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Original Articles

Heart-Focused Anxiety

An Evolutionary Concept Analysis

Barthle, Pamela MSN, RN, APRN-CNP

Author Information
doi: 10.1097/ANS.0000000000000383

Abstract

ANXIETY PLAYS a significant role in the pathogenesis of many cardiac diseases.1 For instance, nearly 40% of individuals experience anxiety after myocardial infarction (MI).1 Anxiety after MI is associated with a 36% risk of adverse outcomes, including recurrent ischemia, arrhythmias, and lower quality of life.2 Anxiety is a factor in almost 50% of health care visits, with somatic complaints related to the heart.3 Heart-focused anxiety (HFA) is a subtype of anxiety that is specifically related to the heart.4 Initially defined as a psychological condition affecting individuals without cardiac disease, later research indicated that HFA was also present in individuals with a wide variety of cardiac conditions.4 In individuals with cardiac disease, HFA is associated with prolonged recovery and a lower quality of life.3 Although the prevalence of HFA is unknown, authors evaluating for the presence of HFA have found that individuals with peripartum cardiomyopathy, heart failure, MI, and resuscitated cardiac arrest experience HFA.3,5–7

BACKGROUND

Heart-focused anxiety has been a subject of interest since 1992 when Georg Eifert first described the concept. The development of the Cardiac Anxiety Questionnaire (CAQ) provided a means to measure HFA. Eifert et al4 identified 3 overarching domains of avoidance, fear, and heart-focused attention that form the foundation of the CAQ. Avoidance involves circumventing activities that cause cardiac stimulation. Fear involves the psychological distress that ensues after the onset of somatic sensations that are linked with the potential for bodily harm or death. Heart-focused attention involves vigilance to bodily sensations, particularly those involving the chest and heart.4 These domains provided the primary foundation for the objective measurement of HFA. Subsequent validity studies of the CAQ indicated that HFA was more precisely measured with an additional domain, reassurance seeking.8

Statements of Significance

What is known or assumed to be true about this topic?

The concept of HFA is primarily found in the literature relating to medicine, psychiatry, and psychology and less commonly the nursing literature, despite its potential importance to patient care. I was not able to identify any prior analyses of the concept of HFA by or for nursing. However, recent nursing studies have uncovered information related to HFA that was not included in earlier definitions.

What this article adds:

My concept analysis highlights the evolving nature of the definition of HFA. Acknowledging the shifting meanings provides valuable information for clinical practice. Findings from this concept analysis provide an updated definition to enable nurses to formulate plans of care, positively influence outcomes and quality of life, and provide a foundation for future research and inquiry.

The concept of HFA is primarily found in the literature relating to medicine, psychiatry, and psychology and less commonly the nursing literature. In 2000, Eifert et al9 provided a review of the concept, examining the relationship between HFA, panic, and chest pain in individuals with and without cardiac conditions. About a decade later, Zvolensky et al10 published a critical analysis on a related term, cardiophobia. However, I was not able to identify any prior analyses of the concept of HFA by or for nursing. Prior analyses from medicine, psychiatry, and psychology focused on HFA as a psychological variable, including its relationship to anxiety disorders and illness behaviors. Recent nursing studies have uncovered information related to HFA that was not included in earlier definitions. Nurses caring for individuals with and without cardiac diagnoses frequently encounter issues related to HFA, including psychological distress, prolonged recovery, and functional impairment.3,7,11 Understanding the concept of HFA could enhance nurses' ability to provide optimal care to individuals with and without cardiac disease, including the identification of HFA and formulation of plans of care. The results of this concept analysis contribute to interprofessional knowledge related to the provision of care to individuals with HFA. Engaging professionals who complement the nurse's expertise to develop strategies to meet the specific needs of individuals with HFA may optimize patient outcomes. The purpose of this concept analysis was to analyze the use of HFA across a range of disciplines, including nursing, to synthesize an up-to-date definition to inform nursing practice and provide a foundation for future inquiry.

