|Year : 2014 | Volume
| Issue : 2 | Page : 80-88
Psychiatric morbidity and lifestyle of patients with coronary artery disease in Nile delta
Maha Borham1, Mohamed El-Atrouny2, Mohamed Abo El-Hoda2, El-Sayed Saleh2, Nevin Zaki3, Gamal Gomaa4
1 Fellow at Student, Mansoura University, Mansoura, Egypt
2 Professor of Psychiatry, Mansoura University, Mansoura, Egypt
3 Lecturer of Psychiatry, Mansoura University, Mansoura, Egypt
4 Professor of Cardiology, Mansoura University, Mansoura, Egypt
|Date of Submission||01-Jul-2013|
|Date of Acceptance||01-Sep-2013|
|Date of Web Publication||11-Jun-2014|
MD El-Sayed Saleh
Faculty of Medicine, Mansoura University, Mansoura
Source of Support: None, Conflict of Interest: None
This study aimed to (i) estimate the clinical variables in anxious and depressive patients with coronary artery disease (CAD), (ii) correlate the severity of anxiety and depression with the severity of CAD measured by coronary arteriography, and (iii) predict the psychopathology leading to the severity of CAD.
A total of 264 patients satisfied the inclusion and exclusion criteria and were enrolled in the study. This study consisted of two parts. (i) The first part included: (a) semistructured clinical psychiatric interview and (b) psychometric assessment such as scale to assess the personality type D, Anxiety-Depression Inventory, and Life Event Scale. (ii) The second part of the interview was concerned with CAD description. The following were performed to assess the cardiac problem such as history of the cardiac complaint, clinical examination, coronary angiography, and assessment of health-related risk markers such as diabetes mellitus and hypertension.
This study was conducted on 264 patients of both sexes; 67.4% were male patients and 32.6% were female patients, with age ranging from 30 to 70 years. Hypertension was more in coronary artery affected patients, with highly significant statistical difference (P < 0.001), whereas diabetes mellitus occurred with no significant difference. Health-related risk markers such as exercise, smoking, adherence to medication, and regular doctor visits were higher in coronary artery affected patients, with high statistically significant difference (P < 0.001). In addition, personality type D, anxiety disorders, depression, and stressful life events were more in coronary artery affected patients (P < 0.001). There was positive correlation between the severity of CAD and age (r = 0.182, P < 0.01), total score of Dl4, social inhibition of Dl4, negative affectivity of Dl4, the severity of depression and anxiety, social introversion, and life events (P < 0.001). Stepwise linear regression indicated that the severity of coronary arteries affection could be significantly predicted by adherence to medication, social introversion, sex, family history of mood disorder, and age.
More than risk factor, for example, anxiety and depression, smoking, personality type D, severity of social introversion, stressful life events, lifestyle such as exercise, adherence to medication, and regular doctor visits when ill are positively correlated with the severity of CAD. These findings suggest that clinicians should assess patients for both anxiety and depression and continue to monitor these symptoms on a regular basis.
