Panic Attacks in Postmenopausal Women Increase Risk of CV Events

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October 15, 2007 By Grendel Burrell [1]

Panic attacks may be a harbinger of coronary heart disease. Postmenopausal women who have panic attacks appear to be at higher risk for cardiovascular disease and death. Dr. Jordan Smoller, Massachusetts General Hospital, and coauthors report their findings in the October 2007 issue of the Archives of General Psychiatry. (1). Researchers followed 3,300 post-menopausal women, ages 51 to 83, enrolled in the Myocardial Ischemia and Migraine Study (MIMS) from 1997-2000. The MIMS consisted of a subset of 10 of the 40 sites enrolled in the Women’s Health Initiative Observational Study, which is assessing risk factors for heart disease, fractures, cancer and other causes of mortality among > 93,000 postmenopausal women. The objective of MIMS was to investigate the relationships among migraine, ischemia as measured on a 24-hour ambulatory ECG Holter monitor, and panic symptoms. Participants enrolled in the WHI clinical trials of hormone therapy or dietary modification were ineligible for the WHI Observational Study and, thus, for MIMS.

The women completed a questionnaire about occurrence of panic attacks in the previous six months and migraine headaches prior to being fitted with Holter monitor. A full blown panic attack was defined as an attack of sudden fear, anxiety, or extreme discomfort during the past 6 months accompanied by 4 or more panic attack symptoms from a checklist. A limited symptom panic attack was defined similarly but with the presence of fewer symptoms from the checklist.

Cardiovascular/cerebrovascular outcomes (fatal and nonfatal myocardial infarction and stroke) and all-cause mortality were measured after a mean follow up of 5.3. The authors found that a history of full-blown panic attacks over six months was associated with a more than fourfold increased risk of fatal or nonfatal MI and a nearly 3-fold increased risk of the combined end point of CHD and stroke. The hazard ratio for all-cause mortality, excluding those with a history of cardiovascular/cerebrovascular events, was 1.75 (95% confidence interval, 1.04-2.94).

In this study women who had panic attacks were also more likely to smoke, and be hypertensive, diabetic and have symptoms of depression as well as a history of cardiovascular problems. For women who had had even one panic attack during the six-month period, risk remained. The authors state that the study “adds panic attacks to the list of emotional states and psychiatric symptoms that have been linked to excess risk of cardiovascular disease and death in nonclinical samples.” In this study, the association of panic attacks with CHD and CHD or stroke persisted after the authors controlled for major CV risk factors including history of CV disease. Does anxiety itself have adverse cardiovascular effects? Studies have suggested that episodes of anger, anxiety, or depression in mood may initiate acute coronary ischemia (2, 3). Steptoe et al found that the odds of ACS following depressed mood were 2.50 (95% confidence intervals 1.05 to 6.56) in their pair-matched analysis, while the relative risk of ACS onset following depressed mood was 4.33 (95% confidence intervals 3.39 to 6.11) compared with usual levels of depressed mood. Depressed mood preceding ACS onset was more common in lower income patients (p=0.032), and was associated with recent life stress, but was not related to psychiatric status. They concluded that acute depressed mood might elicit biological responses including vascular endothelial dysfunction, inflammatory cytokine release, and platelet activation that contribute to ACS (4). In a previous study of the MIMS group by Smoller et al, the authors observed an increased risk of ischemic chest pain, but not silent ischemia during 24-hour Holter monitors in postmenopausal women with a 6-month history of panic attack (odds ration 4.94;95% CI, 1.41-17.30) (5) An analysis published in 2003 by Smoller et al demonstrated that full-blown panic attacks were more common in women with a history of migraine, emphysema, cardiovascular disease, chest pain during ambulatory electrocardiography, and those with symptoms of depression. Full-blown panic attacks were associated in a dose-response manner with negative life events during the previous year. Panic attacks were associated with functional impairment even after adjusting for comorbid medical conditions and depression. There was no significant association with self-reported use of hormone replacement therapy (6). The Nurses’ Health Study found that among women (mean age, 54 years) with no history of cardiovascular disease, high levels of phobic anxiety were associated with increased risk of fatal coronary heart disease (CHD) after 12 years of follow-up (97 SCDs, 267 CHD deaths, and 930 nonfatal MIs). The authors stated, “After control for possible intermediaries (hypertension, diabetes, and elevated cholesterol), a trend toward an increased risk persisted for SCD (P=0.06)” (7).

The results of the current study by Smoller et al suggest that panic attack is a marker for increased risk of CV morbidity and mortality in postmenopausal women. They call for future studies to clarify if there is a causal connection, and if so, to define it. Older women with a recent history of panic attack represent a subgroup at elevated risk of MI and stroke. This group may warrant careful monitoring and modification of cardiovascular risks.


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