METHODS

Approach

I used the evolutionary method of concept analysis developed by Rodgers12 to inductively derive a current definition of HFA. Rodgers's12 approach takes into consideration that concepts are ever-evolving and defined within contexts. Since HFA was first described over 20 years ago and has been developed in a range of disciplines, Rodgers's12 approach was deemed the most appropriate method. Six steps were used to analyze the concept including (a) identify the concept, related terms, and surrogate term; (b) identify the setting and sample for data collection; (c) identify the attributes, antecedents, and consequences of the concept; (d) analyze the characteristics of the concept; (e) describe an exemplar of the concept; and (f) identify opportunities for future concept development.12

Sample

I searched electronic databases for articles related to HFA in peer-reviewed journals published in English between 2000 and 2020. I included mixed-methods articles, review articles, qualitative studies, and quantitative studies. I excluded commentaries and editorials. I chose 2000 as the launch point for data gathering because this is the publication date of the article by Eifert et al4 that outlined the development and preliminary validity of the CAQ. To thoroughly examine the concept of HFA, I located articles from medicine, nursing, psychiatry, and psychology. Databases searched included Cumulative Index of Nursing and Allied Health Literature (CINAHL), Google Scholar, PsycINFO, PubMed, and Scopus. I used the search terms of cardiac anxiety, cardiophobia, heart-focused anxiety, and non-cardiac chest pain. My initial search returned 215 articles. I reviewed 81 abstracts, of which 43 remained after removing duplicates. Of the 43 articles, 40 were relevant. I reread the articles and made a final selection that included only articles that offered a definition of HFA, evaluated the presence of HFA in various populations, or explored aspects of HFA. I included 25 articles in the concept analysis (Figure 1).

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Figure 1.:
A flowchart of literature search. This figure is available in color online (www.advancesinnursingscience.com).

Analysis

I used the thematic analysis process outlined by Braun and Clarke13 to identify, analyze, and synthesize themes in the definitions and applications of HFA that I found in the articles. I first identified exemplary passages that defined or described characteristics of HFA. Second, I analyzed these passages for themes and grouped passages and themes into categories. I developed a matrix table to organize the analysis and to facilitate identification of patterns across the articles and specifically to determine their temporal relationship to HFA, such as those occurring before, following from, or concurrent with the concept. Using this qualitative analytic process, I derived attributes, antecedents, and consequences of the concept and synthesized a definition.

RESULTS

Sample

The 25 articles selected for the concept analysis included 1 mixed-methods article, 9 qualitative articles, 13 quantitative articles, and 2 review articles (Table). Nine of the articles were from nursing: 1 mixed-methods article, 6 qualitative articles, and 2 quantitative articles. There were 8 articles from psychology: 1 review article, 2 qualitative articles, and 5 quantitative articles. Three quantitative articles were from both medicine and psychology, including 2 articles from medicine (1 qualitative and 1 quantitative). Two articles were from psychiatry: 1 review article and 1 quantitative article. Cardiac anxiety and cardiac-related anxiety are surrogate terms used interchangeably for HFA in the literature. Cardiophobia is a related term found in the literature that has been used to describe individuals with HFA who have no prior diagnosis of cardiac disease.10