Keywords: anxiety, artery disease, coronoray, depression, type D personaity
|How to cite this article:|
Borham M, El-Atrouny M, El-Hoda MA, Saleh ES, Zaki N, Gomaa G. Psychiatric morbidity and lifestyle of patients with coronary artery disease in Nile delta. Egypt J Psychiatr 2014;35:80-8
|How to cite this URL:|
Borham M, El-Atrouny M, El-Hoda MA, Saleh ES, Zaki N, Gomaa G. Psychiatric morbidity and lifestyle of patients with coronary artery disease in Nile delta. Egypt J Psychiatr [serial online] 2014 [cited 2022 Jul 7];35:80-8. Available from: http://new.ejpsy.eg.net/text.asp?2014/35/2/80/134193
| Introduction|| |
It has been nearly 20 years since major depression was identified as a risk factor for cardiac events in patients with stable coronary artery disease (CAD) (Carney et al., 1988). Depression has been studied extensively with respect to cardiovascular disease (Pozuelo et al., 2009; Kop et al., 2011). Anger (Chida and Steptoe, 2009) and anxiety (Roest et al., 2010) also may promote CAD, suggesting that emotional distress in general may be related to increased cardiovascular risk. Evidence indicates that the general distress shared across depression, anger, and anxiety predicts CAD, even after controlling for each of these specific negative emotions (Kubzansky et al., 2006). Depression, anxiety, anger, and post-traumatic stress are specific markers of distress that have been related to cardiac disorder (Ladwig et al., 2008; Shen et al., 2008; Roest et al., 2010). Many studies have reported on depression, anxiety, and cardiovascular outcomes (Frasure-Smith and Lesperance, 2008). A number of researchers have examined whether pre-existing mood disorders increase the risk for subsequent cardiac disease. Recent studies support this impression. For example, among African-American women, Collins-McNeil et al. (2007) confirmed statistical associations between the depression scores and the cardiovascular risk scores. In a group of caregivers of dementia patients, Mausbach et al. (2007) determined that higher levels of depressive symptoms correlated with shorter time periods to cardiovascuar disease (CVD) diagnosis. In an Australian study on 755 women, participants with angina were about four times more likely than controls to report past histories of depression. In a controlled study, it was found that participants with a first myocardial infarction (MI) had a greater likelihood of being previously hospitalized for depression (Janszky et al., 2007). In a 12-year, prospective, follow-up study on nearly 1200 elderly Finnish individuals, depression scores at the outset correlated with high subsequent risks of mortality from CVD or MI (Carney and Freedland, 2003).
Although patients may go in and out of depressive and anxious episodes, there is an underlying trait factor that predisposes patients to chronic distress (Denollet, 1993). Symptoms of depression/anxiety not only reflect episodic distress, but also a more ingrained tendency to experience distress (Shen et al., 2008). Six principal mechanisms have been put forward to explain the link between major depression and CAD: (i) behavioral mechanisms, (ii) genetic mechanisms, (iii) dysregulation of the immune mechanisms, (iv) coagulation abnormalities and vascular endothelial dysfunction, (v) polyunsaturated omega-3 free fatty acid deficiency, and (vi) autonomic mechanisms. Other mechanisms have been implicated in the relationship between major depressive disorder (MDD) and CAD, but have little supporting evidence to date. For example, antidepressant cardiotoxicity is suggested to account for the increased incidence of adverse cardiac events in depressed people (Carney et al., 2002).
Depressed people tend to engage in poor health behaviors such as smoking, low physical activity, and maintaining a poor diet (Barth et al., 2004). Depressed patients have higher rates of daily smoking and nicotine dependence (Fergusson et al., 2003) and are less likely to give up smoking (John et al., 2004).
This study was conducted to elucidate the incidence of psychiatric morbidity in CAD patients and its relationship with the disease severity and patients' lifestyle and to study the relationship of the severity of psychiatric morbidity with the severity of coronary artery affection. Hence, this study aimed to (i) estimate the clinical variables in anxious and depressive patients with CAD, (ii) correlate the severity of anxiety and depression with the severity of CAD measured by coronary arteriography, and (iii) predict the psychopathology leading to the severity of coronary artery affection.
| Patients and methods|| |
A cross-sectional study was conducted on patients attending the Department of Cardiology in Mansoura Internal Medical Hospital, Mansoura University, Egypt, over 12 months period from 1 August 2011 to 1 August 2012 before performing coronary arteriography.
Patients of both sexes, with age range 30-70 years, were admitted to the inpatient section in Mansoura Internal Medical Hospital for diagnostic coronary arteriography. They were randomly recruited to the study and randomization was carried out manually without the use of a computer algorithm to allocate every patient on the patients' list. Patients were eligible for participation only if they (i) underwent a coronary angiography during their current hospitalization and (ii) can read Arabic fluently. Of the 287 individuals attending the Department of Cardiology, 264 patients satisfied the inclusion and exclusion criteria and were enrolled in the study after obtaining their written consent. They were included if they were fully conscious, willing and able to participate, with chronic chest pain, stable angina, unstable angina, and first myocardial infarction (MI).
