Skip to main content

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

  • Neeltje M. Batelaan (a1), Adrie Seldenrijk (a1), Mariska Bot (a1), Anton J. L. M. van Balkom (a1) and Brenda W. J. H. Penninx (a1)...

Anxiety has been associated with new-onset cardiovascular disease (CVD), but the quality of this relationship is unclear. Only if anxiety is a causal, independent cardiovascular risk factor might it be a target for CVD prevention.


To determine and examine the independent association and causality between anxiety and incident CVD.


PubMed, EMBASE and PsycINFO databases were searched up to October 2013. A review of Hill's criteria for causality and random effects meta-analysis were conducted of prospective, population-based studies examining anxiety and incident CVD in people free from CVD at baseline.


The meta-analysis comprised 37 papers (n = 1 565 699). The follow-up ranged from 1 to 24 years. Anxiety was associated with a 52% increased incidence of CVD (hazard ratio = 1.52, 95% CI 1.36–1.71). The risk seemed independent of traditional risk factors and depression. The evaluation of Hill's criteria largely argued in favour of causality.


Anxiety may be of interest for CVD prevention. Future research should examine biological and behavioural underpinnings of the association in order to identify targets for intervention.

Corresponding author
Dr Neeltje M. Batelaan, Department of Psychiatry VU University Medical Center, A.J. Ernststraat 1187, 1081 HL Amsterdam, The Netherlands. Email:
Hide All

B.W.J.H.P. is supported by an NWO-VICI grant 91811602.

