Preprocedural Anxiety in Adults With Congenital Heart Disease

Background Preprocedural anxiety may have detrimental effects both cognitively and physiologically. Objectives The objective of this study was to determine the association between state (situational) and trait (persistent in everyday life) anxiety and differences between the adult congenital heart disease (ACHD) and acquired heart disease populations. Methods The State-Trait Anxiety Inventory and financial stress scale were administered to adults with acquired and CHD at 4 tertiary referral centers in the United States prior to cardiac catheterization. Student’s t-test and least absolute shrinkage and selection operator regression analyses were used to assess differences in anxiety between groups and identify the optimal model of predictors of anxiety. Results Of the 291 patients enrolled, those with CHD (n = 91) were younger (age 41.3 ± 16.3 years vs 64.7 ± 11.3 years, P < 0.001), underwent more cardiac surgeries (P < 0.001), and had higher levels of trait anxiety (t[171] = 2.62, P = 0.001, d = 0.33). There was no difference in state anxiety between groups (t[158.65] = 1.37, P = 0.17, d = 0.18). State anxiety was singularly associated with trait anxiety. Trait anxiety was negatively associated with age and positively associated with state anxiety and financial stress. Patients with CHD of great complexity were more trait (F[2,88] = 4.21, P = 0.02) and state anxious (F[2,87] = 4.59, P = 0.01), though with relatively small effect size. Conclusions Trait anxiety levels are higher in the ACHD population and directly associated with state anxiety. Specialists caring for ACHD patients should not only recognize the frequency of trait anxiety but also high-risk subgroups that may benefit from psychological or social interventions to reduce preprocedural anxiety.

D espite improvements in life expec- tancy for adults with congenital heart disease (ACHD), those surviving well into adulthood may be prone to experience psychosocial problems due to their lifelong medical condition.In North America, standardized psychiatric interviews with ACHD patients revealed 27% met criteria for a depressive episode and 9% met criteria for generalized anxiety disorder. 1Interestingly, these patients were felt to be 'well-adjusted' by their ACHD providers suggesting psychological distress is often underrecognized.
Psychosocial challenges occur throughout the lifetime of the ACHD patient and include difficult transition to adulthood, heartfocused anxiety, 2 negative thoughts associated with anxiety, 3 and treatment-related worries.These may create challenges with regard to decisionmaking and preparation for outpatient procedures (eg, cardiac catheterization, radiofrequency, ablation, etc).
Preprocedural anxiety is present in up to 80% of patients. 4Physiologically, anxious patients may require more sedation because of a heightened perception of pain leading to lengthened recovery times.The cognitive effects of anxiety may also render patients unable to fully appreciate the improvements that have been achieved from transcatheter or surgical interventions. 5Previous studies evaluating preprocedural anxiety in patients undergoing angiography or percutaneous coronary intervention, demonstrated anxiety was highest immediately preprocedure, among female patients <65 years of age, in patients with lower levels of education and with acute percutaneous coronary intervention. 6Additional aspects contributing to anxiety at the procedure have included, fears of coronary artery bypass graft, uncertainty about the illness, pain, unfavorable clinical findings, lying flat in bed, and death.set to discover an optimal lambda value, at which tuning provides the optimal model of predictors of the outcome variable.The optimal LASSO lambda value reflects the optimal balance of variance and bias.Lower lambda values are more permissive of predictors.Thus, we selected the largest lambda value within 1 standard error of cross-validated errors for the minimal lambda value, making our exploratory values more conservative and parsimonious.