Patients were excluded if they were less than 30 or more than 70 years of age, refusing to participate, illiterate, with significant valvular lesion, congenital heart disease, or nonischemic cardiomyopathy, with a history of cerebrovascular disease, meeting the criteria for any comorbid axis I psychiatric disorder, mentally retarded, with a history of substance abuse or who recently received antipsychotic drugs or mood stabilizers. A total of 23 patients were excluded because they either did not complete the psychological tests or did not undergo coronary angiography.
Enrolled patients completed our questionnaire before undergoing coronary angiography. The questionnaire was explored to the patients, and when required assistance was given in reading and understanding the question.
Information regarding demographic and clinical data, including family history, symptom profile, applying the DSM-IV-TR criteria (American Psychiatric Association, 2000) for depression and anxiety was given by the attending psychiatrist. Furthermore, assessment of the severity of cardiac problem, for example, history concerning the cardiac complaint, clinical examination, and coronary arteriography was carried out by the attending cardiologist.
Our study consisted of two parts.
- The first part was completed by the psychiatrist before performing coronary arteriography in the Department of Cardiology and included the following.
- Semistructured clinical psychiatric interview was carried out in which the following information were taken in detail: clinical psychiatric interview including demographic data, history of the present illness, personal history, family history for mood disorder, and present mental state examination with focus on the symptom profile. Some information about patient's lifestyle was taken to assess health-related risk markers (i.e. smoking, daily intake of coffee or alcohol, exercise, general medical history, and pharmacological therapy). Thereafter, DSM-IV-TR criteria were applied to diagnose depression and anxiety.
- Psychometric assessment:
- Personality type D is assessed with a scale that measures negative affectivity and social inhibition. Each item is rated according to a five-point Likert scale from 0 (false) to 4 (true). The DS14 is a 14-item questionnaire comprised of two seven-item subscales (Denollet, 2005), measuring the tendency to experience negative emotions (negative affectivity) and inhibit self-expression in social interactions (social inhibition). Scores on this scale ranges from 0 to 4 for items that assess the patient's negative emotions (negative affectivity) and inhibited self-expression in social interaction 'social inhibition'. Participants were defined as having a type D personality if they scored C10 on both negative affectivity and social inhibition. This cutoff value has been used in previous research (Denollet, 2005; Emons et al., 2007) and is derived from the median split on the negative affectivity and social inhibition scores of participants in those studies. This scale was translated by the authors and presented to three professors of psychiatry in Mansoura Faculty of Medicine. They were asked to evaluate the clarity of the items and its suitability for measuring the concept of the scale within our community. Thereafter, it was presented to a small sample of patients (n = 25). Both subscales have good internal validity (negative affectivity: Cronbach's α = 0.88 and social inhibition: Cronbach's α = 0.86) and are stable over a 4-week period (r = 0.82/0.72).
- The degree of depression and anxiety in the cardiac patients was assessed through Anxiety-Depression Inventory (El-Rakhawy and Shaheen, 1972). This personality test is constructed in an Egyptian slang language using the current expression of the patient attending the psychiatric clinic in Kasr El-Aini Hospital. It comprises 90 items presented into three successive pages, each page presenting 30 items. The first page gives the depression scale, the second is for the anxiety scale, and the third is for the social introversion scale. The answers for the items are either right or wrong. This scale was presented to three professors of psychiatry in Mansoura Faculty of Medicine. They were asked to evaluate the clarity of the items and its suitability for measuring the concept of the scale within our community. Thereafter, it was presented to a small sample of patients (n = 25). Item-total correlations for the scale ranged from 0.13 to 0.776 (Cronbach's α = 0.93), all very highly significant.