Declaration of interest


Hide All
1 Mathers, CD, Loncar, D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3: e442.
2 Roger, VL, Go, AS, Lloyd-Jones, DM, Benjamin, EJ, Berry, JD, Borden, WB, et al. Heart disease and stroke statistics – 2012 update: a report from the American Heart Association. Circulation 2012; 125: e2220.
3 Ford, ES, Ajani, UA, Croft, JB, Critchley, JA, Labarthe, DR, Kottke, TE, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med 2007; 356: 2388–98.
4 Unal, B, Critchley, JA, Capewell, S. Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation 2004; 109: 1101–7.
5 Vartiainen, E, Laatikainen, T, Peltonen, M, Juolevi, A, Mannisto, S, Sundvall, J, et al. Thirty-five-year trends in cardiovascular risk factors in Finland. Int J Epidemiol 2010; 39: 504–18.
6 Yusuf, S, Hawken, S, Ounpuu, S, Dans, T, Avezum, A, Lanas, F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364: 937–52.
7 Roest, AM, Martens, EJ, de Jonge, P, Denollet, J. Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol 2010; 56: 3846.
8 Lamers, F, van Oppen, P, Comijs, HC, Smit, JH, Spinhoven, P, van Balkom, AJ, et al. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: the Netherlands Study of Depression and Anxiety (NESDA). J Clin Psychiatry 2011; 72: 341–8.
9 Nicholson, A, Kuper, H, Hemingway, H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 2006; 27: 2763–74.
10 Hill, BA. The environment and disease: association or causation? Proc Roy Soc Med 1965; 58: 295300.
11 Moher, D, Liberati, A, Tetzlaff, J, Altman, DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.
12 Hayden, JA, Cote, P, Bombardier, C. Evaluation of the quality of prognosis studies in reviews. Ann Intern Med 2006; 144: 427–37.
13 Higgins, JP, Thompson, SG, Deeks, JJ, Altman, DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–60.
14 Egger, M, Smith, GD, Schneider, M, Minder, C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–34.
15 Duval, S, Tweedie, R. Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455–63.
16 Biostat, . Comprehensive Meta-Analysis, version 2.2.064. Biostat.
17 Chen, YH, Hu, CJ, Lee, HC, Lin, HC. An increased risk of stroke among panic disorder patients: a 3-year follow-up study. Can J Psychiatry 2010; 55: 43–9.
18 Boscarino, JA. Psychobiologic predictors of disease mortality after psychological trauma: implications for research and clinical surveillance. J Nerv Ment Dis 2008; 196: 100–7.
19 Shen, BJ, Avivi, YE, Todaro, JF, Spiro, A, Laurenceau, JP, Ward, KD, et al. Anxiety characteristics independently and prospectively predict myocardial infarction in men the unique contribution of anxiety among psychologic factors. J Am Coll Cardiol 2008; 51: 113–9.
20 Kubzansky, LD, Kawachi, I, Spiro, A, Weiss, ST, Vokonas, PS, Sparrow, D. Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation 1997; 95: 818–24.
21 Kawachi, I, Sparrow, D, Vokonas, PS, Weiss, ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation 1994; 90: 2225–9.
22 Haines, AP, Imeson, JD, Meade, TW. Phobic anxiety and ischaemic heart disease. BMJ 1987; 295: 297–9.
23 Haynes, SG, Feinleib, M, Kannel, WB. The relationship of psychosocial factors to coronary heart disease in the Framingham Study. III. Eight-year incidence of coronary heart disease. Am J Epidemiol 1980; 111: 3758.
24 Gafarov, VV, Gromova, EA, Gagulin, IV, Gafarova, AV. Study of myocardial infarction risk factors within the framework of the WHO Monica–psychosocial program. Klin Med (Mosk) 2006; 84: 24–6.
25 Gafarov, VV, Pak, VA, Gagulin, IV, Gafarova, AV. Personal anxiety and ischaemic heart disease [in Russian]. Ter Arkh 2005; 77: 25–9.
26 Davidson, KW, Mostofsky, E, Whang, W. Don't worry, be happy: positive affect and reduced 10-year incident coronary heart disease: the Canadian Nova Scotia Health Survey. Eur Heart J 2010; 31: 1065–70.
27 Phillips, AC, Batty, GD, Gale, CR, Deary, IJ, Osborn, D, MacIntyre, K, et al. Generalized anxiety disorder, major depressive disorder, and their comorbidity as predictors of all-cause and cardiovascular mortality: the Vietnam experience study. Psychosom Med 2009; 71: 395403.
