Cardiovascular diseases are the leading cause of death worldwide. Mental disorders like anxiety and depression are common among cardiovascular patients. These mental disorders have adverse effect on quality of life among these patients which further increases mortality and morbidity among them.

Objective: The propose of this study was to assess the effect of anxiety and depression on quality of life among cardiovascular patients.

Methods: A Cross Sectional study was performed at Sir Ganga Ram Hospital Lahore. 100 patients of CVD were selected by non-probability sampling technique. All adults of both genders aged above 18 years having diagnosed cardiovascular disease, Hospital Anxiety and Depression Scale (HADS) was used to measure the anxiety and depression and WHOQOL was used to assess the quality of life of patients.

Results: Out of total 100 patients 53 were males and 47 were females. The mean age of patients was 54.87 ± 16.66. Among CVD patients 52 were borderline cases and 33 were abnormal cases of anxiety. 56 cases were borderline and 28 were abnormal cases of depression. Anxiety and depression had adverse effect on quality of life among cardiovascular patients. Low scores were found for physical, psychological and environmental domains of WHOQOL. A significant association was found between social relationships domain of WHOQOL with anxiety and depression and the level of significance was p-values 0.016 and 0.043 respectively. There was significant association between psychological domain of QoL with depression (P=0.039) and monthly income (P=0.016). There was insignificant Association between educational level, sex, age with QoL, anxiety and depression.

Conclusion: Study concluded that anxiety and depression have negative impact on quality of life and are risk factors for health related quality of life among cardiovascular disease patients. People attending medical care are usually  not being assessed for anxiety  due to lack of facilities ,lack of understanding of disease and over burden of patients. They are responsible for greater mortality and morbidity in cardiovascular disease patients. The depression and Anxiety are the mediating factors and it must be taken into consideration in clinical practices when quality of life is considered as a clinical prerequisite.

Keywords: cardiovascular disease patients, anxiety, depression, quality of life

According to WHO by year 2020 cardiovascular disease and anxiety will result in major disability of life.¹ Anxiety disorders are very common medical health condition in the US and effecting the developing countries as well.  CVD anxiety and depression are rapidly emerging and are matter of major and growing concern in both developing and devolved countries. Anxiety disorders also affect the developed countries like Pakistan about 40 million adults of age group 18 and above.² Anxiety disorders with a 12-month prevalence rate of 17.7% and higher life time prevalence in women 30.5% than men 19.2% are among the most common psychiatric diagnosis.³ CVDs are the common cause of death globally and take lives of 17.7 million people every year. And 3.6 million in south Asia.⁴ Among CVD females risk of depression is higher than men but cardiac prognosis was worse for male.⁵ Approximately one out every five patients suffering from cardiovascular have major depressive disorder⁶  worldwide major depressive disorder(MMD) was the 4^th leading cause of disability in 2002 and by 2020 MMD will result in 2^nd leading cause of disability worldwide.⁷ Most of all mental disorders are because of change in behaviors leading to reduced physical activity, an unhealthy diet, sleeplessness, sedentary lifestyle, increased catecholamine, smoking, alcohol and addiction are the leading cause of anxiety and CVD on both sexes men and women.^8,9 Quality of life has become an important outcome in patients with heart failure. Poor Quality of life is one of the most important characteristics of heart failure.¹⁰ Most studies showed that depression and anxiety were associated with poor Quality of life in patients with heart failure.¹¹ Out of 200million population, one out of three are suffering from these curable diseases.¹² Pakistan contributes a greater share to the global burden of cardiovascular diseases. Pakistan contributes a greater share to the global burden of cardiovascular diseases. CVDs are now the leading cause of death in Pakistan. Prevalence of these disorders are slightly higher in urban areas as compared to the rural areas.¹³

