Journal List > J Korean Acad Nurs > v.41(5) > 1002754

Park and Bae: A Systematic Review of Psychological Distress as a Risk Factor for Recurrent Cardiac Events in Patients with Coronary Artery Disease



The purpose of this study was to determine whether psychological distress is an independent risk factor for recurrent cardiac events in patients with coronary artery disease (CAD).


A prospective cohort of studies that measured psychological distress and the incidence of recurrent cardiac events in the adult population were included. Three computerized databases were assessed (PubMed, CINAHL, and PSYCINFO). Meta-analysis was conducted using a random-effects model to determine summary estimates of risks of major recurrent cardiac events associated with each psychological distress. Of 506 publications identified, 33 met inclusion criteria, and 24 studies were used to estimate effect size of psychological distress on recurrent cardiac events.


Mean number in the research sample was 736 and mean time of follow-up was 4.0 years. Depression, anxiety, anger, and hostility as psychological factors were studied. According to estimation of effect size using random model effect, depression (OR=1.39, 95% CI: 1.22-1.57), anxiety (OR=1.22, 95% CI: 0.96-1.56), and anger/hostility (OR=1.29, 95% CI: 1.07-1.57) CAD patients in significantly increased risk for recurrent cardiac events.


Finding suggests that psychological distress in forms of depression, anxiety, anger, and hostility impact unfavorably on recurrent cardiac events in CAD patients.

Figures and Tables

Figure 1
Flow diagram of study screening.
Figure 2
Psychological distress as a risk factor for recurrent cardiac events.
Figure 3
Funnel plot of selected studies for effect size extraction. A=Depression; B=Anxiety; C=Anger and hostility.
Table 1
Results of the Quality Assessment of Selected Studies (N=33)

Y=Yes; N=No; ?=Not sure; C=Calculated; I=Implied; NR=No relevance.

Table 2
Characteristics Presented in 33 Studies (N=33)

*multiple assessment included.

Table 3
Characteristics of Selected Studies for Effect Size Extraction (N=24)

*NR, not reported; NS, not specified; Data received from Roest et al. (2010); §Data received from Barth et al. (2004); Data calculated from Author.

ACS=Acute coronary syndrome; BDI=Beck depression inventory; BMI=Body mass index; CAD=Coronary artery disease; CABG=Coronary artery bypass graft; CBAHF=Cognitive behavioral assessment hospital form; CES-D=Center for epidemiologic studies depression scale; CMHS=Cook-Medley hostility scale; FHx=Family history; HADS=Hospital anxiety and depression scale; LVEF=Left ventricular ejection fraction; MI=Myocardial infarction; PCI=Percutaneous coronary intervention; S CL-90=Symptom check list-90; SDS=Zung self-rating depression scale; STAI=State trait anxiety inventory; STAS=State-trait anger scale.


This work was supported by the National Research Foundation of Korea (KRF) funded by the Korea government (MEST) (2009-0065948).


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