Review
Is panic disorder associated with coronary artery disease? A critical review of the literature

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Abstract

Objective: To critically review existing literature examining the relationship between panic disorder (PD) and coronary artery disease (CAD). We specifically sought answers to the following questions: (1) What is the prevalence of PD in CAD patients? (2) What is the directionality of the relationship between PD and CAD? (3) What mechanisms may mediate the link between PD and CAD? Methods: Medline and Psychlit searches were conducted using the following search titles: “panic disorder and coronary artery disease”, “panic disorder and coronary heart disease”, and “panic disorder and cardiovascular disease” for the years 1980–1998. The above search was also repeated replacing “panic disorder” with “panic attacks” for the same period. Results: The prevalence of PD in both cardiology out-patients and patients with documented CAD ranges from 10% to 50%. The association between PD and CAD appeared strongest in patients with atypical chest pain or symptoms that could not be fully explained by coronary status. There is some evidence linking phobic anxiety but not PD per se to CAD risk, but little evidence linking CAD to PD risk. Studies of the mechanisms linking PD to CAD are still in their infancy, but there is preliminary evidence linking PD to reduced heart rate variability (HRV) and myocardial ischemia, two pathophysiological mechanisms related to CAD. Conclusion: PD is prevalent in CAD patients, but it is unclear the extent to which PD confers risk for and/or exacerbates CAD. Prospective research is needed to more firmly establish PD as a distinct risk factor for the development and progression of CAD. However, because many of the symptoms of PD mimic those of CAD, differentiating these disorders and learning how they may influence each other is imperative for clinical practice.

Introduction

Over the last decade, cardiologists have become increasingly aware of the significant presence and impact of psychological conditions in patients with coronary artery disease (CAD). Depression is possibly the most studied and established factor influencing both the development and prognosis of CAD [1]. However, another psychological disorder, panic disorder (PD), is becoming increasingly recognized in cardiology settings 2, 3, 4, 5, 6, and its relationship with CAD is the focus of the present study.

PD is characterized by recurrent panic attacks that consist of sudden episodes of intense fear or discomfort associated with several cognitive and somatic symptoms. Six of the 13 diagnostic symptoms of a panic attack are also cardinal features of cardiovascular diseases: chest pain; palpitations; sweating; shortness of breath; sensation of choking; and hot flashes [7] (see Table 1 for a summary of diagnostic criteria). Because of the similarity of symptoms of PD to those of cardiovascular disease, particularly chest pain, patients are often referred to cardiologists. Patients are submitted to costly, invasive cardiac testing, yet results are often normal. In and of itself, noncardiac chest pain is a major public health issue as over 50% of chest pain patients do not have clear cardiac bases for their symptoms and the psychosocial prognosis for these patients is poor 8, 9, 10, 11. Researchers have recently established the prevalence of PD in patients with either normal angiograms or normal scintigraphic tests at between 34% and 56% 2, 12, 13. This makes PD 30–50 times more common in noncardiac chest pain patients than it is in the overall population [14]. Although PD is rarely recognized or diagnosed in the cardiology setting [3], there is no doubt that it is highly prevalent in symptomatic patients without CAD. But can it also occur, like depression, in patients with CAD? If so, how?

The purpose of this review is to examine the relationship between PD and CAD. Specifically, we review the literature searching for answers to the following questions: (1) What is the prevalence of PD in CAD patients? (2) If there is a relationship between PD and CAD, what is the directionality of that relationship? (3) What mechanisms may mediate the link between PD and CAD? (4) What directions need to be taken for future research in this area? To answer these questions, we conducted Medline and Psychlit searches using the search titles “panic disorder and coronary artery disease,” “panic disorder and coronary heart disease,” and “panic disorder and cardiovascular disease,” for the years 1980–1998. We repeated the aforementioned search replacing “panic disorder” by “panic attacks” for the same period. We excluded case reports, and used review articles to gain access to related literature.

Section snippets

Prevalance of PD in CAD patients

In what follows we review studies linking PD to various subgroups of CAD patients. We evaluate each study according to various characteristics, including: (i) sampling procedures (Did authors use consecutive, random, or convenience sampling? Were subjects recruited from primary or tertiary care settings?); (ii) measurement of CAD (Was CAD testing/verification standard across the sample? Was CAD verified at all?); and (iii) measurement of PD (Did investigators use a validated structured

Directionality of the relationship between PD and CAD

The fact that PD co-occurs with CAD raises several questions. One concerns the directionality of the relationship between these two disorders. Specifically, can PD lead to the development of CAD? Conversely, can CAD lead to the development of PD?

Possible mechanisms linking PD to CAD

Although there is limited evidence from prospective research to show that PD is a risk factor for CAD, there is preliminary evidence linking PD to at least two pathophysiological mechanisms related to CAD.

Directions for future research

Although research linking PD and CAD is still in its early stages, there is sufficient evidence to suggest an important association between the two. However, much of the evidence collected to date is derived from studies conducted in tertiary-care (cardiology) settings with other principal objectives, mainly the study of noncardiac chest pain. Future research should: (1) include a large cross-sectional sample of patients from multiple care settings and the community; (2) rely on structured

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