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Revista Brasileira de Anestesiologia

Print version ISSN 0034-7094On-line version ISSN 1806-907X

Rev. Bras. Anestesiol. vol.59 no.4 Campinas July/Aug. 2009 



Evaluation of preoperative anxiety and depression in patients undergoing invasive cardiac procedures*


Evaluación de la ansiedad y depresión en el período preoperatorio en pacientes sometidos a procedimientos cardíacos



Antonio Fernando Carneiro, TSA, M.D.I; Ligia Andrade S. Telles Mathias, TSA, M.D.II; Anis Rassi Júnior, M.D.III; Nelson Siqueira de Morais, M.D.IV; Judymara Lauzi Gozzani, TSA, M.D.V; Aline Pimentel de MirandaVI

IDoutor em Medicina pela FCM/SCSP; Professor de Anestesiologia da Universidade Federal de Goiás; Membro da Comissão do TSA/SBA
IIProfessor Adjunto da SCSP; Diretora do Serviço e Disciplina de Anestesiologia da SCSP
IIIDoutor em Cardiologia pela Universidade de São Paulo; Diretor Científico do Hospital Anis Rassi de Goiânia
IVDiretor Científico da Sociedade Goiana de Cardiologia; Cardiologista do Hospital Anis Rassi de Goiânia
VProfessor Adjunto da UNIFESP; Editor-Chefe da Revista Brasileira de Anestesiologia; Coordenador do Serviço de Dor da FCM/SCSP
VIAluna do sexto ano da Graduação em Medicina da FCM/SCSP

Correspondence to




BACKGROUND AND OBJECTIVES: Specific assessment of anxiety and depression is not included in routine preoperative evaluation; therefore, in cases of cardiac diseases in which the emotional status of the patient may be modified by the disease those disorders may not be diagnosed. The objective of the present study was to compare the level and prevalence of anxiety and depression in patients with cardiac disease undergoing invasive and/or surgical procedures using the Hospital Anxiety and Depression Scale - HAD.
METHODS: After approval by the Ethics Committee, 96 patients, physical status ASA II and III, were divided in three groups: electrophysiological study (EPS), pacemaker (PM) placement, and myocardial revascularization (MR). "Cutting points" were as follows: HAD-anxiety scale (HAD-A) with anxiety > 9; HAD-depression scale (HAD-D) with depression > 9.
RESULTS: All three groups were homogenous regarding sociodemographic parameters. Statistically significant differences were observed among the three groups (p = 0.006; p = 0.034) in the level and prevalence of anxiety (HAD-A); and in the intergroup comparison of the anxiety level significant differences were observed between the EPS x MR and EPS x PM groups (p < 0.05). Significant differences in the level and prevalence of depression (HAD-D) among the study groups were not observed.
CONCLUSIONS: Patients with cardiac diseases undergoing electrophysiological studies, pacemaker implantation, and myocardial revascularization have different levels and prevalence of anxiety, but they do not show differences in the level and prevalence of depression.

Keywords: PRE-ANESTHETIC EVALUATION: psychological status, anxiety, depression; SURGERY, Cardiac: revascularization, pace-maker implantation, electrophysiological study.


JUSTIFICATIVA Y OBJETIVOS: La evaluación específica de la ansiedad y de la depresión no está incluida en la rutina de evaluación preoperatoria, lo que hace con que en algunas situaciones como las enfermedades cardiacas, en que el estado emocional de los pacientes puede estar modificado por la propia enfermedad, puedan no quedar diagnosticadas. El objetivo del estudio fue comparar el nivel y la prevalencia de ansiedad y depresión en pacientes con enfermedad cardiaca a ser sometidos a procedimientos invasivos y/o quirúrgicos, utilizando la Escala Hospitalaria de Ansiedad y Depresión (Hospital Anxiety and Depression Scale - HAD).
MÉTODO: Después de la aprobación por parte de los Comités de Ética, se incluyeron 96 pacientes, estado físico ASA II y III, que constituyeron tres grupos: estudio electrofisiológico (EEF), implante de marcapaso (MP) y revascularización del miocardio (RM). Las puntuaciones consideradas "punto de corte" fueron las siguientes: escala HAD-ansiedad (HAD-A): con ansiedad > 9; escala HAD-depresión (HAD-D): con depresión > 9.
RESULTADOS: Los grupos fueron homogéneos en cuanto a las variables sociodemográficas. Se observó una diferencia estadística significativa entre los tres grupos (p = 0,006; p = 0,034) en lo concerniente al nivel y a la prevalencia de ansiedad (HAD-A) y en la comparación del nivel de ansiedad grupo a grupo, se verificó la diferencia significativa entre los grupos EEF x RM y EEF x MP (p < 0,05). La comparación de los tres grupos en cuanto al nivel y a la prevalencia de Depresión (HAD-D) no arrojó diferencia estadística significativa.
CONCLUSIONES: Los pacientes con enfermedad cardiaca a ser sometidos a estudio electrofisiológico, implante de marcapaso y revascularización del miocardio, tienen diferencia de los niveles y prevalencia de ansiedad, pero no presentan diferencia con relación a los niveles y a la prevalencia de depresión.




