Symptoms of Anxiety and Heart Disease May Overlap in Women

Extract from Interview with Dr. Kim Lavoie, published February 26, 2016

Medical Research: What is the background for this study?

Dr. Lavoie: We were interested in looking at whether rates of ischemia in men and women were different as a function of whether or not you had pre-existing heart disease (we would expect those with existing heart disease to have more ischemia because it’s a major marker of disease) or a comorbid anxiety or mood disorder (we expected anx/mood disorders would be associated with higher rates of ischemia because they reflect clinical levels of chronic stress, which has been linked to higher rates of ischemia in previous studies).

Medical Research: What are the main findings?

Dr. Lavoie: Overall, we found that men have higher rates of ischemia than women, and that anxiety or mood disorders overall aren’t associated with higher or lower risk of ischemia (in those with or without previously diagnosed heart disease).

HOWEVER, what we did find that was interesting and perhaps new, was that if you looked within women, those without previously diagnosed heart disease AND anxiety disorders (which including things like panic disorder and generalized anxiety – panickers and worriers) had higher rates of ischemia compared to those without anxiety disorders. This suggests higher rates of ischemia among women without heart disease, which seems counter-intuitive because you would expect those WITH disease to have more ischemia. The fact that anxiety disorders were present in those without previously diagnosed heart disease – and they were the ones with more ischemia, suggests that these women likely HAD heart disease that just hadn’t been diagnosed up yet, and that the reason might have been because of their anxiety disorder, which can mask many symptoms of heart disease because many of them overlap (e.g., fatigue, decreased energy, heart palpitations, sweating, chest discomfort, hyperventilation, and fear/worry). This could lead physicians to misinterpret symptoms of real heart disease as those of anxiety – but this only appears to be the case in women according to our study, suggesting a possible sex/gender bias here.

Medical Research: What should clinicians and patients take away from your report?

Dr. Lavoie: Clinicians need to recognize three things:

  • (1) that anxiety disorders present with symptoms that are the same as those of heart disease (as mentioned above), and may mask the existence of heart disease if you don’t conduct objective tests like we did in this study (single photon computed emission tomography are 3 dimensional dynamic x-rays that are very good at detected heart disease);
  • (2) that sex/gender bias with regard to psychological disorders may still exist, and continue to negatively bias physicians’ clinical decisions in anxious women (but not anxious men);
  • (3) that when anxiety (or mood) disorders are suspected, patients should be referred for appropriate evaluation and treatment – both to treat the disorders themselves, but also because they may worsen heart disease outcomes.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Lavoie: We conducted an observational study, which means we did not directly test the existence of sex/gender bias in heart disease diagnosis and referral. In order to do this, you would have to present a group of physicians with two identical case vignettes with the exception of making one male and one female (ie, one of a man with both heart disease and an anxiety disorder, and one of a woman with both heart disease and an anxiety disorder), and measure what their diagnosis or referral plan would be. This would allow us to test more directly the existence of sex/gender bias.

The other study you could do is to more directly test the impact of having an anxiety disorder on ischemia. This would be best done in a laboratory setting by comparing patients with vs. without heart disease, and within those, patients with vs. without an anxiety disorder. Then you could subject them to physical stress (like we did in our study – all patients ran on a treadmill) and mental stress (like get them to play a stressful video game) to see who demonstrates ischemia.

In fact, we have done a similar study among heart disease patients with and without an anxiety disorder (panic disorder in this case) – and we found that indeed, those with panic disorder were more likely to have ischemia when subjected to mental stress (see attached article). 

Medical Research: Is there anything else you would like to add?

Response: Yes, that much can be done to prevent heart disease and the negative effects of anxiety/psychological disorders!

  1. Lead a healthy lifestyle to reduce your risk factors; quit smoking (many cessation aids and treatments are now available), eat a healthy diet and maintain a healthy weight, exercise and reduce the amount of time you are sedentary (ie, new data suggests that being “active” (frequent walking and general movement throughout the day) is just as, if not more important that exercise), get enough sleep, manage stress (which is often the cause of depression and anxiety).
  2. If you are concerned about heart disease (maybe you have a relative who had it), if you are post-menopausal, or if you just don’t ‘feel right’, ask your doctor to send you for testing (blood tests, stress tests). Don’t be shy – ask to be tested.
  3. If you have a mood or anxiety disorder, many excellent treatments are available; the most efficacious is some form of cognitive-behavior therapy with or without medication (anti-depressant, which also treat anxiety disorders).


Do women with anxiety or depression have higher rates of myocardial ischemia during exercise testing than men?

Nicola J. Paine, Simon L. Bacon, Roxanne Pelletier, André Arsenault, Jean G. Diodati, and Kim L. Lavoie

Circ Cardiovasc Qual Outcomes. 2016;9:S53S61,doi:10.1161/CIRCOUTCOMES.115.002491