elderly cardiac patients
was not due to ageing. In particular, women and those with low education are at risk of
psychological distress. While Jorm, (2000) reports that ageing actually reduces anxiety
and depression levels, Miller et al. (2004) documented higher levels of negative emotions
in the elderly.

> Heart failure= highest levels of depression in patients

> Heart failure and post myocardial infarction= highest levels of anxiety in patients
> Coronary artery bypass= highest levels of hostility in patients.
PRE-OPERATIONAL ANXIETY:

- universal reaction which can incite very high levels of anxiety in patients (Pritchard,
2009)

- Fears include: the unknown, surgical failure, anesthesia, pain, loss of control, death
and unsuccessful recover (Pritchard, 2009)

- Moderate levels of anxiety before surgery is helpful because it prepare your body for
pain. Too much anxiety can heighten the patients senses and over-sensitise them to
painful stimuli (Pritchard, 2009)

- You can measure pre and post operational anxiety using the STAI method (State-Trait
Anxiety Inventory). A study by Karanci & Dirik (2003) shows pre and post operation
anxiety levels in females and males:

- Anxiety has been proven to cause HIGHER analgesic & anaesthetic requirement, postoperative pain and prolonged hospital stay (Agarwal et al., 2005)
METHODS TO REDUCE/ PREVENT HIGH ANXIETY LEVELS:

- Pre op patient teaching/ tours (Lepczyk, Raleigh & Rowley, 1990).

- Accurate information about the operation (Pritchard, 2009)
- relaxation therapy (Pritchard, 2009)
- acupressure/ acupuncture (Agarwal et al., 2005)
- anti-anxiety medication
- A visit from the anaesthetist pre surgery (Pritchard, 2009)
MANAGEMENT:
The following table by Rozanski, (2012) shows suggested questions for clinicians to
screen for psychological risk factors:

Katz (2003) found that major thoracic surgery patients were at a 5-10% risk of postoperative cardiac events. Because of this, it suggests routine stress testing, in particular,
preoperative stress-testing would be beneficial to identify those who need extra monitoring
for cardiac events following surgery.
WITH REGARDS TO STRESS AND ANXIETY, there is not much a physiotherapist can do
to address it other than look out for and address patients with stress and anxiety. Because
stress can have such an impact on post-op recovery, possible strategies for us as physio
could include:

- Good communication between the patients and their families i.e. make them aware of
what they should expect, why they are getting a particular treatment and how their
treatment works to help with their recovery

- Bring attention to the patients stress and anxiety to the clinical team i.e doctors, nurses,
social workers

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REFERENCES:
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Agarwal, A., Ranjan, R., Dhiraaj, S., Lakra, A., Kumar, M., & Singh, U. (2005).
Acupressure for prevention of pre-operative anxiety: a prospective, randomised,
placebo controlled study. Anaesthesia, 60(10), 978-981.

Dimsdale, J. E. (2008). Psychological stress and cardiovascular disease. Journal of

the American College of Cardiology, 51(13), 1237-1246.

Jorm, A. F. (2000). Does old age reduce the risk of anxiety and depression? A
review of epidemiological studies across the adult life span. Psychological medicine,
30(01), 11-22.

Karanci, A. N., & Dirik, G. (2003). Predictors of pre-and postoperative anxiety

in emergency surgery patients. Journal of psychosomatic research, 55(4), 363-369.

Katz, N. M., Tempesta, B. J., Gharagozloo, F., Margolis, M., Salter, D., & Alexander,
E. P. (2003). Routine Pre-Operative Stress Testing for Patients Without Cardiac Symptoms
Undergoing Major Thoracic Surgery. CHEST Journal, 124(4_MeetingAbstracts), 76S-a.
Konstam, V., Moser, D. K., & De Jong, M. J. (2005). Depression and anxiety in heart
failure. Journal of cardiac failure, 11(6), 455-463.

Lepczyk, M., Raleigh, E. H., & Rowley, C. (1990). Timing of preoperative

patient teaching. Journal of Advanced Nursing, 15(3), 300-306.

Miller, D. K., Malmstrom, T. K., Joshi, S., Andresen, E. M., Morley, J. E., & Wolinsky,
F. D. (2004). Clinically relevant levels of depressive symptoms in community-dwelling
middle-aged African Americans. Journal of the American Geriatrics Society, 52(5),
741-748.
Moser, D. K. (2007). The rust of life: impact of anxiety on cardiac patients.
American Journal of Critical Care, 16(4), 361-369.
Moser, D. K., Dracup, K., Evangelista, L. S., Zambroski, C. H., Lennie, T. A., Chung,
M. L., ... & Heo, S. (2010). Comparison of prevalence of symptoms of depression, anxiety,
and hostility in elderly patients with heart failure, myocardial infarction, and a coronary
artery bypass graft. Heart & Lung: The Journal of Acute and Critical Care, 39(5), 378-385.

Pritchard, M. J. (2009). Identifying and assessing anxiety in pre-operative patients.

Nursing standard, 23(51), 35-40.
Richardson, S., Shaffer, J. A., Falzon, L., Krupka, D., Davidson, K. W., &
Edmondson, D. (2012). Meta-analysis of perceived stress and its association with incident
coronary heart disease. The American journal of cardiology, 110(12), 1711-1716.
Roest, A. M., Martens, E. J., de Jonge, P., & Denollet, J. (2010). Anxiety and risk of
incident coronary heart disease: a meta-analysis. Journal of the American College of
Cardiology, 56(1), 38-46.

Rohrbaugh, M. J., Cranford, J. A., Shoham, V., Nicklas, J. M., Sonnega, J. S., &
Coyne, J. C. (2002). Couples coping with congestive heart failure: role and gender
differences in psychological distress. Journal of Family Psychology, 16(1), 3.
Rozanski, A. (2012). Integrating the Management of Psychosocial and Behavior
Risk Factors into Clinical Medical Practice. In Stress and Cardiovascular Disease (pp.
355-374). Springer London.
Schwartz, A. R., Gerin, W., Davidson, K. W., Pickering, T. G., Brosschot, J. F.,
Thayer, J. F., ... & Linden, W. (2003). Toward a causal model of cardiovascular responses
to stress and the development of cardiovascular disease. Psychosomatic medicine, 65(1),
22-35.

Shibeshi, W. A., Young-Xu, Y., & Blatt, C. M. (2007). Anxiety worsens prognosis in
patients with coronary artery disease. Journal of the American College of Cardiology,
49(20), 2021-2027.
Tsay, S. L., & Chao, Y. F. C. (2002). Effects of perceived self-efficacy and functional
status on depression in patients with chronic heart failure. Journal of Nursing Research,
10(4), 271-278.

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