Original articles
Effects of anxiety and depression on 5-year mortality in 5057 patients referred for exercise testing

https://doi.org/10.1016/S0022-3999(99)00086-0Get rights and content

Abstract

Objective: Beyond acute myocardial infarction, little is known about the effect of depression, and especially anxiety, on prognosis in cardiology patients. The present study aims to examine the effect of anxiety and depression on 5-year mortality in patients referred for exercise testing. Methods: A total of 5057 patients referred for routine exercise testing completed the Hospital Anxiety and Depression Scale (HADS) before undergoing the exercise test. Survival data were obtained from 5017 (99.2%) of those patients after 5.7 ± 0.8 years. HADS scores and cardiological baseline data were used to predict mortality. Results: In univariate analyses, HADS depression was not a significant predictor; high anxiety was associated with improved survival. Logistic regression revealed nine independent objective predictors from which we computed a composite somatic risk index. When controlling for this physical risk index, anxiety and depression had independent, opposite effects; that is, anxiety was associated with a lower mortality and depression with a higher mortality. Conclusion: Anxiety and depression scores have different predictive effects on mortality in patients referred for exercise testing. These effects are independent of a highly effective physical risk index, suggesting that psychological screening of cardiology patients might improve risk stratification.

Introduction

Depression has been identified as an independent predictor of mortality in patients recovering from an acute myocardial infarction 1, 2, 3. In contrast, results from other patient groups with cardiovascular disease such as chronic coronary artery disease (CAD) or arterial hypertension are more conflicting 4, 5. Even less is known about the effect of anxiety on survival. Although some investigators have reported increased event rates, including sudden cardiac death in different groups with phobic anxiety 6, 7, 8, other studies found no such relationship [9] or even inverse relationships [10] between anxiety and objective CAD endpoints. It is not clear whether the latter observation simply reflects a selection bias of some retrospective studies or, at least in part, a real protective effect of nonphobic anxiety.

The present study was undertaken to investigate the effects of anxiety and depression on mortality in a large cohort of patients referred for diagnostic exercise testing.

Section snippets

Method

Between January 1990 and December 1992, a total of 7079 patients were referred to the cardiology department of a German university hospital for routine exercise testing. Of these, 5057 (71.4%) completed a screening questionnaire before undergoing the exercise test. Most of the remaining patients were missed because of logistical problems. These were mainly due to the fact that the electrocardiogram (ECG) assistants who distributed the questionnaires as part of their routine work after

Results

After a mean follow-up period of 5.7±0.8 years, follow-up survival data could be obtained for 5017 patients (99.2% of the initially screened 5057 patients). Forty patients were lost to follow-up, either because they were foreigners who had never been registered in Germany or because they emigrated from Germany after the baseline assessment. During the follow-up period, 457 patients (9.1% of the 5017 patients with valid survival data) had died. Univariate analyses revealed a variety of

Discussion

Chronic negative emotions have been implicated in morbidity and mortality from coronary artery disease [13]. However, inconclusive results have recently led to the suggestion that different groups of heart patients might be affected in different ways and that different psychological disturbances might have distinguishable effects [14]. For example, in a large study of 4367 elderly hypertensives, Wassertheil-Smoller et al. [5] did not find an increased 4.5-year mortality in patients who were

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