ReviewIs panic disorder associated with coronary artery disease? A critical review of the literature
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
References (42)
- et al.
Panic disorder in patients with chest pain and angiographically normal coronary arteries
Am J Cardiol
(1989) - et al.
Panic disorder in emergency department chest pain patientsprevalence, comorbidity, suicidal ideation, and physician recognition
Am J Med
(1996) - et al.
Cardiovascular death from panic disorder and panic-like anxietya critical review of the literature
J Psychosom Res
(1998) - et al.
Common symptoms in ambulatory careincidence, evaluation, therapy and outcome
Am J Med
(1989) - et al.
Continuing disability of patients with chest pain and normal coronary arteriograms
J Chron Dis
(1979) - et al.
Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries
Am J Cardiol
(1986) - et al.
Unimproved chest pain in patients with minimal or no coronary diseasea behavioral phenomenon
Am Heart J
(1984) - et al.
Chest painrelationship of psychiatric illness to coronary arteriographic results
Am J Med
(1988) - et al.
Panic disorder and chest paina study of cardiac stress scintigraphy patients
Am J Cardiol
(1994) - et al.
Panic disorder in coronary artery disease patients with noncardiac chest pain
J Psychosom Res
(1998)