RESULTS
Of  EXPLORING FOR ANXIETY PREDICTORS.Patients who were younger, had more financial stress, and had less income were observed to be more trait anxious (Table 2).In the exploratory model, having CHD vs acquired heart disease was no longer independently predictive of trait anxiety (lambda ¼ 1.62).This indicated while patients with CHD were more likely to be

FIGURE 1 Differences in Trait Anxiety
Violin plots demonstrating the differences between congenital and acquired heart disease groups on trait anxiety symptoms and is often triggered by perceived negative consequences associated with feared sensations. 16In a prior retrospective study of ACHD patients who underwent psychological assessment, 71% patients reported heart anxiety, 49% reported difficulty coping with a medical decision as well as other health-specific concerns including treatment decision-making, surgical preparation, and adjustment to implanted devices. 17e results of this study clearly demonstrate elevated levels of trait anxiety in ACHD patients compared to patients with acquired heart disease.
Furthermore, trait anxiety was greatest in those patients with CHD of greatest complexity.The relationship between anxiety and clinical outcomes in ACHD remains unknown.Prior studies have demonstrated the direct effects of anxiety on cardiovascular physiology and increased risk of incident cardiovascular disease. 18There are several behavioral and physiologic mechanisms that may explain the underlying associations between anxiety disorders and subsequent cardiovascular disease.Therefore, maintaining behaviors such as a healthy diet and an active lifestyle, as well as medication adherence, that may reduce cardiovascular risks associated with anxiety while simultaneously relieving and/or reducing anxiety symptoms.Thus, it was interesting to note that our cohort reporting increased trait anxiety was on average overweight or obese.Although we did not explore the relationships between trait anxiety, Cook et al Preprocedural Anxiety in ACHD Patients S E P T E M B E R 2 0 2 3 : 1 0 0 5 8 9 impact on lifestyle, and obesity, the role of anxiety and cardiovascular outcomes warrants further investigation in ACHD patients.For patients with heart failure, attendance at cardiac rehabilitation programs is an important step to improving quality of life and reducing risk of future hospitalization. 19Importantly, anxiety can lead to autonomic dysfunction.The disruption in the body's ability to maintain heart rate variability and blood pressure has been shown to be important with regard to both overall cardiovascular health and mortality risk.Patients with acquired heart disease and autonomic instability are at increased risk for all-cause mortality. 20Although research is limited in ACHD patients, a prospective study of 171 patients with moderate/severe symptoms of major depressive disorder showed significantly lower heart rate variability. 21Decreased heart rate variability was associated with an increased risk of heart failure, hospitalization, and mortality.
Additional physiologic mechanisms that may explain the association between anxiety and cardiovascular disease include inflammation, 22 endothelial dysfunction, 23 and platelet aggregation. 24These mechanisms may also be present and 'activated' in the anxious ACHD patient placing patients at increased risk for future cardiovascular events.
In Other factors outside the scope of this study that likely help explain elevated levels of trait anxiety in younger ACHD patients include the high prevalence of post-traumatic stress disorder (PTSD) in both adolescents and ACHD patients. 25,26Approximately 1 in 8 ACHD patients meet criteria for PTSD which is w50% higher compared to adults without CHD. 27 STUDY LIMITATIONS.This study has several limitations.Despite the prospective, multicenter approach to our study, the sample size of the total ACHD population is small in contrast to the number of adults

Figure 1 .
Figure 1.There was no difference in state anxiety between groups (t[158.65]¼ 1.37, P ¼ 0.17, d ¼ 0.18).Across groups, state anxiety was singularly associated with trait anxiety.Trait anxiety was negatively associated with age and positively associated with financial stress and state anxiety.ACHD patients with CHD of great complexity were more trait anxious compared to those with simple or moderate CHD complexity (F[2,88] ¼ 4.21, P ¼ 0.02) and, after removing one extreme outlier of simple complexity, also more state anxious (F[2,87] ¼ 4.59, P ¼ 0.01).IMPUTING DATA.In preparation for the exploratory models, which cannot be performed with partial cases, a small proportion of missing values (5.6% of the data set) were imputed so all patients had complete data on selected variables.Missing data occurred across the 3 individual items of the financial stress scale and 3 aspects of demographic data including income, current employment, and education level, (dichotomously coded).An important assumption to missing data imputation is that data are missing completely at random. 12We performed Little's test of missing completely at random and found no evidence to suggest any discernible patterns in missingness, X2(59) ¼ 67.5, P ¼ 0.21.It appeared that missing data occurred randomly, perhaps due to the regular course of realworld implementation of a clinical study.We therefore proceeded with multivariate imputation