- Psychosocial stress was measured by the Life Event Scale (Horowitz et al., 1977). It is a 37-item self-report instrument designed to evaluate cumulative stress from the impact of life events and to assess categories of stressors including deaths, separations, health concerns, threats to self or self-image, and threats to material well-being (e.g. 'death of your mother', 'loss of a personally valuable object', and 'failing an important examination'). Liang et al. (1984) classified the scores of life events questionnaire into: no life crises (0-149), mild to moderate crises (150-149), and major life crises (≥300).
- The second part of the interview was concerned with CAD description, which was evaluated by the cardiologist in the Department of Cardiology at Mansoura Internal Medical Hospital. The following were performed to assess cardiac problem in the study population.
- History was taken concerning the cardiac complaint.
- Clinical examination was carried out.
- Coronary angiography: it is the gold standard for detecting clinically significant coronary atherosclerotic disease. All patients prepared the following standard procedures for percutaneous transluminal coronary angiography; vascular access was obtained through the right femoral approach using the modified Seldinger technique with single anterior wall puncture of the right common femoral artery. It is used for assessment of the severity of CAD, which was defined by the number of coronary arteries affected by CAD (i.e. 0 = normal arteries, 1 = atherosclerotic CAD, 2 = one artery affected, or 3 = more than one artery affected).
- Assessment of health-related risk markers (e.g. blood sugar level) was carried out to detect diabetes mellitus, and blood pressure was measured.
The study was approved by the local medical research and ethics committee. Informed consent was obtained from all participants after being informed in detail of the purpose and methods of the study. The study was conducted according to the Good Clinical Practice guidelines.
The SPSS program (version 16; SPSS Inc., Chicago, Illinois, USA) was used for data analysis, the χ2 test was used to compare observed data with expected data. It was used according to a specific hypothesis (null hypothesis) stating that there is no significant difference between the expected and the observed result. Hence, it detects whether there is significant difference between the incidence of physical dysfunction (hypertension, diabetes, and coronary artery affection) and behavioral dysfunction (less exercise, irregular intake of treatment, and follow-up) in different group of patients who are either suffering or not suffering from psychiatric illness. In addition, the Pearson correlation test was used to detect the relationship between the severity of coronary affection and the level of depression or anxiety and social isolation in this group of patients. Stepwise linear regression analysis was made to explain the relationship between the severity of coronary artery affection (as dependent) and other clinical and psychometric variables (as independent). A P value less than 0.05 was considered statistically significant.
This study was conducted on 264 patients of both sexes, 178 (67.4%) male patients and 86 (32.6%) female patients with age range 30-70 years (mean age 53.68 ± 8.77 years), who were admitted to the inpatient section in Mansoura Internal Medical Hospital for diagnostic coronary arteriography.
Coronary artery affection was found in 149 patients admitted to the inpatient section in Mansoura Internal Medical Hospital for diagnostic coronary arteriography. As shown in [Table 1], they are of both sexes (113 men and 36 women) with moderate statistically significant difference (χ2 = 13.322, P < 0.01) and their mean age was higher (t = 3.570, P < 0.5), with age range 30-70 years. They were classified into four groups: group 0, patients had no coronary artery affection (115 patients); group 1, patients were atherosclerotic (94 patients); group 2, patients had one coronary artery affection (29 patients); and group 3, patients had more than one coronary artery affection (26 patients). Incidence of hypertension was high in coronary artery affected patients; of them, hypertension was present more in group 3 than in groups 2 and 1 (76.9, 51.7, and 23.4%, respectively) with highly significant statistical difference (χ2 = 51.649, P < 0.001), whereas diabetes mellitus occurred in all groups with no significant difference (χ2 = 4.973, P > 0.05). Incidence of health-related risk markers such as exercise (i.e. walk at least once weekly) was less in coronary artery affected patients, with high statistically significant difference (χ2 = 81.033, P < 0.001), whereas incidence of smoking was higher in coronary artery affected patients, with high statistically significant difference (χ2 = 45.074, P < 0.001). In addition, incidence of adherence to medication and regular doctor visits when ill was less in coronary artery affected patients, with high statistically significant difference (χ2 = 150.697, P < 0.001).