Table 1. - Articles Selected for Analysis
Author Study Design Key Themes Attribute (A) Antecedent (B) Consequence (C) Other (D) Discipline Exemplary Quotation
Eifert et al4 Cross-sectional Not applicable Psychology “HFA differs from other types of health-related anxiety in that HFA is specific to the heart.”(p1040)
Eifert et al9 Conceptual and clinical review Attention (A)Avoidance (A)Fear (A)Recurrent chest pain (C) Psychology “We have defined heart-focused anxiety as the fear of cardiac-related stimuli and sensations based upon their perceived negative consequences.”(p408)
Jackson et al14 Qualitative descriptive Fear (A) Nursing “Other participants were also contemplating a return to paid employment, and experiencing were concerned about aspects of lifestyle, and their state of health, especially the possibility of having a further heart attack.”(p1409)
Marker et al8 Cross-sectional cohort Attention (A)Somatic symptoms (B) Psychology “In fact, compared to patients with heart disease, noncardiac chest pain patients endorse similar or greater levels of fear, distress, and autonomic sensations than individuals who have coronary calcium present.”(p825)
Zvolensky et al10 Critical analysis Cardiophobia (D) Psychiatry “Cardiophobics interpret chest pain and/or cardiac sensations in a catastrophic manner, fearing heart disease despite physician feedback suggesting their chest pain is not caused by cardiac pathology.”(p236)
Sjöström-Strand et al15 Phenomenology Attention (A) Nursing “The women described how they were aware of having a heart and how the heart was beating.”(p463)
Fischer et al3 Cross-sectional cohort Social variables of HFA (D) Medicine psychology “Given that HFA is rather considered a symptom than a diagnosis, it is neither included into the International Classification of Diseases (ICD-10) nor the diagnostic and Statistical Manual of Mental Disorders (DSM-IV).”(p113)
Hamang et al16 Prospective cohort, longitudinal Familial factors (B) Medicine “When investigating the importance of the patients' perspective of health in relation to the outcomes, poor perceived health was the factor that related significantly to higher scores on all indicators of heart-focused anxiety (avoidance, attention, fear).”(p80)
Fors et al17 Qualitative descriptive Vulnerability (A) Nursing “The patients felt that something was wrong and they were afraid of losing control since they were dependent of the healthcare professionals to survive.”(p433)
Junehag et al18 Qualitative descriptive Avoidance (A) Nursing “They were sometimes limited because they were unsure about what they dared to do and this affected their social lives.”(p26)
Panzaru and Holman19 Cross-sectional cohort Illness perceptions (D) Psychology “Furthermore, these negative illness perceptions lead to higher heart-focused anxiety and poorer quality of life.”(p556)
Rosman et al7 Cross-sectional cohort Attention (A)Avoidance (A)Fear (A) Medicine “Collectively, these data highlight that many survivors of cardiac arrest experience mild to severe levels of cardiac-specific anxiety, which for some, may increase their risk for adverse functional outcomes.”(p75)
Simonÿ et al20 Phenomenological-hermeneutic Attention (A)Avoidance (A)Facing mortality (A)Fear (A)Vulnerability (A) Nursing “They felt that their hearts were too weak to be able to withstand the exertions of physical exercise, thereby causing them to forego the exercises.”(p2585)
Webster et al21 Qualitative descriptive Fear (A)Worry (A) Psychology “Chest pain appeared to have at least some impact on all participants, varying from restriction of daily activities to fear of serious consequences (e.g. death, disability).”(p1940)
Bunz et al22 Cross-sectional cohort Avoidance (A)Cardiac diagnosis (B)Reassurance seeking (C) Medicine psychology “The high correlations of HFA with general anxiety, depression and QoL are consistent with results from patients undergoing heart surgery, illustrating that higher levels of general anxiety and depression are associated with increased HFA.”(p221)
Konstanti et al23 Cross-sectional cohort Attention (A)Familial factors (A) Nursing “Thus, our results suggest that ICU adaptation is triggering a mind-body hypervigilance in family members and an increased tendency to become upset and worried about heart-related symptoms such as palpitations, chest discomfort, and/or chest pain.”(p454)
Patel et al5 Concurrent triangulation Facing mortality (A)Rumination (A) Nursing “Women with continued symptoms after birth found the situation very complex because of their own illness and inability to take care of a new-born baby. They were scared, angry and helpless. When the symptoms became unbearable, feelings of impending death emerged.”(p17)
van Beek et al24 Prospective cohort Cardiac diagnosis (B)Health risks (C) Psychiatry “Although the prognostic association of cardiac anxiety with a MACE was particularly driven by avoidance of physical activity, it is important to realise that physical activity was not assessed in the present study and some of the other dimensions of cardiac anxiety (fear and attention, respectively) showed even higher hazard ratios than avoidance.”(p405)
Gwaltney et al25 Qualitative descriptive Disruption of life (C)Fear (A)Recurrent chest pain (C) Medicine “Worry and fear also included other concerns; for example, patients were worried about what would happen to loved ones if the patient had another MI.”
Israel et al11(p95) Cross-sectional cohort Fear (A)NCCP (O)Reassurance seeking (C) Psychology “To this point, empirical findings have demonstrated that individuals with HFA are uniquely vigilant to and exceptionally fearful of cardiac sensations.”(p231)
Merritt et al26 Interpretive phenomenology Facing mortality (A)Fear (A) Psychology “This triggered anxiety and catastrophic interpretations around a second MI and premature death.”(p598)
Félin-Germain et al27 Retrospective cohort Avoidance (A)Disruption of life (C) Medicine psychology “Heart-focused anxiety may impact presenteeism by promoting the adoption of fear avoidance behaviors and increased focus and worrying relating to NCCP and overall anxiety.”(p785)
Strömbäck et al28 Qualitative descriptive Facing mortality (A)Fear (A) Nursing “Feelings of uncertainty were manifest due to their anxiety about suffering a third MI, and those kinds of thoughts were frightening.”(p4)
Hohls et al29 Cross-sectional cohort Health risks (C) Psychology “Additionally, after myocardial infarction, people with higher levels of HFA had an increased risk for major adverse cardiac events, which might have been partially driven by the avoidance of exercise due to HFA.”(p6)
Sager et al6 Prospective cohort Fear (A) Nursing “To our knowledge, this pilot study is the first to investigate patient with W-IHM technology and to demonstrate a decrease in cardiac fear from pre-to-post implantation.”(p3)
Abbreviations: HFA, heart-focused anxiety; NCCP, noncardiac chest pain.