Preprocedural 28 CONCLUSIONS
Anxiety in ACHD Patients with acquired heart disease.Still, our patients were obtained from 4 tertiary ACHD centers across the United States, suggesting trait anxiety is common among ACHD patients.The data were obtained through survey responses, which may be subject to response bias, recall bias, and selection bias.The Institutional Review Board at the center organizing the study required the survey questions to be optional resulting in missing data.However, the STAI is a well-validated tool that is commonly utilized to evaluate preprocedural anxiety and is designed to minimize bias from self-reported data.Adults with CHD have high levels of trait anxiety compared to adults with acquired heart disease and experience preprocedural state anxiety in addition to their underlying trait anxiety.Upon exploration of contributing factors, it appeared that the highest levels of anxiety were experienced among younger patients, patients with CHD of great complexity, and those with greater financial stress.ACHD specialists should now be cognizant of the coexistence of anxiety disorders in ACHD patients and employ strategies to address coexisting mood or anxiety disorders that may alleviate preprocedural anxiety in this vulnerable population.A collaborative, patientcentered approach that incorporates mental health counseling as well as preprocedural and postprocedural education may offer the most successful opportunity to reduce anxiety, improve cardiovascular health, and improve health-related quality of life.
the 291 patients enrolled in the study, 58% were male (n ¼ 168) with a mean age of 57.36 AE 16.9 years.
Adult patients with CHD (n ¼ 91) were younger (age 41.3 AE 16.3 years vs 64.7 AE 11.3 years, P < 0.001), underwent more cardiac surgeries (P < 0.001), included more women (57%, n ¼ 52), and represented a more racially diverse (P ¼ 0.053) population compared to adults with acquired heart disease.Table 1 shows the clinical characteristics of the entire study population.Compared to adults with acquired heart disease, ACHD patients had higher levels of trait anxiety (t[171] ¼ 2.62, P ¼ 0.001, d ¼ 0.33) as shown in

TABLE 1
Values are mean AE SD or n (%).

Table 2 )
2 , N O .7 , 2 0 2 3 .In the sample of CHD patients, severity of STATE ANXIETY.State anxiety was also explored using the same cross-validated LASSO regression procedure and discovered only trait anxiety as a predictor (lambda ¼ 3.27).Therefore, it appeared that anxiety on the day of catheterization was better explained by the patient's more general trait anxiety, B ¼ 0.64, SE ¼ 0.06, t(289) ¼ 11.46, P < 0.001, rather than a separate process perhaps more immediate to the day of catheterization.ACHD SAMPLE POPULATION.Finally, an exploratory LASSO regression was performed on the sample of ACHD patients in predicting trait anxiety.The variable of CHD complexity was included in this analysis.The same core set of predictors, state anxiety, age, and financial stress were noted.CHD complexity was observed to be present in the model (lambda ¼ 2.29) (DISCUSSION This is the largest prospective cohort to investigate preprocedural anxiety in adults with CHD.ACHD patients undergoing cardiac catheterization were observed to demonstrate elevated levels of trait anxiety compared to adults with acquired heart disease.Predictors of anxiety in ACHD patients also included younger age, CHD complexity, and financial stress.Importantly, state anxiety was exclusively predicted by trait anxiety.interventions.Consequently, many ACHD patients develop heart-focused anxiety.Heart-focused anxiety may include worry, avoidance, and attention specific to heart-related activity.It is usually accompanied by fear of heart-related sensations and

TABLE 2
Exploratory Models of Trait Anxiety Congenital heart disease (CHD) complexity variables are dummy-coded in comparison to simple complexity.