Panic Attacks May Be an Independent Risk Factor for Cardiovascular Disease

October 8, 2007 — A new analysis of data from a substudy of the Women's Health Initiative Observational Study suggests panic attacks may be an independent risk factor for cardiovascular morbidity and mortality.
Postmenopausal women in this study who reported having had a panic attack in the previous 6 months had a 4-fold increased risk for coronary heart disease (CHD) and a 3-fold increased risk for the combined endpoint of CHD and stroke for approximately 5 years of follow-up. The risk persisted after controlling for known cardiovascular risk factors and was similar in magnitude to other established risk factors.
"Although it was quite a significant increase in relative risk, the absolute numbers of women who had those outcomes was still relatively small," first author Jordan W. Smoller, MD, ScD, from Harvard Medical School and Massachusetts General Hospital in Boston, told Medscape Psychiatry.
"On the clinical side, this may identify a subgroup of women who warrant additional monitoring or assessment of their overall cardiac risk," Dr. Smoller said.
The report appears in the October issue of the Archives of General Psychiatry.
Depression, Phobic Anxiety, Panic Attacks
The new findings related to panic attacks are consistent with previous studies that have implicated negative emotional states and psychological symptoms in cardiovascular outcomes, Dr. Smoller said. For example, previous work has shown an association between depression and phobic anxiety and cardiovascular morbidity and mortality. "This is the first large prospective study to look at panic attacks in particular," he said.
Panic attacks involve sudden episodes of fear, anxiety, or extreme discomfort accompanied by 4 or more associated cognitive or autonomic symptoms, the study authors write. Panic attacks may occur sporadically or as a feature of several anxiety disorders, including panic disorder, social anxiety disorder, and specific phobias.
The present report, called the Myocardial Ischemia and Migraine Study (MIMS), is an ancillary study of the Women's Health Initiative Observational Study, an ongoing, multicenter prospective survey of risk factors for heart disease, cancer, fractures, and other causes of morbidity and mortality among 93,676 postmenopausal women.
MIMS was carried out at 10 of the 40 centers that participated in the Women's Health Initiative. Included were 3369 community-dwelling, generally healthy postmenopausal women aged 51 to 83 years. They were enrolled between 1997 and 2000 and completed a questionnaire about the occurrence of panic attack within the last 6 months.
The study authors report that 10% of women reported full-blown panic attacks. "It was surprising how common it was," Dr. Smoller said. "We had a somewhat broad definition of panic attacks, but previous studies had suggested the frequency would not be as high as 10%, but closer to 1% or 2%."
A 6-month history of panic attack was associated with a 4-fold increase in CHD, as well as an increased risk for the combined endpoint of CHD and stroke. After excluding those with a history of cardiovascular and cerebrovascular events, there was still an increased risk for all-cause mortality associated with panic attacks.
"The study doesn't really address whether this is a direct effect of anxiety on the cardiovascular system or whether panic attacks were a proxy for some other risk factor, although we controlled for known risk factors and it did not seem due to those," Dr. Smoller said. It is possible that because panic attacks have symptoms that overlap with cardiovascular and pulmonary disease, these symptoms may represent unrecognized symptoms of underlying disease, he noted.
However, there is evidence from previous studies that physiologic aspects of panic attacks have effects on the cardiovascular system. For example, panic attacks can reduce heart rate variability. Stress hormones that accompany panic attacks can have adverse effects on the cardiovascular system or increase cardiac ischemia, "but again, at this level, it's just a hypothesis because we were not able to look directly at that," Dr. Smoller said.
"We also don't know from this study whether treating panic has any effect on cardiac outcomes, and that would obviously be an important question for follow-up studies," he noted.
Finally, Dr. Smoller pointed out that because the question asked was simply whether these women had had a panic attack in the last 6 months, those who said they had would include both those with a single panic attack and those with chronic, severe, recurrent panic disorder. "So we can't look at the effect of frequency or severity of the panic in the association here. For example, panic attacks can occur as part of a number of psychiatric conditions including anxiety disorders and depression, or sometimes be related to medical conditions, or substances, or medications, and we couldn't really tease that apart."
The Women's Health Initiative program is funded by the National Heart, Lung, and Blood Institute, US Department of Health and Human Services. Glaxo Wellcome (now GlaxoSmithKline) has funded the MIMS. Dr. Smoller has disclosed receiving honoraria from Hoffman-La Roche, Inc; has served on an advisory board for Roche Diagnostics Corp; and may receive an honorarium for a lecture he may give to an Eli Lilly and Co Advisory Board in the near future. The complete list of disclosures is available in the original article.
Arch Gen Psychiatry. 2007;64:1153-1160.