As indicated by research done by Imtiaz Dogar in Pakistan shows high prevalence of anxiety and depression in cardiac patients which is responsible for greater risk of morbidity and mortality. Hence the timely investigation of anxiety and depression disorders in cardiac patients and their referral to psychiatrists and psychologists can plays role in good prognosis of patients.¹⁴ Study conducted by Kyrouf I, Kollia N et al., to find out the association (2002–2012), between depression and anxiety status with 10-year cardiovascular disease incidence among apparently healthy Greek adults in his study 853 members were participated without previous history of CVD 453 men were men and 400 women. And they reported depression and anxiety levels were positively and independently associated with the 10-year CVD incidence, with depression markedly increasing the CVD risk by approximately fourfold.¹⁵ A cross sectional study carried out in Afghanistan in 2015 – 2016 by Hamrah MS et al., to access the wide spread interrelationship of depression and anxiety in hypertensive patients in Afghanistan with depression and anxiety among adult hypertensive out patient in Afghanistan. A total of 234 hypertensive patients were enrolled from which 34.6% were males and 65.4 were females and the average age was 54.6 +12.7 for the hypertensive patient with anxiety and 63.8 +15.0 with depression and 49 +10.2 for general population. It was concluded that depression and anxiety were common in hypertensive patients and further studies were needed and preventive strategies to control psychological problems¹⁶ by Kemp AH, Quintana DS et al., in (2006-2007) to determine depression, ailments of anxiety, and discrepancy of heart rate in healthy patient’s implication for CVD risk. Major depressive disorder patients of which 24 patients were without anxiety 24 with general anxiety disorder and 14 with Parkinson Disease and 94 healthy aged people. These people had no previous record of drug abuse, stroke or any other medical problems these four groups had almost same age gender and BMI. Heart rate variability (HRV) was recorded in these people in resting state condition. The results show that there was decrease in HRV in MDD patients than control ones. And those patients with GAD had the greatest decrease in HRV.¹⁷ A cross sectional study conducted by Hallas CN et al., at United Kingdom 146 patients were examined to determine the psychological and clinical variables predicting mood and quality of life among heart failure (HF). And it was found that depressed and anxious patients have more negative beliefs about Heart Failure, which is responsible for poor quality of life and negative coping behavior.¹⁸

A Cross Sectional study performed at Sir Ganga Ram Hospital Lahore for period of 4 months. 100 patients of CVD were selected by non-probability sampling technique. All adults of both genders aged above 18 years having diagnosed cardiovascular disease attending Tertiary Care Hospitals, Lahore. Hospital Anxiety and Depression Scale (HADS) was used to measure the anxiety and depression and WHOQOL was used to assess the quality of life of patients. Data were collected by pretested questionnaire and analyzed by using Statistical Packages for Social Sciences (SPSS) version 21.

In current study data was collected from 100 cardiovascular the results revealed that the majority of patients were male i.e. 53 and 47 were females of the total population. 53 patients were from urban areas and 47 were from rural areas.46 patients belonged to middle class, 44 patients belonged to lower class while 9 Patients were from upper middle class and 1 patient were from upper class.19 patients were illiterate, 21 patients attended primary school, 37 attended secondary school and 23 attended territory school. As shown in Table 1.

According to the first aim of the study was to find the effect of depression and anxiety among cvd patients Analysis showed that out of all the 100 patients of cardiovascular disease, higher anxiety was observed among cardiovascular patients i.e. 15 patients were not having anxiety, 52 were borderline cases of anxiety and 33 falling in the range of abnormally high anxiety as shown in Figure 1. While in the case of depression higher depression was observed among CVD patients i.e. 16 normal and 56 were of borderline cases of depression and 28 were having abnormally severe depression as shown in Figure 1.

Figure 1 Frequency of cardiovascular patients according to different levels of anxiety.

As, per the second aim of the study; to find out the effect on quality of life among CVD patients, A strong significant association between social relationships domain of WHOQOL with anxiety and depression and the level of significance was p-values 0.016 and 0.043 respectively. As shown in Table 2.

There was insignificant association between Anxiety (P=0.440) and Depression (P=0.809) on Environmental Domain of WHOQOL among cardiovascular patients as shown in Table 3.