28 Holt, RI, Phillips, DI, Jameson, KA, Cooper, C, Dennison, EM, Peveler, RC. The relationship between depression, anxiety and cardiovascular disease: findings from the Hertfordshire Cohort Study. J Affect Disord 2013; 150: 8490.
29 Shirom, A, Toker, S, Jacobson, O, Balicer, RD. Feeling vigorous and the risks of all-cause mortality, ischemic heart disease, and diabetes: a 20-year follow-up of healthy employees. Psychosom Med 2010; 72: 727–33.
30 Nabi, H, Hall, M, Koskenvuo, M, Singh-Manoux, A, Oksanen, T, Suominen, S, et al. Psychological and somatic symptoms of anxiety and risk of coronary heart disease: the health and social support prospective cohort study. Biol Psychiatry 2010; 67: 378–85.
31 Eaker, ED, Sullivan, LM, Kelly-Hayes, M, D'Agostino, RB, Benjamin, EJ. Tension and anxiety and the prediction of the 10-year incidence of coronary heart disease, atrial fibrillation, and total mortality: the Framingham Offspring Study. Psychosom Med 2005; 67: 692–6.
32 Carriere, I, Ryan, J, Norton, J, Scali, J, Stewart, R, Ritchie, K, et al. Anxiety and mortality risk in community-dwelling elderly people. Br J Psychiatry 2013; 203: 303–9.
33 Brenes, GA, Kritchevsky, SB, Mehta, KM, Yaffe, K, Simonsick, EM, Ayonayon, HN, et al. Scared to death: results from the Health, Aging, and Body Composition study. Am J Geriatr Psychiatry 2007; 15: 262–5.
34 Bowlin, SJ, Medalie, JH, Flocke, SA, Zyzanski, SJ, Goldbourt, U. Epidemiology of intermittent claudication in middle-aged men. Am J Epidemiol 1994; 140: 418–30.
35 Gomez-Caminero, A, Blumentals, WA, Russo, LJ, Brown, RR, Castilla-Puentes, R. Does panic disorder increase the risk of coronary heart disease? A cohort study of a national managed care database. Psychosom Med 2005; 67: 688–91.
36 Cohen, HW, Gibson, G, Alderman, MH. Excess risk of myocardial infarction in patients treated with antidepressant medications: association with use of tricyclic agents. Am J Med 2000; 108: 28.
37 Hamer, M, David, BG, Seldenrijk, A, Kivimaki, M. Antidepressant medication use and future risk of cardiovascular disease: the Scottish Health Survey. Eur Heart J 2011; 32: 437–42.
38 Smoller, JW, Allison, M, Cochrane, BB, Curb, JD, Perlis, RH, Robinson, JG, et al. Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative study. Arch Intern Med 2009; 169: 2128–39.
39 Lapane, KL, Zierler, S, Lasater, TM, Barbour, MM, Carleton, R, Hume, AL. Is the use of psychotropic drugs associated with increased risk of ischemic heart disease? Epidemiology 1995; 6: 376–81.
40 Albert, CM, Chae, CU, Rexrode, KM, Manson, JE, Kawachi, I. Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women. Circulation 2005; 111: 480–7.
41 Batelaan, NM, ten Have, M, van Balkom, AJ, Tuithof, M, de Graaf, R. Anxiety disorders and onset of cardiovascular disease: the differential impact of panic, phobias and worry. J Anxiety Disord 2014; 28: 252–8.
42 Sareen, J, Cox, BJ, Clara, I, Asmundson, GJ. The relationship between anxiety disorders and physical disorders in the U.S. National Comorbidity Survey. Depress Anxiety 2005; 21: 193202.
43 Roy-Byrne, PP, Davidson, KW, Kessler, RC, Asmundson, GJ, Goodwin, RD, Kubzansky, L, et al. Anxiety disorders and comorbid medical illness. Gen Hosp Psychiatry 2008; 30: 208–25.
44 Hasler, G, Gergen, PJ, Kleinbaum, DG, Ajdacic, V, Gamma, A, Eich, D, et al. Asthma and panic in young adults: a 20-year prospective community study. Am J Respir Crit Care Med 2005; 171: 1224–30.
45 Nicholl, BI, Halder, SL, Macfarlane, GJ, Thompson, DG, O'Brien, S, Musleh, M, et al. Psychosocial risk markers for new onset irritable bowel syndrome – results of a large prospective population-based study. Pain 2008; 137: 147–55.
46 Laan, W, Termorshuizen, F, Smeets, HM, Boks, MP, de Wit, NJ, Geerlings, MI. A comorbid anxiety disorder does not result in an excess risk of death among patients with a depressive disorder. J Affect Disord 2011; 135: 284–91.
47 Denollet, J, Maas, K, Knottnerus, A, Keyzer, JJ, Pop, VJ. Anxiety predicted premature all-cause and cardiovascular death in a 10-year follow-up of middle-aged women. J Clin Epidemiol 2009; 62: 452–6.
48 Van Hout, HP, Beekman, AT, de Beurs, E, Comijs, H, van Marwijk, H, de Haan, M, et al. Anxiety and the risk of death in older men and women. Br J Psychiatry 2004; 185: 399404.
