Depression and health-related quality of life in cardiovascular patients: A cross-sectional study on the mediating roles of fear, attention, and avoidance

Depression and anxiety are prevalent among patients with cardiovascular disease (CVD) and detrimentally affect their health-related quality of life (HRQoL). Although current guidelines recommend screening for both conditions, the mechanisms underlying the association between depression and HRQoL, particularly through the anxiety subdomains of fear, attention, and avoidance, remain unclear. This study investigates how anxiety-related factors mediate the relationship between depression and HRQoL in patients with CVD. This cross-sectional study analyzed 204 CVD outpatients from a tertiary hospital in South Korea. Each patient completed the Patient Health Questionnaire-9 to assess depression, the Cardiac Anxiety Questionnaire to evaluate anxiety subdomains, and the 12-Item Short Form Health Survey to measure HRQoL. Serial multiple mediation analyses were conducted to examine the direct and indirect associations between depression and HRQoL. This approach allowed the potential pathways of mediators to be simultaneously tested, particularly the sequential path from fear to attention to avoidance. Higher depression scores showed a significant negative association with HRQoL (total effect: β = -0.5449, P < .001). Moreover, indirect pathways were observed: increased depression was associated with heightened levels of fear, attention, and avoidance. The direct association between depression and HRQoL remained significant when the indirect pathways were controlled (β = -0.3888, P < .001), supporting a partial mediation model. The overall mediation model explained 18% of the variance in HRQoL. Our findings suggest that a complex interplay between depression and anxiety subdomains influences quality of life among patients with CVD. Therefore, future prospective or interventional studies are needed to evaluate whether interventions targeting depressive symptoms and maladaptive anxiety responses can improve HRQoL in this population.