Patients awaiting surgical procedures including simple ones should be considered in the context of its severity when fragility, anguish, and apprehension are present 1,2. The number of individuals with anxiety symptoms after procedures that treated cardiac disease varies from 16% to 50%, while 40% of those undergoing myocardial revascularization can have psychological symtoms 3.

The state of anxiety and depression in non-psychiatric hospitalized patients can be assessed by several scales. The Hospital Anxiety and Depression - HAD scale has been used both to screen and measure the severity of the disorder 4,5; it has a high degree of acceptance and it is easily answered 4. This instrument can detect cases of mood disorders than could go unnoticed in the conventional assessment 5. A detailed pre-anesthetic assessment and the use of the HAD scale can contribute for a better evaluation of the preoperative emotional status 6.

The objective of this study was to compare the level and prevalence of anxiety and depression in patients with cardiac diseases undergoing invasive and/or surgical procedures, such as the electrophysiological study (EEF), pacemaker implantation (PM), and myocardial revascularization (MR), using the Hospital Anxiety and Depression Scale.



After approval by the Ethics Committee of the Irmandade Santa Casa de Misericórdia de São Paulo and the Hospital Anis Rassi de Goiânia, 96 patients undergoing myocardial revascularization, pacemaker implantation, and electrophysiological studies were enrolled in this opened transversal study.

Inclusion criteria were as follows: patients with physical status ASA II and III due to a specific cardiac disease (coronary insufficiency or cardiac diseases with indication of electrophysiological studies or pacemaker), requiring myocardial revascularization, pacemaker implantation, or electrophysiological studies, and age equal or greater than 18 years. Illiterate patients, hearing impaired, hearing-speech impaired, visual or mental impairment, present or past history of anxiety and/or depression, and patients using psychoactive drugs were excluded.

Patients were allocated into three groups:

  • EPS group: patients undergoing electrophysiological study (n = 32);
  • PM group: patients undergoing pacemaker implantation (n = 32);
  • MR group: patients undergoing myocardial revascularization (n = 32).

At the time of the pre-anesthetic evaluation, patients were informed about the study and signed an informed consent. Those who agreed to participate in the study were asked to answer by themselves to the following forms before the pre-anesthetic evaluation:

a) Sociodemographic questionnaire with information about gender, age, race, marital status, schooling, and employment status;

b) Hospital Anxiety and Depression Scale (HAD).

The cutting points indicated by Zigmond and Snaith7 were adopted and recommended for both subscales:

  • HAD-A - absence of anxiety, 0 to 8; with anxiety, > 9;
  • HAD-D - absence of depression, 0 to 8; with depression, > 9.

Parameters analyzed included: age, gender, race; marital status; schooling; current employment status; and HAD-anxiety and HAD-depression medians and scores.

The size of the study population was calculated considering a 25% difference in the prevalence of anxiety among the study groups with an alpha error of 5% and beta error of 20% 6. This required 32 patients per group. The Kolmogorov-Smirnov test was used to analyze normal data distribution. ANOVA was used to compare age and anxiety and depression scores. The Chi-square test was used to compare gender, race, marital status, schooling, current employment status, and prevalence of anxiety and depression. Differences were considered statistically different when p < 0.05. The tests used are part of the software SPSS for Windows 10.



None of the patients in the three groups were excluded and the final study population consisted of 96 patients. According to table I, all three groups were similar regarding the sociodemographic characteristics (gender, age, race, marital status, schooling, and current employment status).