49 Mykletun, A, Bjerkeset, O, Dewey, M, Prince, M, Overland, S, Stewart, R. Anxiety, depression, and cause-specific mortality: the HUNT study. Psychosom Med 2007; 69: 323–31.
50 Holman, EA, Silver, RC, Poulin, M, Andersen, J, Gil-Rivas, V, McIntosh, DN. Terrorism, acute stress, and cardiovascular health: a 3-year national study following the September 11th attacks. Arch Gen Psychiatry 2008; 65: 7380.
51 Ostir, GV, Goodwin, JS. High anxiety is associated with an increased risk of death in an older tri-ethnic population. J Clin Epidemiol 2006; 59: 534–40.
52 Ringback Weitoft, G, Rosen, M. Is perceived nervousness and anxiety a predictor of premature mortality and severe morbidity? A longitudinal follow up of the Swedish survey of living conditions. J Epidemiol Community Health 2005; 59: 794–8.
53 Smoller, JW, Pollack, MH, Wassertheil-Smoller, S, Jackson, RD, Oberman, A, Wong, ND, et al. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch Gen Psychiatry 2007; 64: 1153–60.
54 Yasuda, N, Mino, Y, Koda, S, Ohara, H. The differential influence of distinct clusters of psychiatric symptoms, as assessed by the general health questionnaire, on cause of death in older persons living in a rural community of Japan. J Am Geriatr Soc 2002; 50: 313–20.
55 Janszky, I, Ahnve, S, Lundberg, I, Hemmingsson, T. Early-onset depression, anxiety, and risk of subsequent coronary heart disease: 37-year follow-up of 49,321 young Swedish men. J Am Coll Cardiol 2010; 56: 31–7.
56 Aberg, MA, Waern, M, Nyberg, J, Pedersen, NL, Bergh, Y, Aberg, ND, et al. Cardiovascular fitness in males at age 18 and risk of serious depression in adulthood: Swedish prospective population-based study. Br J Psychiatry 2012; 201: 352–9.
57 De Jonge, P, Roest, AM. Depression and cardiovascular disease: the end of simple models. Br J Psychiatry 2012; 201: 337–8.
58 Nicholson, A, Fuhrer, R, Marmot, M. Psychological distress as a predictor of CHD events in men: the effect of persistence and components of risk. Psychosom Med 2005; 67: 522–30.
59 Moylan, S, Jacka, FN, Pasco, JA, Berk, M. Cigarette smoking, nicotine dependence and anxiety disorders: a systematic review of population-based, epidemiological studies. BMC Med 2012; 10: 123.
60 Falk Dahl, CA, Dahl, AA. Lifestyle and social network in individuals with high level of social phobia/anxiety symptoms: a community-based study. Soc Psychiatry Psychiatr Epidemiol 2010; 45: 309–17.
61 Jacka, FN, Mykletun, A, Berk, M, Bjelland, I, Tell, GS. The association between habitual diet quality and the common mental disorders in community-dwelling adults: the Hordaland Health study. Psychosom Med 2011; 73: 483–90.
62 Papakostas, GI, Ongur, D, Iosifescu, DV, Mischoulon, D, Fava, M. Cholesterol in mood and anxiety disorders: review of the literature and new hypotheses. Eur Neuropsychopharmacol 2004; 14: 135–42.
63 Player, MS, Peterson, LE. Anxiety disorders, hypertension, and cardiovascular risk: a review. Int J Psychiatry Med 2011; 41: 365–77.
64 Pitsavos, C, Panagiotakos, DB, Papageorgiou, C, Tsetsekou, E, Soldatos, C, Stefanadis, C. Anxiety in relation to inflammation and coagulation markers, among healthy adults: the ATTICA study. Atherosclerosis 2006; 185: 320–6.
65 Von Kanel, R, Mills, PJ, Fainman, C, Dimsdale, JE. Effects of psychological stress and psychiatric disorders on blood coagulation and fibrinolysis: a biobehavioral pathway to coronary artery disease? Psychosom Med 2011; 63: 531–44.
66 Young, EA, Abelson, JA, Liberzon, I. Stress hormones and anxiety disorders. In Handbook of Anxiety and Fear (eds Blanchard, DC, Griebel, G, Nutt, D): 455473. Elsevier, 2008.
67 Vreeburg, SA, Zitman, FG, van Pelt, J, Derijk, RH, Verhagen, JC, van Dyck, R, et al. Salivary cortisol levels in persons with and without different anxiety disorders. Psychosom Med 2010; 72: 340–7.
68 Friedman, BH. An autonomic flexibility–neurovisceral integration model of anxiety and cardiac vagal tone. Biol Psychol 2007; 74: 185–99.
69 Licht, CM, Penninx, BW, de Geus, EJ. Effects of antidepressants, but not psychopathology, on cardiac sympathetic control: a longitudinal study. Neuropsychopharmacology 2012; 37: 2487–95.
