Cardiac Anxiety in Adults with Cardiovascular Disease: Prevalence, Predictors, and Implications for Cardiac Rehabilitation — A Systematic Review

Abstract

Introduction. Heart-focused anxiety (HFA) is characterised by fear of cardiac sensations, hypervigilance, and avoidance of physical exertion. Although distinct from generalised anxiety, HFA is rarely assessed during cardiac rehabilitation (CR). This systematic review synthesised evidence regarding HFA prevalence, predictors, prognostic implications, and responses to rehabilitation interventions in adults with cardiovascular disease (CVD).

Methods. PubMed, CINAHL, PsycINFO, and the Cochrane Library were searched following PRISMA 2020 guidelines. Eligible studies assessed HFA using the Cardiac Anxiety Questionnaire (CAQ) or Herzangstfragebogen (HAF-17) in adults with confirmed CVD. Methodological quality was evaluated using NIH NHLBI assessment tools and Cochrane RoB 2. Findings were narratively synthesised. The review was prospectively registered in PROSPERO (CRD420261394690).

Results. Twenty-six studies involving 9,628 participants across eight countries were included. Clinically elevated HFA prevalence ranged from 15% to 49%, depending on population characteristics, assessment timing, and CAQ thresholds. HFA was associated with depressive symptoms, illness perceptions, impaired quality of life, and physical inactivity. Two prospective cohorts identified HFA as an independent predictor of major adverse cardiac events and post-myocardial infarction mortality (hazard ratio range: 1.30–1.59), with avoidance behaviour emerging as a principal contributor. Standard and specialised psychocardiological CR, device therapy, and early mobilisation were associated with reduced HFA.

Discussion. HFA represents a prevalent and potentially prognostically relevant psychological burden in patients with CVD. Rehabilitation and psychological interventions may reduce HFA, although supporting evidence remains predominantly observational. Routine CAQ screening and targeted cognitive-behavioural interventions warrant further prospective evaluation.