There was significant association between psychological domain of WHOQOL with depression (P=0.039) while with Anxiety there was insignificant association (P=0.143) as shown in Table 4. There was insignificant association between Anxiety (P=0.835) and Depression (P=0.439) on Physical Health Domain of WHOQOL among Cardiovascular patients as shown in Table 5.

There was insignificant Association between educational level, sex, age with QoL, anxiety and depression.

The current study was aimed to find the effect of anxiety and depression on quality of life among patients with cardiovascular disease by using Hospital Anxiety and Depression scale to determine the levels of anxiety and depression that a person is experiencing a cross sectional study done by Frasure-Smith Net al., also used similar scale.¹⁹ A study conducted by Dickens et al., to examine the effect of depression on health related quality of life among coronary heart disease patients according to Dickens et al., it was noticed that only the depression not having the significant effect on health related quality of life among CHD patients but depression and anxiety both had significant effect on health related quality of life among coronary disease patients.²⁰ Present results showed that 53% males and 47% females were suffering from cardiovascular disease. A study carried out by Lerner DJ et al., showed that the incidence of CHD among men was considerably high than that in women almost a 2:1 ratio of male to female CHD patients in the population. Current study generally confirmed these findings but suggests that the sex differential may not be as large as was previously suggested.²¹ There is contradiction about the distribution of cardic disease in male and female genders because different studies showed different results. A study conducted by Maas AH et al., in 2010²² showed that cardiovascular diseases were more common in women than men however the risk of heart disease was often underestimated. While study conducted by Ko HY et al., in 2015 showed that there were no differences between male and female genders.²³ In current results no significant relationship between the level of education and CVD had been established on the other hand educational level of the patients with CVD was found to be significantly lower. the proportion of male patients was found to be 52.5 % and there was no significant relation between gender and QoL and study conducted by Çeviker K et al., also revealed corresponding results.²⁴ The current study showed that anxiety and depression had been negatively associated with health related quality of life. Similar results were found by study conducted by Lim Let al., in 2012.²⁵ The current study showed a strong significant association between social relationships domain of WHOQOL with anxiety and depression and the level of significance was p-values 0.016 and 0.043 respectively. A cross sectional study conducted by Ola BA et al., to evaluate the relationship between depression and health-related quality of life (QoL) among heart failure (HF) Patients and it was found that patients suffering from major depressive disorder MDD had worse QoL on dimensions of psychological health, physical health and environment.²⁶ Further studies which correlate with current study were Juenger J (2002) and Jiang W (2001) they found that depression significantly associated with poorer QoL in patients with HF.^27,28

Study concluded that there was an association between anxiety and depression on quality of life among cvd patients. Depression and anxiety were risk factors for Health related quality of life among cvd patients in addition, it was concluded that People attending medical care are not being assessed for anxiety and due to lack of facilities and lack of understanding of disease. They are responsible for greater mortality and morbidity in cardiovascular disease patients. The depression and Anxiety are the mediating factors and it must be taken into consideration in clinical practices when quality of life is considered as a clinical prerequisite. Early diagnosis of these psychological conditions can improve quality of life among cvd patients.

None.

The author declares there are no conflicts of interest.

