Heart-focused Anxiety

Health-related quality of life (QOL) is defined as the functional effect of an illness and its treatment. Quality of life assessments include an evaluation of patient-perceived physical, mental, social, and occupational functioning, as well as overall health.1 As a key contributor to mental well-being, anxiety plays a significant role in the QOL of cardiac patients. Of particular concern for this population is heart-focused anxiety (HFA), which refers to the fear of cardiac-related events and sensations due to their presumed negative consequences.2 Individuals with high HFA tend to monitor or focus on cardiac sensations and avoid activities believed to elicit cardiac symptoms.2 Heart-focused anxiety and subsequent behavioral avoidance may have adverse consequences on the QOL outcomes of cardiac patients. Greater attention to the detection and treatment of anxiety is an important consideration for health professionals working in a secondary prevention setting.3 This is particularly true now that there is growing evidence of an association between psychological distress and the development of coronary artery disease.4 Indicators of socioeconomic status (SES), such as income, education, and employment status, are key determinants of cardiovascular health, access to cardiac services (including cardiac rehabilitation), and psychosocial adjustment.5-7 It follows that there is a need to identify factors, such as socioeconomic determinants of health, which may predispose or influence a cardiac patient to experience a poorer QOL and/or HFA. The purpose of this study was to investigate whether QOL and HFA differed as a function of SES in a cross-sectional sample of secondary prevention patients. METHODS Seventy-one English-speaking adults who were physician-referred to a full-day cardiac risk-reduction education program participated in this study. This program provides education regarding the modification of cardiac risk factors in an attempt to reduce the likelihood of future cardiac events. After obtaining informed consent, participants were administered a brief questionnaire packet that included measures of SES, cardiac anxiety, and health-related QOL. Background Information Form Questions pertained to ethnocultural background, marital status, household status, education, occupation, and income. Response categories were later collapsed into fewer categories to facilitate statistical analysis. For example, 11 income brackets were collapsed into 3 categories (all in Canadian dollars): less than $40,000, $40,000 to $79,999, and $80,000 or more. Cardiac Anxiety Questionnaire The Cardiac Anxiety Questionnaire (CAQ) has 18 items to which individuals respond on a 5-point Likert-type scale.8 A total score plus the following 3 subscales are calculated: (1) heart-related worry and fear, (2) avoidance behavior, and (3) attention. Scores reflect mean item scores and higher scores indicate greater cardiac anxiety. Short-form Health Status Instrument The SF-12 is an efficient and reliable alternative to the Short Form-36 (SF-36), its 36-item predecessor,9 which has been deemed to be the most appropriate generic instrument to assess QOL among cardiac patient populations.10,11 SF-12 algorithms produce 8 health domain subscales and 2 summary scales: (1) Physical Component Summary (PCS) and (2) Mental Component Summary (MCS). Higher PCS and MCS scores reflect fewer limitations and better health-related QOL. RESULTS Of the 125 individuals who attended the group education session during the study period, 71 (57%) consented to participate in the study; of these, 9 were women and 62 were men. The female and male participation rates were 35% (9/26) and 63% (62/99), respectively. Approximately half of the participants were born outside of Canada (54.3%) and did not describe themselves as Canadian (52.2%). For those individuals born outside of Canada, the mean year of immigration was 1974 (with a range of 1949-2002). Most of the study participants had coronary artery disease (83.6%), had experienced a myocardial infarction (53.3%), and had undergone a percutaneous coronary intervention and/or bypass surgery (64.9%). The mean number of cardiac medications was 5.3. With regard to cardiac risk factors, 33.3% had diabetes, 58.9% had hypertension, and 63.9% had hypercholesterolemia. Table 1 presents the demographic, socioeconomic, and medical characteristics of study participants.Table 1: DEMOGRAPHIC AND MEDICAL PARTICIPANT CHARACTERISTICSCorrelation analyses revealed that CAQ was significantly correlated with PCS (r = −0.382, P = .001) and MCS (r = −0.527, P < .001), suggesting that greater cardiac anxiety was associated with poorer health-related QOL. There were no significant correlations between age and PCS, MCS, or total CAQ scores. A series of independent-sample t tests was conducted in order to examine whether PCS, MCS, and total CAQ scores differed as a function of SES indices. Multiple ttests were deemed appropriate given the exploratory nature of the study. In Table 2, we present the raw scores and indicate significant differences with asterisks. Compared to participants born in Canada, participants who were born outside of Canada reported higher CAQ scores (t64.13 = −2.02, P = .048), and lower MCS scores (t64.58 = 2.10, P =.039). Relative to participants who defined themselves as "Canadian," those who did not reported lower MCS scores (t64.00 = −2.26, P = .012), and there was also a trend for these participants to