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Written by: Lexie Villariasa
Medically reviewed by: Robert Philibert MD PhD

Heart disease and anxiety share a complex relationship. Because symptoms are shared between both syndromes,  it’s common to mistake one condition for another. Furthermore,  some anxiety disorders are clinically associated with cardiovascular disease. Finally, heart disease and anxiety disorders have shared psychological and biological vulnerability factors. By examining  both the shared and unique  physiologic and behavioral mechanisms, we can grasp a better understanding of the correlation between the two otherwise distinct disorders. This allows for better treatment and  outcomes for both of these conditions.

The Heart and Anxiety

Anxiety can be a normal response to stressful situations. During panic attacks or other anxiety disorders, extra strain is put onto the heart. This can be especially damaging for those already suffering from heart disease. For example,  rapid heart rate is a common feature of panic attacks. In certain circumstances, this rapid rate can be potentially life threatening if not addressed promptly. High blood pressure is another common occurrence with anxiety disorders.  If left untreated, this can cause serious issues in the long run such as heart failure or coronary heart disease (CHD). If a patient has suffered from a heart attack, the added anxiety that can occur after an infarction can impede the recovery process. This  excessive uncertainty can leave patients feeling incapable of engaging with  their treatment plans and may lead to medication non-adherence.

Anxiety disorders are even more common than heart disease.  Approximately 3% of all American adults suffer from Generalized anxiety disorder (GAD), a condition characterized by excessive worry about a broad range of events.  GAD is much more frequent, up to 4 times the frequency in the general population,  in those with cardiac disease. Its presence is associated with poor outcomes for those with CHD, even for patients with stable CHD. The presence of GAD doubles the risk for major adverse cardiac events, especially within  2 to 5 years of diagnosis. Another anxiety disorder that is common is panic disorder (PD). Although less prevalent than GAD, it poses a higher threat in increasing the development of cardiac disease. Surviving a heart attack itself is traumatic and can further exacerbate existing anxiety symptoms. Although uncommon, this can lead to an anxiety syndrome similar to PTSD and impede obtaining optimal treatment outcomes for CHD patients.

There are a variety of potential mechanisms that explain why such an association exists between anxiety disorders and cardiac disease. On a behavioral level, the effects of GAD, PD, and Post-Traumatic Stress Disorder (PTSD), can lead to unhealthy diets, physical inactivity, smoking, and decreased adherence to recommended medication or lifestyle changes. Some of these  changes are also risk factors that are already associated with heart disease and can produce unwanted co-morbidities like diabetes, obesity, and hyperlipidemia. On a physiological level, autonomic dysfunction and inflammation can contribute to adverse cardiac outcomes.

Heart Anxiety Neurosis

The growth in our modern understanding of the relationship between anxiety and CHD stretches for several hundred years. Heart Anxiety Neurosis, also known as Da Costa’s syndrome, was first described during the American Civil war.  It  is characterized by the feeling of having symptoms of a heart attack but the appearance of a physically healthy heart.  Symptoms often included tachycardia, heart palpitations, and pain that radiates to the left arm. Since then, our understanding of this set of symptoms has advanced and the term “Da Costa’s syndrome” is no longer used.  In its place, we now have a variety of well defined anxiety disorders such as PTSD or Panic Disorder (PD).  PD is characterized by episodes of intense fear accompanied by a racing heart.  In many of those suffering repeated attacks, the constant alarm leads to shortness of breath and hyperventilation, with fearful periods anticipating the “next attack.” Those who suffer from this often check their blood pressure, pulse, and find comfort in hospitals or clinics. If  symptoms suggestive of a heart attack appear, an EKG or echocardiogram may be done to rule out heart disease. In the case of symptoms persisting, pharmaco- or psychotherapy is initiated. Although the majority of those with severe cases receive medication therapy, cognitive behavioral therapy (CBT) is always recommended.  Particularly in milder cases, CBT can allow the patient to learn how to address the challenge without the use of medication.

Differences between Heart Disease and Anxiety

While some symptoms are similar, it is important to be able to differentiate between the two disorders.  If in any doubt, consult with a licensed clinician. Although some patients may feel shy about reporting such experiences, in reality, clinicians see quite literally millions of patients each year for this very reason. Although most cases are easily assessed by Primary Care Clinicians, even for seasoned clinicians, referral of patients to specialists is sometimes recommended.  So do not feel shy. Best yet, no matter whether you have an anxiety disorder, heart disease or both, your provider will also be able to provide the appropriate treatment and management options.  Be smart; get a professional’s opinion!

COVID-19 and Anxiety

Needless to say, with the pandemic affecting so many, anxiety has been on the rise. During such difficult times, it is important to still see a physician and get treatment if needed. Social distancing measures can create a feeling of isolation and loneliness, increasing stress and anxiety. Learning to cope with this in a healthy way is crucial, and can benefit your mental health in the long run. Make sure to take care of yourself by:

  • Connecting with others online through either Zoom meetings, FaceTime, etc.
  • Spend some time to unwind with your favorite activities (read a book, listen to music)
  • Listen to your body and get plenty of sleep
  • Stay hydrated and eat healthy, nutritious meals
  • Continue preventative measures (wearing masks, washing hands, social distancing)
  • Stay up to date by checking the CDC website!