Anxiety is common among patients with coronary heart disease (CHD); however, there is a dearth of studies examining efficacy of anxiety treatments in patients with CHD. A randomized clinical trial examined whether 12 weeks of aerobic exercise (3 times per week at an intensity of 70% to 85% heart rate reserve) or escitalopram (up to 20 mg per day) improved anxiety symptoms compared to a placebo pill. Outpatients with stable CHD and a Hospital Anxiety and Depression-Anxiety (HADS-A) score of 8 or higher (73% diagnosed with anxiety disorder) who were older than 40 years, sedentary, and not currently receiving mental health treatment participated in the study (N=128). The escitalopram group had a greater reduction in HADS-A scores (-5.7), the primary endpoint, compared with the exercise (-4.0) and placebo (-3.5) groups, while the exercise and placebo groups were not significantly different (Figure 1). A 2-point (20%) improvement in the HADS-A is considered clinically meaningful, therefore, the improvement in anxiety following escitalopram treatment (compared to placebo) was both statistically and clinically significant. Secondary analyses showed that escitalopram and exercise both improved state anxiety, while only escitalopram improved depressive symptoms, compared to placebo, at 12 weeks. Finally, escitalopram, but not exercise, reduced urinary epinephrine following treatment, compared to placebo. Urinary catecholamines, an index of sympathetic nervous system activity, have been shown to be positively correlated with anxiety. There were no differences in CHD biomarkers between treatment groups, and no participants reported adverse effects on a 36-item symptom checklist. Altogether, these findings suggest that escitalopram is a safe and effective treatment for reducing anxiety in patients with CHD, while the effects of aerobic exercise are less consistent.
Figure 1. Anxiety (HADS-A scores) decreased after 12 weeks of treatment. The largest decrease was due to treatment with escitalopram, as it was significantly greater than exercise or placebo after 12 weeks. Exercise and placebo treatments were not significantly different. HADS-A, Hospital Anxiety and Depression-Anxiety.
Blumenthal JA et al. JAMA Psychiatry 2021; Epub ahead of print. Abstract