|Table 1: Comparison between patients with different stages of coronary artery diseases and those without coronary artery diseases|
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As shown in [Table 2], incidence of personality type D was more in coronary artery affected patients; of them, personality type D was present more in group 3 than in groups 2 and 1 (88.5, 41.4, 8.5, and 0.9%, respectively) with highly significant statistical difference (χ2 = 134.409, P < 0.001). Incidence of anxiety disorders [i.e. subthreshold, generalized anxiety disorder (GAD), and post-traumatic stress disorder] was more in patients with coronary artery affection, with high statistically significant difference (χ2 = 62.348, P < 0.001). Incidence of depression (i.e. subthreshold and clinical depression) was higher in patients with coronary artery affection, with high statistically significant difference (χ2 = 183.143, P < 0.001). Generally, incidence of stressful life events was higher in coronary artery affected patients, with high statically significant difference (χ2 = 37.906, P < 0.001).
|Table 2: Comparison between patients with different stages of coronary artery diseases and those without coronary artery diseases|
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There was a positive correlation between the severity of coronary arteries affection (as examined by coronary angiography) and age (r = 0.182, P < 0.01), total score of Dl4, social inhibition of Dl4, negative affectivity of Dl4, the severity of depression and anxiety, social introversion, and life events (r = 0.592, 0.527, 0.601, 0.703, 0.545, 0.698, and 0.200, respectively; P < 0.001) [Table 3]. Stepwise linear regression indicated that the severity of coronary arteries affection (as examined by coronary angiography) could be significantly predicted by adherence to medication, social introversion, sex, family history of mood disorder, and age [Table 4].
|Table 3: Severity of coronary artery affection with respect to some clinical variables|
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|Table 4: Predictors of the severity of coronary artery affection using long linear regression analysis|
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| Discussion|| |
The results of this study confirmed the notion that prolonged distress or misery accelerates the development and progression of cardiovascular diseases through many pathways. The pathways from negative affect to CAD are marked by a set of behavioral and biological mechanisms associated with exposure to depression, anxiety, and acute or chronic stress on one hand and by the outcomes of CAD and related conditions on the other (Rozanski et al., 1999; Carney et al., 2002). The behavioral pathways to coronary disease include physical inactivity, smoking, social isolation, high-fat and high-carbohydrate diets, and poor adherence to medication and self-management regimens. Each of these behavior patterns is associated with exposure to clinical depression and anxiety. Our study indicate that incidence of health-related risk markers such as exercise (i.e. walk at least once weekly) was less in coronary artery affected patients, with high statistically significant difference (χ2 = 81.033, P < 0.001), whereas incidence of smoking was higher in coronary artery affected patients, with high statistically significant difference (χ2 = 45.074, P < 0.001). In addition, incidence of adherence to medication and regular doctor visits when ill was less in coronary affected patients, with high statistically significant difference (χ2 = 150.697, P < 0.001). The strength of the association is of similar magnitude to that of the standard risk factors such as smoking or hypercholesterolemia. Cigarette smokers have almost three times increased incidence of acute MI as compared with nonsmokers (Yusuf et al., 2004), potentially establishing a causal link between increased smoking behavior in MDD and increased incidence of CAD.