Table II shows median and the 25th and 75th percentiles of HAD-anxiety and HAD-depression scores and ANOVA results. Significant differences in HAD-anxiety among the study groups were observed (p = 0.006); the Tukey test was used for intergroup comparison and a significant difference was observed (p < 0.05) between the EPS x MR and EPS x PM groups. Statistically significant differences in HAD-depression scores among the three groups were not observed (p = 0.102).

Table III shows the total number and percentage of patients with/without anxiety and with/without depression in the study groups according to the HAD scale; significant differences were observed only in the prevalence of anxiety (p = 0.034).



This study demonstrated that patients with cardiac disease undergoing invasive and/or surgical procedures, such as electrophysiological studies, pacemaker implantation, and myocardial revascularization showed a high prevalence of anxiety and depression, and those patients undergoing EPS had the highest level of anxiety.

According to the cutting points proposed by Snaith et Zigmond 7, only patients in the EPS group who presented a median HAD-A score of 10.0 crossed the cutting point and would be considered as having anxiety. However, analyzing the prevalence of anxiety one can notice that all groups presented a relevant number of patients with anxiety, i.e., 62.5% in the EPS group and 34.4% in the PM and MR groups. Similarly, depression was seen in 46.9% of the patients in the EPS group, 31.1% in the PM group, and 28.1% in the MR group.

Comparing of the results of the present study to those found in the literature was difficult, specifically for the data of the group of patients undergoing electrophysiological study and pacemaker implantation because studies comparing the incidence of anxiety and depression in those groups of patients are rare. In a comparative study between patients undergoing electrophysiological study and pacemaker implantation, Duru et al. 8 did not observe differences in the prevalence of anxiety and depression after the procedure. However, those authors did not evaluate the presence of anxiety and depression before the procedures. The remainder of the studies found did not compare both groups, assessed anxiety and depression only in the late postoperative period of electrophysiological studies, and reported an increase prevalence of depression in patients undergoing EPS 9-13.

The frequency observed in this study, 34.4% of anxiety in the MR group, is within the levels reported in the literature. However, the majority of the studies refer to the evaluation of anxiety and depression after the surgical procedure with a prevalence ranging from 16% to 50% 14-18 or only mention that patients undergoing surgical myocardial revascularization showed high preoperative anxiety indexes 9,20.

The frequency of depression observed varied from 28 to 47%, which is more worrisome in the group of patients undergoing EPS, PM, and MR. Those results are in agreement with studies that document an increase in the prevalence of depression, which affected up to 60% of the patients with coronary artery disease 23.

It should be emphasized that a lower frequency of anxiety was observed in the MR group, which was unexpected. The elevated frequency of anxiety (between 34.4% and 62.5%) in all three groups demonstrated that a considerable percentage of the patients in the present study had those symptoms and therefore should have undergone more detailed assessment of their emotional status before the surgical intervention.

Moerman et al. 24 defended the application of anxiety assessment questionnaires to all surgical patients during the pre-anesthetic evaluation, especially patients with cardiac disease, who need special attention.

In the present study, the HAD scale was chosen because it is easy to handle and rapidly executed (mean time of ten minutes), and it can be answered by the patient. Other factors that influenced this choice include the absence of items that evaluate somatic symptoms and its validity and reliability have been demonstrated by several studies 25.

This study corroborated the importance of the HAD scale in patients scheduled to undergo electrophysiological studies, pacemaker implantation, and myocardial revascularization. By identifying patients with elevated levels of anxiety and/or depression and consider the use of appropriate and continuous psychological support in the pre- and postoperative period it would be possible to prevent the development of other psychological disorders that require differentiated pharmacological intervention.

Since the decade of 1960, studies have been reporting the association between the presence of anxiety and depression and an increase in morbidity and mortality after myocardial revascularization and currently studies have demonstrated that the presence of anxiety and depression can influence the development of cardiovascular lesions in previously healthy patients 20,26.

The results of the present study reinforce the importance of evaluating the emotional status of the patient with cardiac disease undergoing invasive and/or surgical procedures such as electrophysiological studies, pacemaker implantation, and myocardial revascularization since the prevalence of mood disorders is high.



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Correspondence to:
Dra. Ligia Andrade da S. Telles Mathias
Alameda Campinas 139/41
01404-000 São Paulo, SP

Submitted em 19 de janeiro de 2009
Accepted para publicação em 08 de abril de 2009



* Received from Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCM/SCSP), São Paulo, SP

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