1. Murray CJ, Lopez AD. World Health Organization. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020.
2. De Hert M, Detraux J, Van Winkel R, et al. Metabolic and cardiovascular adverse effects associated with antipsychotic drugs. Nature Reviews Endocrinology. 2012;8(2):114–126.
3. Skarl S. Anxiety and Depression Association of America. Journal of Consumer Health on the Internet. 2015;19(2):100–106.
4. Ouakinin SR. Anxiety as a risk factor for cardiovascular diseases. Frontiers in psychiatry. 2016;7:25.
5. Laslett LJ, Alagona P, Clark BA, et al. The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology. Journal of the American College of Cardiology. 2012;60(25 Supplement):1–49.
6. Elderon L, Whooley MA. Depression and cardiovascular disease. Progress in cardiovascular diseases. 2013;55(6):511–523.
7. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS medicine. 2006;3(11):442.
8. Raison CL, Capuron L, Miller AH. Cytokines sing the blues: inflammation and the pathogenesis of depression. Trends in immunology. 2006;27(1):24–31.
9. Bonnet F, Irving K, Terra JL, et al. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. 2005;178(2):339–344.
10. Chung ML, Moser DK, Lennie TA, et al. The effects of depressive symptoms and anxiety on quality of life in patients with heart failure and their spouses: Testing dyadic dynamics using Actor–Partner Interdependence Model. Journal of psychosomatic research. 2009;67(1):29–35.
11. Cully JA, Phillips LL, Kunik ME, et al. Predicting quality of life in veterans with heart failure: the role of disease severity, depression, and comorbid anxiety. Behavioral Medicine. 2010;36(2):70–76.
12. Arif A, Naveed S, Aslam R. Factors causing stress among Pakistani working women. Pakistan Administrative Review. 2017;1(3):159–174.
13. Abbasi IN, Gajoo DH, Kumar S, et al. Pattern of cardiovascular diseases according to age and gender in a rural district of Pakistan. Pakistan Heart Journal. 2013;46(3).
14. Dogar IA, Khawaja IS, Azeem MW, et al. Prevalence and risk factors for depression and anxiety in hospitalized cardiac patients in Pakistan. Psychiatry (Edgmont). 2008;5(2):38–41.
15. Kyrou I, Kollia N, Panagiotakos D, et al. Association of depression and anxiety status with 10-year cardiovascular disease incidence among apparently healthy Greek adults: the ATTICA study. European journal of preventive cardiology. 2017;24(2):145–152.
16. Hamrah MS, Hamrah MH, Ishii H, et al. Anxiety and Depression among Hypertensive Outpatients in Afghanistan: A Cross-Sectional Study in Andkhoy City. International journal of hypertension. 2018;2018.
17. Kemp AH, Quintana DS, Felmingham KL, et al. Depression, comorbid anxiety disorders, and heart rate variability in physically healthy, unmedicated patients: implications for cardiovascular risk. PloS one. 2012;7(2):e30777.
18. Hallas CN, Wray J, Andreou P. Depression and perceptions about heart failure predict quality of life in patients with advanced heart failure. Heart & lung. 2011;40(2):111–121.
19. Frasure-Smith N, Lespérance F. Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Archives of general psychiatry. 2008;65(1):62–71.
20. Dickens C, Cherrington A, McGowan L. Do cognitive and behavioral factors mediate the impact of depression on medical outcomes in people with coronary heart disease? Journal of cardiopulmonary rehabilitation and prevention. 2011;31(2):105–110.
21. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. American heart journal. 1986;111(2):383–390.
22. Maas AH, Appelman YE. Gender differences in coronary heart disease. Netherlands Heart Journal. 2010;18(12):598–603.
23. Ko HY, Lee JK, Shin JY. Health-related quality of life and cardiovascular disease risk in Korean adults. Korean journal of family medicine. 2015;36(6):349–356.
24. Çeviker K, Şahinalp Ş, Çiçek E, et al. Quality of life in patients with chronic venous disease in Turkey: influence of different treatment modalities at 6-month follow-up. Quality of Life Research. 2016;25(6):1527–1536.
25. Lim L, Jin AZ, Ng TP. Anxiety and depression, chronic physical conditions, and quality of life in an urban population sample study. Social psychiatry and psychiatric epidemiology. 2012;47(7):1047–1053.
26. Ola BA, Adewuya AO, Ajayi OE, et al. Relationship between depression and quality of life in Nigerian outpatients with heart failure. Journal of psychosomatic research. 2006;61(6):797–800.
27. Juenger J, Schellberg D, Kraemer S, et al. Health related quality of life in patients with congestive heart failure: comparison with other chronic diseases and relation to functional variables. 2002;87(3):235–241.
28. Jiang W, Alexander J, Christopher E, et al. Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure. Archives of internal medicine. 2001;161(15):1849–1856.