experience greater cardiac anxiety (t64.77 = 1.79, P = .078). There were significant differences as a function of income along CAQ scores (F2,61 = 5.58, P=.01) and MCS scores (F2,61 = 10.84, P < .01), whereas the relationship between income and PCS scores approached significance (F2,61 = 2.72, P = .074). Individuals who were not employed outside the home reported lower PCS scores than those who were engaged in part-time or full-time paid work (t61.78 = 2.90, P = .005). Factors such as sex, marital status, education, prior myocardial infarction, and medication usage (ie, beta-blockers) were unrelated to CAQ, PCS, or MCS scores (all P > .10).Table 2: CAQ AND SF-12 SCORES RELATIVE TO DEMOGRAPHIC AND SES CHARACTERISTICSTherefore, CAQ, MCS, and PCS scores differed as a function of whether participants were born in Canada, whether they considered themselves Canadian, and their income categories. Chi-square analyses were subsequently performed to examine whether income differed as a function of ethnic status. Results indicated that income differed significantly as a function of whether participants were born in Canada [χ2(2, n = 66) = 8.76, P = .013], such that Canadian-born individuals were more likely to fall into the highest income category. There was a similar trend for individuals who identified themselves as Canadian [χ2(2, n = 65) = 5.82, P = .055]. DISCUSSION Although cardiac anxiety and QOL did not vary as a function of demographic (eg, age, sex) and medical (ie, prior myocardial infarction) variables, they did vary as a function of ethnic background and income. Canadian birth and Canadian identity were associated with a lower cardiac anxiety score and better health-related mental QOL than those born outside of Canada and/or who did not define themselves as Canadian. In addition, individuals who earned less than CDN$40,000 per year reported greater cardiac anxiety and poorer QOL than those with higher incomes. However, ethnic status and income should not be considered as mutually exclusive categories, as individuals born outside the country and/or who did not self-identify as Canadian had lower incomes. A larger sample of multiethnic participants would be required to further investigate whether self-defined ethnicity is independently associated with poor QOL and/or HFA. Our results are limited by the low enrollment and participation rates, particularly of females, and the absence of non-English-speaking patients. Although our study sample differs from the general population, individuals referred to and attending comprehensive cardiac rehabilitation programs tend to be young, men, of higher SES, and from nonminority ethnic backgrounds.12 Our finding that women were more likely to refuse study participation is consistent with past research involving patients after a myocardial infarction.13 The results might have differed slightly with a greater proportion of females in our sample, because women seem to fare worse in terms of both physical and psychosocial outcomes following a cardiac event.14 We also speculate that many of the nonresponders declined participation because English was not their first language; although their English skills might have allowed program attendance, it might have interfered with a willingness or ability to complete questionnaires in English. However, this limitation might actually serve to strengthen our conclusions, as we would expect larger differences (ie, greater cardiac anxiety and lower QOL) among non-English-speaking immigrants. Although we consider our ethnically diverse sample to be a strength of this study, we recognize that this likely differs from the general population in other areas or cities with less diversity. We agree with Sykes et al7 who recommended that a thorough evaluation of cardiac patients should include indices of SES in addition to biomedical factors. Although we recognize that this study investigated associations rather than causal factors, the results suggest that inquiry into whether an individual was born outside of the country should also be included in this evaluation. Given that success in health promotion and prevention requires an understanding of variables that influence health-related attitudes and behaviors, such as ethnocultural background and SES,7 these are important considerations for professionals working in cardiac rehabilitation programs who serve a diverse and multicultural population. A better appreciation of explanatory models and health beliefs may shed some light on the discrepancies in access to care, but also allows health professionals to negotiate with patients an informed "action plan" that will facilitate positive outcomes through adherence to lifestyle modification and pharmacological interventions. Unfortunately, there is a lack of research exploring the psychological aspects of coping with coronary artery disease in minority groups. Daly et al15 emphasize how such insight would enhance our knowledge of the needs and expectations of our patients and would allow for the development of culturally sensitive services. Health professionals working in multicultural settings are encouraged to acknowledge and pay particular attention to the cardiac anxiety and QOL among apparently vulnerable populations. Further research investigating the psychological adjustment to coronary artery disease in differing cultural contexts is also required to allow us to better counsel our patients.

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