The Influence of Anxiety and Depression on Outcomes of Patients With Coronary Artery Disease

F or years, patients with cardiac disease have been thought to exhibit characteristic emo-tional features. However, the modern understanding of the relationship between affec-tive disorders and the heart may be traced to the mid-19th century, with the publica-tion of Williams ’ seminal text regarding “nervous and sympathetic palpitations of the heart.”1 This was followed through the late 1800s by numerous works that described the concept of neurologically based, or “neurasthenic, ” cardiac disorders. In the 20th century, large advances occurred in the area of mood-related issues that pertained to coronary artery disease (CAD) and sudden cardiac death (SCD). In his 1910 Lumleian lecture, Sir William Osler described his typical patient with angina pectoris as “a man whose engine is always set full speed ahead ” and further noted his patients with cardiac disease to be “worriers.”2 The Menningers,3 in early psychoanalytic studies, described a characteristic tendency to suppress anger among patients with CAD, as did Helen Flanders Dunbar,4 a pioneer of psychosomatic medicine. More recently, Stewart Wolf, in his 1969 lecture “Psychosocial Forces in Myocardial Infarction and Sudden Death, ” commented on a phenomenon of “joyless striving ” among his patients with heart disease.5 The results of work conducted in the 20th century suggested that several psychoso-cial risk factors contribute to the devel-opment of cardiovascular disease and in-