Attributes

The attributes of a concept are those aspects that taken together define the concept. The definition thus produced is neither fixed nor unidimensional—as might be provided in a dictionary—but in flux, changing over time and in context.12 Eifert et al9 provided a foundational definition of HFA that included the 3 primary attributes of avoidance, fear, and heart-focused attention. Each attribute bore its own meaning, but there were overlapping characteristics. These attributes continue to be found in current uses. However, in the literature published since 2000, I identified additional attributes, uses, and interpretations that pointed to a broader and deeper meaning of the concept of HFA. The novel attributes, facing mortality and vulnerability, emerged as integral to understanding HFA. Though cited less frequently in the literature but worth remarking were the further emerging attributes of worry and rumination.

Avoidance

Avoidance was a fundamental attribute of HFA in the Eifert et al9 article and was also prominent in the more recent articles I reviewed, appearing in Simonÿ et al,20 Junehag et al,18 and Félin-Germain et al.27 Eifert et al9 provided the foundational definition of avoidance as the purposeful act of forgoing activities that are perceived to precipitate sensations in the chest and heart. In the more recent literature, researchers in 1 study reported that individuals participating in cardiac rehabilitation felt their hearts were too weak to tolerate exercise, so they decided to forgo exercise altogether to avoid potentially adverse situations.20 Avoidance can involve forgoing social activities due to concerns about the effect on the heart, and other studies have shown that some individuals may avoid work due to HFA.18,27 While the Félin-Germain et al27 article was from psychology, the articles by Simonÿ et al20 and Junehag et al18 were from nursing.

Fear

Previously identified as an attribute by Eifert et al,9 fear was another predominant attribute of HFA in the literature and was located in 5 articles. Fear is defined as an unpleasant sensation that occurs in response to a real or perceived danger.30 Eifert et al4 found that fear can be initiated by chest pain with or without a cardiac etiology, palpitations, shortness of breath, or other sensations originating in the chest that are unrelated to the heart, such as gastroesophageal reflux. In the more recent literature, authors found that thoughts of disability or death can also initiate fear.21 For individuals with a history of cardiac problems, feelings of fear may be triggered by memories of past cardiac events, thinking about having another cardiac event, or the consequences of another cardiac event.14,25,26 On the other hand, individuals may experience improvement in HFA with certain cardiac interventions. In a prospective cohort study of 26 participants with heart failure, Sager et al6 found that individuals experienced reduced HFA, particularly in the domain of fear, after implantation of a wireless hemodynamic monitor.

Facing mortality

Facing mortality was a new attribute not identified in the original description of the concept. In a qualitative study with 10 male participants, Merritt et al26 found that thoughts of another cardiac event, premature death, or the possibility of a foreshortened future were common in individuals after MI. In another qualitative study, Strömbäck et al28 found that individuals may form a different perspective of life after their second MI, one that involves facing their mortality not with fear but stoicism. A participant in the study by Strömbäck et al noted, “I don't have the energy to think of when life will end; it will end when it ends. I don't have to worry about that.”28(p4) Some individuals imagine the possibility of missing family events, such as a child's birthday.5 Conclusions drawn from a phenomenological-hermeneutic study about patients' lived experience of dealing with anxiety while participating in an exercise-based cardiac rehabilitation program highlighted how the fragility of life and the inevitability of death were realized in the knowledge of having a vulnerable heart.20

Heart-focused attention

Heart-focused attention was noted consistently as a core component of HFA in the articles. Eifert et al9 identified heart-focused attention as an attribute in their review of the concept and described the attribute as vigilance specifically related to the chest and heart. The attribute was found in more recent studies by Sjöström-Strand et al15 and Simonÿ et al.20 In a phenomenological study of 12 women 5 years after MI, participants described how they were more aware of their heartbeats and the movement of their hearts.15 As one participant in the Sjöström-Strand et al study described, “You're not usually aware of your internal organs but I am really aware of my heart, that it's beating all the time, I can feel that it's moving, I feel my chest. I am really aware of my heart.”15(p463) During exercise, while participating in cardiac rehabilitation, individuals with unstable angina pectoris or non-ST elevation MI were acutely aware of when they became short of breath and when their pulses increased.20 Findings from these studies highlight the acute awareness of the heart and sensations such as breathing and heart rate.