In this research, the incidence of personality type D was more in coronary artery affected patients; of them, personality type D was present more in the coronary artery affected patients in group 3 than in groups 2 and 1(88.5, 41.4, 8.5, and 0.9%, respectively) with highly significant statistical difference (χ2 = 134.409, P < 0.001). Denollet et al. (1995, 1996) have examined the effect of 'type D personality' on coronary disease outcomes, a set of traits that combine a pattern of anxious and depressive feelings with a tendency toward social inhibition and isolation. In addition, there was positive correlation between the severity of coronary arteries affection and total score of Dl4, social inhibition of Dl4, negative affectivity of Dl4 (r = 0.592, 0.527, and 0.601, respectively, P < 0.001). Denollet et al. (2006) have shown in several controlled studies that people who score high on the 14-item type D questionnaire have higher early mortality rates from coronary disease. They argue that the cause of the cardiovascular system damage is not only depressed mood or feeling bad, but also the persistent pattern of feeling bad alone over many years (Denollet et al., 2006).
Nevertheless, several studies suggest a relationship between anxiety disorders and increased cardiac outcomes (Shah et al., 2004). Many studies showed that there were increased sympathetic activity (Cohen et al., 2000) and enhancement of the hypothalamus-pituitary-adrenal axis (Gerra et al., 2000) when patients were in the anxiety state, which can result in enhanced myocardial contractility, increased cardiac output, and high blood pressure. This occurred in this study where the incidence of anxiety disorders (i.e. subthreshold, GAD, and post-traumatic stress disorder) was more in patients with coronary artery affection, with high statistically significant difference (χ2 = 62.348, P < 0.001). Anxiety is a negative affective state resulting from an individual's perception of threat and is characterized by a perceived inability to predict, control, or gain the preferred results in given situations (Barlow, 1988). Anxiety appears to be linked with negative cardiac outcomes across the spectrum of cardiac disease. Individuals with elevated anxiety have higher rates of subsequent development of CAD compared with nonanxious persons, independent of other risk factors. Indeed, anxiety may be more strongly associated with the onset of cardiac disease than depression (Kubzansky and Kawachi, 2000). In particular, worry is a component of anxiety that appears to be especially associated with cardiac disease (Kubzansky et al., 2005). In patients with acute cardiovascular disease, the population most vulnerable to catastrophic cardiac events and complications, several studies have found that elevated anxiety after MI has been independently associated with in-hospital cardiac complications (Huffman et al., 2008). Multiple recent studies have also found that anxiety following MI is associated with long-term cardiac complications and mortality (Grace et al., 2004).
Severity of coronary arteries affection could be significantly predicted by positive family history of mood disorder as in [Table 4], which is one of the risk factors of depression. Several systematic reviews have summarized the evidence supporting the hypothesis that clinical depression increases the risk for both the development and progression of CAD (Rugulies 2002; Wulsin and Singal, 2003; Barth et al., 2004; Van Melle et al., 2004). In this study, incidence of depression (i.e. subthreshold and clinical depression) was higher in patients with coronary artery affection, with high statistically significant difference (χ2 = 183.143, P < 0.001). Generally, incidence of stressful life events was higher in coronary artery affected patients, with high statically significant difference (χ2 = 37.906, P < 0.001). Some indicated that depression may have behavioral and direct pathophysiologic effects on CAD. Depression is associated with nonadherence to risk factor modification in many medical conditions (Druss, 2000) such as smoking cessation (Covey et al., 2002). Poor patient compliance (Ziegelstein et al., 2000), for example, poor glycemic control in diabetic patients (Lustman et al., 2000) and poor adherence to prescribed medication in general (Carney et al., 1995) were confirmed in this study. Although the link between episodes of major depression and health risk has been emphasized (Rozanski et al., 1999), the presence of depressive symptoms has been associated with an increased risk for all causes of mortality (Wilson et al., 2003), cardiovascular disease (Anda et al., 1993), and metabolic syndrome (Räikkonen et al., 2002). Individuals with the subclinical levels of depression symptoms have difficulty with the frequency and intensity of emotion. They reported symptoms such as difficulty controlling their crying, an inability to stop feeling sad, irritability, fatigue, and lack of motivation (Beck, 1978). Although there is an ongoing debate about the relationship between major depression and subclinical depressive symptoms, Rozanski et al. (1999) concluded that continuum depression affects the relative risk for CAD (i.e. the greater the magnitude of depressive symptoms, the greater the risk for future cardiac events). Cardiac patients with as few as two or three symptoms of depression are at elevated risk for cardiac morbidity and mortality, whereas patients with more symptoms are at greater risk (Glassman et al., 2009). Many studies including a well-designed study by Frasure-Smith and Lesperance (2008) found that GAD in the setting of CAD was associated with 2-year major adverse cardiac events, independent of other patient characteristics, and a study by Strik et al. (2003) found that post-MI anxiety symptoms, independent of depression and medical characteristics, predicted recurrent cardiac events. CAD risk is directly related to the severity of depression: a 1-2-fold increase in CAD for minor depression and a 3-5-fold increase for major depression (Scheier and Bridges, 1995; Musselman et al., 1998; Kuper et al., 2002).
