Cardiac Anxiety in Adults with Cardiovascular Disease: Prevalence, Predictors, and Implications for Cardiac Rehabilitation - A Systematic Review.

Background

Heart-focused anxiety (HFA) is a disease-specific construct characterised by fear of cardiac sensations, attentional hypervigilance, and behavioural avoidance of exertion. It is conceptually related to, but empirically separable from, generalized anxiety, but is rarely screened for in cardiac rehabilitation (CR). No prior systematic review has synthesised evidence on its prevalence, predictors, or CR implications.

Methods

PubMed, CINAHL, PsycINFO, and the Cochrane Library were searched following PRISMA 2020 guidelines. Eligible studies measured HFA using the Cardiac Anxiety Questionnaire (CAQ) or Herzangstfragebogen (HAF-17) in adults with confirmed cardiovascular disease (CVD). Cross-sectional, cohort, validation, and intervention designs were eligible. Quality was appraised using NIH NHLBI Study Quality Assessment Tools and Cochrane Rob-2. Narrative synthesis was performed. This systematic review was prospectively registered on PROSPERO (CRD420261394690).

Results

Twenty-six studies, with a combined enrolled sample of 9,628 patients across eight countries were included. Clinically elevated HFA ranged from 15% to 49% depending on the population, timing of assessment, and CAQ cut-off used. HFA was associated with depressive symptoms, illness perception, and impaired quality of life, and findings suggests a bidirectional relationship with physical inactivity. HFA independently predicted major adverse cardiac events and mortality post-MI in two prospective cohorts (HR range 1.30-1.59), with avoidance as the primary driver. Standard CR, specialised psychocardiological CR, device therapy, and early mobilisation were associated with reductions in HFA.

Conclusions

HFA is prevalent across CVD diagnoses and was independently prognostic for adverse cardiovascular outcomes in two prospective cohorts. Several rehabilitation and psychological interventions were associated with HFA reductions, though the evidence remains largely observational. Routine CAQ screening at CR intake and targeted cognitive behavioural interventions for patients with elevated HFA warrant evaluation in future prospective studies.