Vulnerability

While not a defining characteristic of HFA in the original description of the concept, vulnerability, or the feeling of being exposed and unprotected, was frequently noted in the literature that featured HFA.20 In an interpretive interview study with 12 participants hospitalized with acute coronary syndrome, Fors et al17 documented how feelings of vulnerability arose when individuals placed their lives in the hands of health care professionals during an acute cardiac event. As a participant in that study described, “And then you become afraid that it will go ‘bang' and then it will be over, because you want to live happily, life is dear to you.”17(p433) Feelings of vulnerability may arise from the cardiac event itself or the experience of relinquishing control to health care professionals.

Other possible attributes

Rumination and worry were novel themes in the literature. In a qualitative study with 7 participants who experienced noncardiac chest pain (NCCP), feelings of worry emerged in individuals' contemplation of the consequences of their diagnosis and symptoms.21 As one participant described, “I worry about the pain so because I get all stressed, I think this is what's happening, the pain gets worse and then I worry more.”21(p1940) Escalation of somatic symptoms caused increased worry that, in some cases, led to a cycle of ever-worsening worry and somatic symptoms.21 Rumination, or recurring thoughts about the symptoms, diagnosis, and consequences, may occur early after cardiac diagnosis or at any point in the future. Patel et al5 found that women with peripartum cardiomyopathy continued to recall feelings of anxiety and sorrow years after their diagnosis. As a participant in the Patel et al study described, “Although I don't feel sick all the time, a constant reminder is there, making me anxious and sad.”5(p18) Although noted less frequently in the literature, rumination and worry may be emerging themes.

Contextual bases

Exploring the contextual bases of a concept provides an understanding of the situations in which the concept or phenomenon occurs in a field of study or body of research.12 Contextual bases may include temporal aspects, such as antecedents or those things that occur as preconditions of a concept, and effects or consequences that follow from a concept. Context also refers to disciplines, discourses, or arenas in which the concept has been used and that have bearing on shades of meaning or ways in which a concept has meaning.12

Antecedents

A predominant antecedent noted in the literature was the presence of a cardiac diagnosis and especially a recent acute cardiac event such as an MI or cardiac arrest.7,24 Other medical diagnoses such as heart failure, hypertrophic cardiomyopathy, peripartum cardiomyopathy, and congenital arrhythmogenic cardiac disorders were noted as events leading to HFA.5,6,16

A variety of somatic symptoms preceded HFA. Chest pain was the most significant and distressing symptom identified.9 Other somatic symptoms in the literature that acted as precursors of HFA were diaphoresis, palpitations, and shortness of breath.9 Chest pain associated with HFA occurred with or without the presence of cardiac disease.11 Individuals with NCCP were described as more sensitive to sensations related to the chest and heart, more apt to experience higher levels of distress related to these sensations, and tended to seek medical attention for evaluation of the sensations more frequently than individuals with cardiac disease.8 Additionally, individuals with NCCP exhibited higher levels of HFA than individuals with angiographically documented coronary artery disease.8 A single somatic symptom or any combination of symptoms could provide a catalyst for HFA.

Also related to antecedents was the finding that HFA occurred in family members who had experienced a triggering event, such as when a family member was hospitalized. Exposure to the intensive care unit environment caused family members to contemplate their health, which led to hypervigilance of bodily sensations and HFA.23 In a longitudinal cohort study of 126 participants attending genetic counseling for hypertrophic cardiomyopathy or long QT syndrome, Hamang et al16 found that participants who experienced the death of a close family member experienced higher levels of HFA. Familial factors play a significant role in the development of HFA.