In this research, coronary arteries affection was positively correlated with the severity of social introversion (r = 0.698, P < 0.001). In addition, stepwise linear regression indicated that the severity of coronary arteries affection could be significantly predicted by social introversion.
Extroversion/introversion are personality traits that appear in the health literature. Extroversion includes characteristics such as sociability, friendliness, and talkativeness (McCrae and Costa, 1987), whereas introverts are the individuals who are socially uninvolved or inactive (Jackson, 1994). Higher levels of extroversion have been linked to healthier outcomes, but less is known about introversion and health. Miller et al. (1999) found low extroversion to be related to higher systolic and diastolic blood pressures, norepinephrine, and epinephrine and lower cortisol, even after controlling for behavioral practices and demographic factors. Goodwin and Friedman (2006) found that extroversion was significantly higher in those who did not have high blood pressure or a history of stroke. In addition, Grant and Langan-Fox (2007) found extroversion to be negatively correlated with physical ill health. With respect to extroversion/introversion, social relationships appear to be closely related to CVD risks; in healthy populations, a small number of social ties and low perceived emotional support have been linked to CVD over time. In patient and healthy samples, there is an inverse graded relationship between the amount of social support and the onset of CVD or cardiac events (Rozanski et al., 1999).
There was a significant positive correlation between stressful life events and the severity of coronary artery affection, as in this research (r = 0.200, P = 0.001). In the largest case-control study on predictors of MI, the INTERHEART study found that, of the 11 × 119 patients with MI in 52 countries, psychosocial factors, which included self-reports of stress and depression, were ranked as the third highest predictor of MI, raising the risk for MI by an odds ratio of 2.67, similar to smoking and diabetes (Rosengren et al., 2004). Several prospective studies on initially healthy men and women found that high anxiety at baseline increased the risk for subsequent development of arteriosclerotic plaques, carotid artery intimal thickening, nonfatal MI, and cardiac death. In the Framingham Heart Study, high levels of tension predicted an increased risk for new coronary disease and anxiety predicted an increased risk for mortality from all causes (Eaker et al., 2005).
Differences in major cardiovascular risk factors explained a substantial part of the sex difference in CAD risk. An increase in the risk factor levels was associated with the age-related increase in CAD incidence and mortality in both sexes but to a larger extent in women (Jousilahti et al., 1999). In contrast to this study, the severity of coronary arteries affection could be significantly predicted by sex and age as in [Table 4]. In both sexes, the risk for CAD increases markedly with age (Rich-Edwards et al., 1995) and among middle-aged people, CAD is two to five times more common in men than in women, and this sex ratio varies between populations (Jackson et al., 1997).
| Conclusion|| |
Anxiety, depression, personality type D, severity of social introversion, stressful life events, and other risk factors such as smoking, hypertension, diabetes mellitus in addition to lifestyle such as exercise and adherence to medication and regular doctor visits when ill are common in coronary artery affected patients during hospitalization for coronary angiography. These factors indicate that clinicians should assess patients for both anxiety and depression and continue to monitor these symptoms on a regular basis. 
| Acknowledgements|| |
Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4]