Panic attacks may hike heart attack risk

By CARLA K. JOHNSON, Associated Press WriterMon Oct 1, 4:06 PM ET
The rapid pulse and shortness of breath of a panic attack can feel like a heart attack, and it may signal heart trouble down the road, a study of more than 3,000 older women suggests.
Women who reported at least one full-blown panic attack during a six-month period were three times more likely to have a heart attack or stroke over the next five years than women who didn't report a panic attack.
The researchers took into account other risk factors such as smoking, high blood pressure, inactivity and depression and still found that panic attacks raised risk.
The findings add panic attacks to a list of mental health issues — depression, fear, hostility and anxiety — already linked in previous research to heart problems, said study co-author Dr. Jordan Smoller of Boston's Massachusetts General Hospital.
"Postmenopausal women who are experiencing panic attacks may be a subgroup with elevated risk," Smoller said. "Monitoring them and reducing their cardiovascular risk may be important."
The study, published in Monday's Archives of General Psychiatry, wasn't designed to explain the link, Smoller said. He speculated that a panic attack may trigger heart rhythm problems or that stress hormones released during an attack may harm the heart.
The findings don't surprise Susie Rissler, 51, of Terre Haute, Ind. A panic attack sufferer since childhood, she's also has had three mini-strokes.
"You feel like the whole world is caving in," Rissler said of her panic attacks, which can include a racing heartbeat and chest pains. "I've had shaking, sweating, curling up in a ball totally afraid to even look around. Panic attacks can really destroy a person in a lot of different ways."
Some of the reported panic symptoms may have been heart problems in disguise, Smoller said. Symptoms such as racing heart, chest pain or shortness of breath, experienced as a panic attack, may have been caused by an undiagnosed heart problem.
"One study doesn't settle a question," he cautioned. "The number of events seen in this sample is still relatively small." Forty-one of the 3,243 women in the analysis had a heart attack or death from a heart problem. An additional 40 had strokes.
The study, which enrolled women from 1997-2000 and followed them for five years, was funded by the drug company Glaxo Wellcome, which is now GlaxoSmithKline PLC. The company makes Paxil, an anti-anxiety drug. Some of the study's co-authors reported financial ties to that company and others.
The research relied on the women's memories, rather than doctors' diagnoses, which could be considered a weakness of the study, said Dr. JoAnn Manson of Harvard's Brigham and Women's Hospital. But Manson, who wasn't involved in the study, said it's likely the findings point to a real connection between panic and heart problems.
"It does tie together very well with what we know about the biology and physiology of the stress hormones," Manson said. "I think it does suggest that this is something to discuss with your doctor" for women prone to panic attacks.
Previous research has found that panic attacks are more common in women than in men. The researchers found that 330 of the women, ages 51 to 83 years at the start of the study, reported a full-blown panic attack during the previous six months. Of those, about 4 percent, went on to have a heart attack or stroke. That compares with 2 percent of the women who reported no panic attacks but who had heart attacks or strokes.
Once the researchers adjusted for other health factors, they found the heart and stroke risk three times greater among women who had panic attacks.
A full-blown attack was defined as a sudden attack of fear, anxiety or discomfort accompanied by at least four of 12 symptoms, such as shortness of breath.
Laura Kubzansky of the Harvard School of Public Health, who wasn't involved in the new study but does similar research, said stress hormones may cause immediate heart damage or wear-and-tear over time. During panic, "the body is flooded with hormones that in the short run help the body cope with an emergency, but in the long run take a toll," she said.
While treating panic with medication may help some people with the psychological distress, there's no evidence yet that medication alone reduces heart risk, Kubzansky said.
"We still don't know how best to address this or how reversible these effects are," Kubzansky said.
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