HEART Insight:
doi: 10.1097/01.HEARTI.0000411129.86551.db
Features: Related Risk

Take it Easy

Lewis, Darcy

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New Research Shows Anxiety May Play a Role in Heart Disease.

Modern life is complicated: We all have appointments to keep, bills to pay and conflicts to resolve. So it comes as no surprise that anxiety—or uncontrolled worrying—has become part of life for most people. That's not necessarily bad, according to Biing-Jiun Shen, Ph.D., a clinical/health psychology professor at Ohio University in Athens. “Almost every person experiences anxiety periodically and that can be beneficial,” he says. “An occasional burst of anxiety can help you respond effectively to life's challenges.”

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But prolonged, severe anxiety can harm physical health and may even be associated with an increased risk of heart disease. “We know that what happens in the mind affects the body, but carefully controlled studies are being published that show a harmful connection between anxiety and physical health,” says Julie L. Pike, Ph.D., a psychologist at the Anxiety Disorders Treatment Center in Durham, N.C. “In other words, this is an intuitive belief that is now shown by [published] research.”

A long-term study published in the American Journal of Cardiology in 2010 showed for the first time that anxiety appears to be an independent risk factor for developing cardiovascular disease. A team of psychologists reviewed the records of 735 American men aged 60 or older who had good cardiovascular health in 1986. Those who showed the most anxiety according to four different anxiety-measuring scales were far more likely to have suffered heart attacks within the next 12 years.

Shen, the study's lead author, explains that his team isolated the connection between heart disease and anxiety while removing any possible effects of other factors that could have explained the findings. “When we controlled for physical factors like age, cholesterol, blood pressure and body mass index, anxiety was still a significant factor in predicting which men developed heart disease,” he says. “Anxiety remained a significant factor even when we adjusted for psychosocial factors like education, marital status, depression and Type A behaviors, including anger.”

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Shen is careful to point out that his study does have some limitations. “It's important not to overstate the results and scare people needlessly,” he says. “The study only included men, which means we don't know how anxiety affects women's chances of developing heart disease. Also, all the patients were initially healthy, which means this study does not show how anxiety affects people who already have cardiovascular disease.”

Reid Wilson, Ph.D., a psychologist at the Anxiety Disorders Treatment Center in Chapel Hill, N.C., hopes these new findings don't overburden people who are already prone to anxiety. “Most people with heart disease do not develop a clinical level of anxiety,” he says. “It is those who are vulnerable to begin with who are more susceptible to anxious symptoms.”

Clyde W. Yancy, M.D., chief of cardiology at Northwestern University's Feinberg School of Medicine in Chicago, believes the emerging anxiety/heart disease link is intriguing. “Those who are very anxious, very fearful and who internalize a lot of their emotions can be putting themselves at risk,” he says. “I hesitate to say there is a cause-and-effect relationship at this point, but it's clear there is an association. Exactly how that works is open to ongoing research.”

What's clear is that anxiety is an emotional process that creates physical responses. “We know that when a person is under stress, there are a lot of things happening in the body,” says Shen. “Blood pressure and heart rate increase as part of the stress response and the stress hormone levels of epinephrine, norepinephrine and cortisol all increase, too.”

Whatever the precise anxiety/heart disease link turns out to be, what's clear today is that people who worry too much can use this information as an inspiration to work on reining in their anxiety levels. Here are some tips designed to help you cope with everyday anxiety and help prevent worries from spiraling out of control.

* Talk with family and friends. When you feel connected to the most important people in your life, worries have a way of becoming more manageable. “Try to be forthcoming about your fears with family, friends and your healthcare provider,” says Yancy. “We all want to help.”

* Be physically active every day. Embrace the benefits of daily physical activity. Not only will your physical health benefit from getting and staying active, the feel-good endorphins that are released during exercise can combat some of the worries of everyday life. Aim for at least 30 minutes of moderate physical activity, such as brisk walking, on most days of the week, for a total of at least 150 minutes a week. If you can't do at least 30 minutes at one time, you can add up 10-minute sessions throughout the day.

* Remember to slow down—and laugh along the way. Learning to slow down in today's hectic society can be harder than it sounds. To help, Pike encourages her patients to try yoga, meditation or mindfulness training. Yancy advises his patients to explore life's positives. “Learn what calms you, makes you happy and gives you joy,” he says. “You don't have to sit back and let stress and anxiety control your life.”

* Give up bad habits. Some things are even more harmful than anxiety. “Smoking, drinking and overeating can ease stress initially but these are not healthy behaviors,” says Shen. “They only make things worse in the long run.”

To read more about ways to deal with anxiety, visit heartinsight.com to read our online-only bonus article, “Time to kick back.”

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Are you anxious?

The physical symptoms of anxiety can vary from person to person, but here are some of the most common.

* disrupted sleep

* racing heart

* dizziness

* stomach problems like nausea or diarrhea

* sweating

* irritability

* muscle tension, including shakiness

* concentration difficulties

* fatigue

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As a cardiologist interested in all facets of what puts a person at risk for heart disease, Yancy believes that doctors can do more to identify anxious patients and to recognize just how much anxiety medical situations can create. “We should be proactive and anticipate that some people will be quaking in their boots just from coming to see us and, unfortunately, there are times when we as physicians do have to deliver very sober and difficult news to patients,” he says. “It's better to discuss anxiety openly so patients can be forthcoming and ask us for help in how to deal with their worries.”

If you find yourself anxious while at your doctor's office due to either the situation or as part of a larger pattern, don't hesitate to ask for advice. “Very few physicians practice in isolation anymore,” says Yancy. “Between doctors, nurses, educators, dietitians, physical therapists and support staff, there's almost always a collection of individuals who are there to support patients and help them improve their health.”

Depending on what's causing your anxiety, you might find that the solution lies within the doctor's office. “If I had any cardiac or other major medical event, I'd be anxious, too,” notes Pike. “That's a normal reaction.” In this case, perhaps what you need to lessen your worries is more information or time with the doctor—if that's so, don't hesitate to ask.

If your anxiety is more broad-based and isn't just about being nervous about being at the doctor's office, ask your doctor for a referral to a mental health professional. He or she may refer you to a psychiatrist, psychologist or social worker. Treatment for anxiety typically consists of medication, psychological-behavioral therapy or both and is often a targeted, short-term course of treatment. “It's not so much about the stress itself but your response to it,” says Shen. “Anxiety therapy is about learning healthier ways to deal with stress.”

And that's the good news: Anyone can learn these techniques. “Anxiety is a modifiable risk factor for heart disease,” says Yancy. “Once you understand you are prone to anxious responses, you can change the way you react and that, in turn, will lessen your risk and make your life more pleasant and enjoyable in other ways, too.”

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Square up your breathing

It's a vicious cycle: During bouts of anxiety, your breathing can get faster and shallower, leading to feelings of even greater panic as your body struggles to get enough air.

But if you can slow down your breathing, you're halfway to feeling calm again. Pike advocates so-called four-square breathing as an effective self-calming technique:

1. Breathe in through your nose for four seconds.

2. Hold that breath for four seconds.

3. Exhale for four seconds.

4. Pause for four seconds before starting the next breaths.

Pike suggests doing a set of at least 10 breaths: “When you're anxious, it takes a little while for the brain to get the message that it's safe to calm down.”

© 2012 American Heart Association, Inc.