70 Petticrew, M, Davey Smith, G. The monkey puzzle: a systematic review of studies of stress, social hierarchies, and heart disease in monkeys. PLoS One 2012; 7: e27939.
71 Watson, SL, Shively, CA, Kaplan, JR, Line, SW. Effects of chronic social separation on cardiovascular disease risk factors in female cynomolgus monkeys. Atherosclerosis 1998; 137: 259–66.
72 Dhabhar, FS, Saul, AN, Holmes, TH, Daugherty, C, Neri, E, Tillie, JM, et al. High-anxious individuals show increased chronic stress burden, decreased protective immunity, and increased cancer progression in a mouse model of squamous cell carcinoma. PLoS One 2012; 7: e33069.
73 Lenze, EJ, Mantella, RC, Shi, P, Goate, AM, Nowotny, P, Butters, MA, et al. Elevated cortisol in older adults with generalized anxiety disorder is reduced by treatment: a placebo-controlled evaluation of escitalopram. Am J Geriatr Psychiatry 2011; 19: 482–90.
74 Rice, KM, Blanchard, EB, Purcell, M. Biofeedback treatments of generalized anxiety disorder: preliminary results. Biofeedback Self Regul 1993; 18: 93105.
75 Middleton, HC, Ashby, M. Clinical recovery from panic disorder is associated with evidence of changes in cardiovascular regulation. Acta Psychiatr Scand 1995; 91: 108–13.
76 Sullivan, GM, Kent, JM, Kleber, M, Martinez, JM, Yeragani, VK, Gorman, JM. Effects of hyperventilation on heart rate and QT variability in panic disorder pre- and post-treatment. Psychiatry Res 2004; 125: 2939.
77 Licht, CM, de Geus, EJ, van Dyck, R, Penninx, BW. Association between anxiety disorders and heart rate variability in The Netherlands Study of Depression and Anxiety (NESDA). Psychosom Med 2009; 71: 508–18.
78 Thombs, BD, de Jonge, P, Coyne, JC, Whooley, MA, Frasure-Smith, N, Mitchell, AJ, et al. Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA 2008; 300: 2161–71.
79 De Jonge, P, Honig, A, van Melle, JP, Schene, AH, Kuyper, AM, Tulner, D, et al. Nonresponse to treatment for depression following myocardial infarction: association with subsequent cardiac events. Am J Psychiatry 2007; 164: 1371–8.
80 Carney, RM, Blumenthal, JA, Freedland, KE, Youngblood, M, Veith, RC, Burg, MM, et al. Depression and late mortality after myocardial infarction in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study. Psychosom Med 2004; 66: 466–74.
81 Chida, Y, Steptoe, A. The association of anger and hostility with future coronary heart disease: a meta-analytic review of prospective evidence. J Am Coll Cardiol 2009; 53: 936–46.
82 Bogers, RP, Bemelmans, WJ, Hoogenveen, RT, Boshuizen, HC, Woodward, M, Knekt, P, et al. Association of overweight with increased risk of coronary heart disease partly independent of blood pressure and cholesterol levels: a meta-analysis of 21 cohort studies including more than 300 000 persons. Arch Intern Med 2007; 167: 1720–8.
83 Gami, AS, Witt, BJ, Howard, DE, Erwin, PJ, Gami, LA, Somers, VK, et al. Metabolic syndrome and risk of incident cardiovascular events and death: a systematic review and meta-analysis of longitudinal studies. J Am Coll Cardiol 2007; 49: 403–14.
84 Li, J, Siegrist, J. Physical activity and risk of cardiovascular disease – a meta-analysis of prospective cohort studies. Int J Environ Res Public Health 2012; 9: 391407.
85 Kessler, RC, Chiu, WT, Demler, O, Merikangas, KR, Walters, EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 617–27.
86 Batelaan, N, Rhebergen, D, de Graaf, R, Spijker, J, Beekman, A, Penninx, B. Panic attacks as a dimension of psychopathology: evidence for their impact on onset and course of mental disorders and functioning. J Clin Psychiatry 2012; 73: 1195–202.
87 Kessler, RC, Chiu, WT, Jin, R, Ruscio, AM, Shear, K, Walters, EE. The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2006; 63: 415–24.
88 Lewinsohn, PM, Shankman, SA, Gau, JM, Klein, DN. The prevalence and co-morbidity of subthreshold psychiatric conditions. Psychol Med 2004; 34: 613–22.
89 National Institute for Health and Clinical Excellence. Generalised Anxiety Disorder and Panic Disorder (With or Without Agoraphobia) in Adults: Management in Primary, Secondary and Community Care. Clinical Guideline 113. NICE, 2011.