Consequences

Consequences are the conditions or events that occur as the result of a concept.12 Adverse health outcomes, reassurance-seeking behavior, disruption of life, and recurrent chest pain were identified as consequences of HFA:

  • Adverse health outcomes. Individuals with HFA tend to avoid activities that stimulate the heart, including activities such as exercise that are beneficial to the heart.11 One consequence of HFA was thus, ironically, escalated anxiety and further avoidance, leading to adverse health outcomes.11 In a cross-sectional cohort study of 1007 participants with coronary heart disease, participants with higher avoidance scores on the CAQ exhibited less physical activity and had lower participation rates in cardiac rehabilitation.29 Elsewhere, van Beek et al24 found that higher levels of HFA, especially avoidance behaviors, were associated with a higher incidence of major adverse cardiac events in 193 participants with MI. Furthermore, HFA was found to be associated with angina and myocardial ischemia in individuals with coronary artery disease.9
  • Reassurance seeking. Reassurance-seeking behavior was another consequence of HFA noted in the literature. To relieve anxiety, individuals with HFA commonly seek reassurance for their symptoms through frequent utilization of the health care system.11 Individuals with NCCP and HFA seek health care more frequently than individuals who have confirmed coronary heart disease.11 Fear of adverse health consequences, including death, compels individuals to seek medical attention, leading to repeated diagnostic and laboratory testing that leads to substantial health care costs.22 When evaluating patients' perceptions of NCCP, a participant in a qualitative study by Webster et al commented, “And they said everything was fine, I've been able to keep telling myself it's not my heart, it's ok ... but then I've had this irrational fear.”21(p1940) Fear is a significant factor that drives individuals to seek reassurance for their symptoms.
  • Disruption of life. The cycle of constant attention to bodily sensations, avoidance of activities linked to cardiac stimulation, and fear exert a significant burden on the individual, leading to disruption in multiple areas of life. In a qualitative study involving interviews with 38 participants with a recent MI, Gwaltney et al25 noted changes in lifestyle and social functioning in participants after MI. A participant in the Gwaltney study commented, “I love clothes. I loved to go shopping. I loved to have lunch. I loved to go to the bar and have a drink and listen to good music. I can't do that anymore. I don't care.”25(p232) Heart-focused anxiety can also affect occupational performance. In a retrospective cohort study of 375 participants who sought medical attention in the emergency department with NCCP, Félin-Germain et al27 found that HFA was associated with higher levels of work absenteeism and presenteeism.
  • Recurrent chest pain. Although chest pain was noted to be an antecedent to HFA, chest pain was also implicated as a consequence. Chest pain causes muscle tension and activation of the sympathetic nervous system.9 If chest pain occurs repeatedly, the cycle of muscle tension and sympathetic nervous system stimulation causes sympathetic hyperactivity increasing the likelihood of further episodes of chest pain.9 This pattern leads to more episodes of HFA.9 In a qualitative study by Gwaltney et al,25 chest pain was a common symptom experienced by participants after MI, occurring with exertion, at rest, and with feelings of anxiety.

Definition

In reviewing the literature from medicine, psychiatry, psychology, and nursing, I found that HFA occurs in individuals with and without cardiac disease, family members of patients in an intensive care unit, and family members of individuals with cardiac disease. Heart-focused anxiety was defined by 5 core attributes: avoidance, awareness of mortality, fear, heart-focused attention, and vulnerability. Emergent attributes included rumination and worry. Antecedents included the presence of cardiac diagnoses, somatic symptoms, and familial factors. Heart-focused anxiety led to adverse health outcomes, reassurance-seeking behaviors, disruption in life, and further episodes of chest pain.

I developed the following definition: Heart-focused anxiety is a heightened attention to somatic sensations of the chest and heart that is accompanied by feelings of vulnerability and fear of potential harm or death that may cause an individual to avoid activities that may cause cardiac stimulation (Figure 2).

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Figure 2.:
A model of heart-focused anxiety. This figure is available in color online (www.advancesinnursingscience.com).

DISCUSSION

The purpose of this concept analysis was to qualitatively analyze instances from the literature to synthesize an up-to-date definition of HFA. My findings highlighted how the previously identified attributes of avoidance, fear, and heart-focused attention continue to be applicable in an updated definition. Also important to understanding HFA were the newer contributions of facing mortality and vulnerability. Rumination and worry may be emergent themes in the literature.

