‘Worried well’ may increase their risk of heart disease

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worriedwebPeople who needlessly worry that they have, or will develop, serious illness – popularly referred to as ‘the worried well’ – may be boosting their risk of developing heart disease, suggests a large Norwegian study.

Anxiety is a known risk factor for heart disease. And health anxiety, which describes persistent preoccupation with having or acquiring a serious illness, and seeking prompt medical advice, on the basis of misattributed bodily symptoms in the absence of
any physical disease, seems to be no exception, say the researchers.

And as such, it needs to be taken seriously and treated properly, they suggest.

They base their findings on 7,052 participants of the Norwegian Hordaland Health Study (HUSK), a long term collaborative research project between the National Health Screening Service, the University of Bergen, and local health services.

The participants, all of whom were born between 1953 and 1957, filled in two questionnaires about their health, lifestyle, and educational attainment. And they had a physical check-up, consisting of blood tests, weight, height, and blood pressure measurements, taken between 1997 and 1999.

Levels of health anxiety were assessed using a validated scale (Whiteley Index), comprising 14 items scored from 1-5. Those (710) whose total score amounted to 31 or more were in the top 10% of the sample and considered to have health anxiety. The heart health of all the participants was subsequently tracked using national data on hospital treatment episodes and death certification up to the end of 2009.

Anyone who received treatment for, or whose death was linked to, coronary artery disease occurring within a year of entering the study, was excluded, on the grounds that they might already have been ill.

In all, 234 (3.3%) of the entire sample had an ischaemic event – a heart attack or bout of acute angina – during the monitoring period, with the average time to the first incident just over 7 years. But the proportion of those succumbing to heart disease was twice as high (just over 6%) among those who displayed health anxiety as it was among those who didn’t (3%).

While established risk factors for heart disease explained part of the association found, health anxiety was still linked to a heightened risk, after taking account of other potentially influential factors.

Those with health anxiety at the start of the study were 73% more likely to develop heart disease than those who weren’t in this state of mind, the analysis showed. And the higher the Whiteley Index score, the greater was the risk of developing heart disease.

This is an observational study, so no firm conclusions can be drawn about cause and effect, added to which the researchers admit that health anxiety often exists alongside other mental health issues, such as general anxiety and depression, making it hard to differentiate. But the findings back current thinking on the potentially harmful effects of anxiety on health, they say.

“(Our research) further indicates that characteristic behaviour among persons with health anxiety, such as monitoring and frequent check-ups of symptoms, does not reduce the risk of (coronary heart disease) events,” they write.

If anything, putting the body on a permanent state of high alert may have the opposite effect, they suggest.

“These findings illustrate the dilemma for clinicians between reassuring the patient that current physical symptoms of anxiety do not represent heart disease, contrasted against the emerging knowledge on how anxiety, over time, may be causally associated with increased risk of (coronary artery disease),” they conclude. The findings “underline the importance of proper diagnosis and treatment of health anxiety,” they add.

Background: The risk of ischaemic heart disease (IHD) is largely influenced by lifestyle. Interestingly, cohort studies show that anxiety in general is associated with increased risk of IHD, independent of established risk factors for cardiovascular disease. Health anxiety is a specific type of anxiety characterised by preoccupation of having, acquiring or possibly avoiding illness, yet little is known about lifestyle and risk of disease development in this group.
Aim: Investigate whether health anxiety is prospectively associated with IHD, and whether a potential association can be explained by the presence or absence of established risk factors for cardiovascular diseases.
Methods: Incident IHD was studied among 7052 participants in the community-based Hordaland Health Study (HUSK) during 12 years follow-up by linkage to the Cardiovascular Diseases in Norway (CVDNOR) project. Scores above 90th centile of the Whiteley Index defined health anxiety cases. Associations were examined with the Cox proportional regression models.
Results: During follow-up, 6.1% of health anxiety cases developed IHD compared with 3.0% of non-cases, yielding a gender-adjusted HR of 2.12 (95% CI 1.52 to 2.95). After adjustments for established cardiovascular risk factors, about 70% increased risk of IHD was found among cases with health anxiety (HR: 1.73 (95% CI 1.21 to 2.48)). The association followed a dose–response pattern.
Conclusions: This finding corroborates and extends the understanding of anxiety in various forms as a risk factor for IHD. New evidence of negative consequences over time underlines the importance of proper diagnosis and treatment for health anxiety.

Line Iden Berge, Jens Christoffer Skogen, Gerhard Sulo, Jannicke Igland, Ingvard Wilhelmsen, Stein Emil Vollset, Grethe S Tell, Ann Kristin Knudsen

BMJ material
BMJ Open abstract

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