90 Wang, PS, Lane, M, Olfson, M, Pincus, HA, Wells, KB, Kessler, RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 629–40.
91 Gustad, LT, Laugsand, LE, Janszky, I, Dalen, H, Bjerkeset, O. Symptoms of anxiety and depression and risk of acute myocardial infarction: the HUNT 2 study. Eur Heart J 2014; 35: 1394–403.
92 Vaccarino, V, Goldberg, J, Rooks, C, Shah, AJ, Veledar, E, Faber, TL, et al. Post-traumatic stress disorder and incidence of coronary heart disease: a twin study. J Am Coll Cardiol 2013; 62: 970.
93 Chou, PH, Lin, CH, Loh, E, Chan, CH, Lan, TH. Panic disorder and risk of stroke: a population-based study. Psychosomatics 2012; 53: 463–9.
94 Chen, YH, Tsai, SY, Lee, HC, Lin, HC. Increased risk of acute myocardial infarction for patients with panic disorder: a nationwide population-based study. Psychosom Med 2009; 71: 798804.
95 Jordan, HT, Miller-Archie, SA, Cone, JE, Morabia, A, Stellman, SD. Heart disease among adults exposed to the September 11, 2001 World Trade Center disaster: results from the World Trade Center Health Registry. Prev Med 2011; 53: 370–6.
96 Scherrer, JF, Chrusciel, T, Zeringue, A, Garfield, LD, Hauptman, PJ, Lustman, PJ, et al. Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans Administration patients. Am Heart J 2010; 159: 772–9.
97 Kubzansky, LD, Koenen, KC, Jones, C, Eaton, WW. A prospective study of posttraumatic stress disorder symptoms and coronary heart disease in women. Health Psychol 2009; 28: 125–30.
98 Boscarino, JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosom Med 2008; 70: 668–76.
99 Jakobsen, AH, Foldager, L, Parker, G, Munk-Jorgensen, P. Quantifying links between acute myocardial infarction and depression, anxiety and schizophrenia using case register databases. J Affect Disord 2008; 109: 177–81.
100 Walters, K, Rait, G, Petersen, I, Williams, R, Nazareth, I. Panic disorder and risk of new onset coronary heart disease, acute myocardial infarction, and cardiac mortality: cohort study using the general practice research database. Eur Heart J 2008; 29: 2981–8.
101 Gafarov, VV, Gromova, HA, Gagulin, IV, Ekimova, YC, Santrapinskiy, DK. Arterial hypertension, myocardial infarction and stroke: risk of development and psychosocial factors. Alaska Med 2007; 49: 117–9.
102 Boyle, SH, Michalek, JE, Suarez, EC. Covariation of psychological attributes and incident coronary heart disease in U.S. Air Force veterans of the Vietnam war. Psychosom Med 2006; 68: 844–50.
103 Kubzansky, LD, Cole, SR, Kawachi, I, Vokonas, P, Sparrow, D. Shared and unique contributions of anger, anxiety, and depression to coronary heart disease: a prospective study in the normative aging study. Ann Behav Med 2006; 31: 21–9.
104 Thurston, RC, Kubzansky, LD, Kawachi, I, Berkman, LF. Do depression and anxiety mediate the link between educational attainment and CHD? Psychosom Med 2006; 68: 2532.
105 Haines, A, Cooper, J, Meade, TW. Psychological characteristics and fatal ischaemic heart disease. Heart 2001; 85: 385–9.
106 Bowen, RC, Senthilselvan, A, Barale, A. Physical illness as an outcome of chronic anxiety disorders. Can J Psychiatry 2000; 45: 459–64.
107 Kawachi, I, Colditz, GA, Ascherio, A, Rimm, EB, Giovannucci, E, Stampfer, MJ, et al. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation 1994; 89: 1992–7.
108 Vogt, T, Pope, C, Mullooly, J, Hollis, J. Mental health status as a predictor of morbidity and mortality: a 15-year follow-up of members of a health maintenance organization. Am J Public Health 1994; 84: 227–31.
109 Eaker, ED, Pinsky, J, Castelli, WP. Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study. Am J Epidemiol 1992; 135: 854–64.
110 Rosengren, A, Tibblin, G, Wilhelmsen, L. Self-perceived psychological stress and incidence of coronary artery disease in middle-aged men. Am J Cardiol 1991; 68: 1171–5.
111 Pearson, TA, Blair, SN, Daniels, SR, Eckel, RH, Fair, JM, Fortmann, SP, et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases. American Heart Association Science Advisory and Coordinating Committee. Circulation 2002; 106: 388–91.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
Type Description Title
Supplementary materials