Of the 25 articles included in this concept analysis, 9 of the articles were from nursing, including 1 mixed-methods article, 6 qualitative articles, and 2 quantitative articles. The articles from nursing contributed to the definition of HFA in various ways. In a mixed-methods study, Patel et al5 described the attributes of facing mortality and rumination in women with peripartum cardiomyopathy. Using qualitative methods, Fors et al,17 Jackson et al,14 Junehag et al,18 Simonÿ et al,20 Sjöström-Strand et al,15 and Strömbäck et al28 explored the experiences of individuals with various cardiac conditions, unearthing new attributes of facing mortality and vulnerability. The quantitative study by Konstanti et al23 provided information about the presence of HFA in family members of intensive care unit patients. In their study of heart failure patients, Sager et al6 added vital information about the trajectory of HFA after implantation of wireless hemodynamic monitoring sensors. The findings of these nursing studies have added to our knowledge and understanding of HFA.

The articles from medicine, psychiatry, and psychology also contributed to the updated definition of HFA. Quantitative methods were the primary method used in these studies with the exception of the articles by Gwaltney et al,25 Merritt et al,26 and Webster et al,21 who used qualitative methods. The findings in the study by Gwaltney et al25 provided a deeper understanding of fear, disruption of life, and recurrent chest pain in individuals with a recent MI. Using interpretive phenomenology, Merritt et al26 provided insight on facing mortality and fear when exploring younger men's experience of MI. In a qualitative descriptive study, Webster et al21 uncovered information about fear, worry, and reassurance seeking in individuals with NCCP. The authors of quantitative studies evaluated HFA in different populations. For instance, Fischer et al3 evaluated HFA in the general population, Hamang et al16 evaluated HFA in individuals with long QT syndrome and hypertrophic cardiomyopathy, and Rosman et al7 evaluated HFA in individuals with cardiac arrest.

Quantitative studies from medicine, psychiatry, and psychology have added to knowledge about the prevalence and effects of HFA in different populations. The studies grounded in nursing were primarily qualitative, providing information that supported the prior attributes of avoidance, fear, and heart-focused attention but also uncovering new attributes. Collectively, the studies included in this concept analysis highlighted the continued importance of the previous attributes identified by Eifert et al,9 while adding new concepts of facing mortality and vulnerability and uncovering the emerging concepts of rumination and worry.

The representation of male and female gender in the studies deserves remarking. Patel et al,5 Jackson et al,14 and Sjöström-Strand et al15 conducted qualitative studies with exclusively female participants. Merritt et al26 focused on younger men's experiences of MI in their qualitative study. All the quantitative studies, however, featured predominantly male samples. Historically, the higher prevalence of coronary heart disease in males has been offered as a rationale for higher representation of males in studies of heart disease, an argument that has not gone unchallenged. In terms of HFA, studies with a higher representation of male participants were predominantly quantitative, while studies with exclusively female participants were qualitative, focusing on feelings and meanings. The bifurcation in types of evidence linked to gender makes it challenging to offer a strong comparison of how men versus women might experience HFA.

While not identified as attributes, generalized anxiety and illness perceptions also have documented relevance to the level of HFA experienced by individuals. Despite the similarities, generalized anxiety and HFA are different constructs.3 Several studies have found a correlation between generalized anxiety and HFA, although the degree of correlation varied by diagnosis. For example, in a cross-sectional cohort study by Rosman et al7 of 188 sudden cardiac arrest survivors, researchers found a weak to moderate association between generalized anxiety and HFA. Fischer et al3 reported moderate associations between generalized anxiety and HFA in a cross-sectional cohort study that assessed the reliability of the CAQ and social variables related to HFA in the general population. Bunz et al22 found generalized anxiety to be a predictor of HFA when performing a cross-sectional cohort study of 110 participants with chronic heart failure before implantation of a cardioverter-defibrillator. However, only half of the participants had elevated scores of generalized anxiety, indicating that HFA and generalized anxiety are separate constructs.22

Another important aspect of HFA was illness perceptions. Illness perceptions are based on an individual's beliefs about illness and the meaning of illness in the context of their lives.19 In a cross-sectional study if 106 participants with cardiovascular disease, Panzaru and Holman19 found that participants who underwent surgery for their condition perceived their illnesses more positively and had lower levels of HFA. Inversely, participants who were treated with medication perceived their illnesses more negatively and had higher levels of HFA. This finding is significant because it supports previous findings indicating that the severity of coronary artery disease does not always match the level of HFA.19 Illness perceptions play a significant role in mediating the intensity of HFA experienced by individuals.

Exemplar

An exemplar provides a practical example of a concept in a real-life case. The author encountered MG in her practice as a cardiology nurse practitioner. The details have been changed to protect the identity of the individual. MG was a 49-year-old man who underwent a coronary angiogram due to unstable angina. Before the coronary angiogram, MG had no significant medical problems and was taking only a multivitamin daily. After the angiogram, MG was taking 5 medications for his heart. He had 3 visits to the emergency department with complaints of chest pain and palpitations since his coronary angiogram. He called the cardiology clinic almost daily for reassurance. During a follow-up visit in the clinic, MG admitted to feeling every heartbeat and said that he could tell when his heart was skipping beats. MG speculated that these sensations might represent a worsening of his coronary artery disease or a potential heart attack. He reported recurrent thoughts of having a significant blockage in his “widow maker” and forebodings of death have caused him to lose sleep and noted that his father died of sudden cardiac arrest when he was 52 years old. MG explained that he had not returned to his construction job because he was afraid of what would happen to his heart. Even mild discomforts caused him anxiety, and if the sensations lasted for more than a few minutes, he sought medical attention. MG decided not to go to cardiac rehabilitation because he was fearful that exercise would cause him to have more chest pain.

MG's case displayed many elements of the HFA concept, from the antecedents of a recent diagnosis and somatic symptoms to his family history of sudden cardiac arrest. MG demonstrated defining features of HFA, including avoidance of work and cardiac rehabilitation, hyperattentiveness to symptoms, and rumination on the possible meaning of chest pain and skipped heartbeats. MG's fear, vulnerability, and awareness of mortality were manifest in his thoughts of having another heart attack, loss of sleep, and decision to forgo work. MG's frequent episodes of chest pain caused him yet more anxiety. which, in turn, likely led to more chest pain. The consequences of his anxiety were reassurance-seeking behaviors, including frequent emergency department visits and calls to the clinic and the decision to avoid activities like work and rehabilitation that might have been protective against further cardiac events.

Nursing implications

Heart-focused anxiety like MGs can impact individuals with and without cardiac diagnoses. While there are concept analyses of anxiety and stress in the nursing literature, there has been no development of the concept of HFA by or for nurses. Individuals with HFA have frequent encounters with the health care system when seeking evaluation of their symptoms.11 The anxiety that accompanies their physical symptoms often goes unrecognized.27 Nurses are the first point of contact for these individuals, in many instances. Understanding the concept of HFA will facilitate nurses' identification of HFA in patients, formulation of appropriate plans of care, and develop strategies for promoting adherence to therapeutic regimens. Furthermore, this updated definition provides a holistic view of HFA as it applies to different patient populations, allowing nurses to apply the concept in different fields of nursing.

An expanded understanding of HFA with a nursing perspective has significant implications for nursing science. Development of an updated CAQ is needed to assess HFA using this new definition. An updated instrument would allow nurses to accurately assess HFA and provide better education and guidance to patients who experience HFA. Gender-specific qualitative and quantitative research is needed to understand HFA, as it specifically applies to men and women. The evaluation of potential benefits or health-promoting applications of HFA is also a consideration for future nursing research. Authors of previous studies have indicated that anxiety may motivate individuals to adhere to treatment plans and positive health behaviors. For instance, in a longitudinal cohort study of 540 patients with MI, Benyamini et al31 found anxiety to be a motivator for healthy behaviors 5 years after MI. Although Benyamini et al31 did not evaluate HFA in their study, the motivating force of anxiety suggests promise of a similar role for HFA. As a more immediate next step, nursing research might aim to develop a conceptual model and theory on which to base future interventional research and clinical guidance.

Limitations

A limitation of this concept analysis is the fact that only one person conducted the search and analysis of the literature. To remedy the limitation of having only one person surveying the literature, the sample and findings were discussed with an advisor who provided critical feedback. Although I was diligent about searching and extracting information related to HFA from the literature, a more exhaustive search and multiple readers of the articles might have uncovered additional information about HFA.

CONCLUSION

The results of this concept analysis illustrate the evolving nature of the definition of HFA. I used Rodgers's evolutionary approach to develop an up-to-date definition of HFA, based on its application in studies from medicine, nursing, psychiatry, and psychology. The attributes of avoidance, fear, and heart-focused attention continue to be applicable in this updated definition. New attributes of facing mortality and vulnerability add greater meaning to the definition and the emerging attributes of rumination and worry signify the evolving nature of the definition. Acknowledging the shifting meanings provides valuable information for clinical practice.

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Keywords:

anxiety; cardiac disease; concept analysis; heart-focused anxiety; nursing

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