Batelaan et al. supplementary material
Supplementary Material

 PDF (778 KB)
778 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 25 *
Loading metrics...

Abstract views

Total abstract views: 85 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 19th March 2018. This data will be updated every 24 hours.

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

  • Neeltje M. Batelaan (a1), Adrie Seldenrijk (a1), Mariska Bot (a1), Anton J. L. M. van Balkom (a1) and Brenda W. J. H. Penninx (a1)...
Submit a response


Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

Zulijana M Anastasova, Psychiatrist, Mercy University Hospital Journal Club, Cork
Michele J Hill, Psychiatrist, Mercy University Hospital Journal Club, Cork
16 March 2016

We read with interest the recent paper by Batelaan et al 1 evaluating the relationship between anxiety and cardiovascular disease at our weekly Journal Club. The authors found that anxiety is associated with a 52% increased incidence of CVD, that the relationship appeared to be causal, and independent of depression and traditional risk factors. Their definition of anxiety ranged from self-reported symptoms to post traumatic stress disorder. The magnitude of the association was similar to that of obesity. Their definition of anxiety ranged from self-reported symptoms to post traumatic stress disorder.

This is very important, as stress and anxiety are the leading cause of workplace absenteeism and do not receive the same level of attention at a government or societal level as obesity. If anxiety is indeed as potent a risk factor for CVD as obesity, one would hope that a comparable system level approach to its management, involving media campaigns, schools and workplaces, would naturally follow.

The authors stopped short of this recommendation, instead promoting further examination of the biological and behavioural underpinnings of their association, and in the meantime encouraging healthy life habits. While we recognise the importance of improved understanding of underlying mechanisms, surely, with the ready availability of effective treatments for anxiety at a primary prevention level (eg. Mindfulness, Positive Psychology), and secondary prevention level (eg. Psychotherapy, SSRIs), it might indeed be sensible to strongly encourage experimental studies, despite the challenge involved, particularly in view of the fact that this was identified as a gap in the knowledge on the area?

Another issue raised was the inclusion of PTSD in the study. PTSD has been associated with elevated basal heart rates and bood pressure 2. It has been moved from the Anxiety Disorders section to the Trauma and Stressor Related Disorders section in DSM V 3 and differs greatly in its biology from anxiety in terms of central noradrenergic effects and sympathoadrenal axis activity 4. The subgroup analysis in Batelaan et al’s study showed no differences between pooled hazard ratios in studies examining PTSD versus anxiety, however the proportion of positive studies was higher in the PTSD group (five out of six studies comprising a fifth of the overall population studied). If future efforts are to focus on biological underpinnings of the association between anxiety and CVD, it stands to reason that PTSD ought to be excluded.

1.Batelaan N, Seldenrijk A, Bot M, van Balkom A, Penninx B

Anxiety and new onset of cardiovascular disease: critical review and meta-analysis

Br J of Psychiatry (2016) 208, 223-231

2. Buckley TC, Kaloupek DG

A meta-analytic examination of basal cardiovascular activity in posttraumatic stress disorder

Psychosom Med. 2001 Jul-Aug; 63(4):585-94.


4. Bedi US, Arora R

Cardiovascular manifestations of posttraumatic stress disorder

J Natl Med Assoc. 2007 Jun;99(6):642-9.

... More

Conflict of interest: None Declared

Write a reply


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *