Does Anxiety Cause Abnormal ECG Results?

An estimated 31.1 percent of Americans will experience an anxiety disorder in their lifetime, according to reporting from the National Institute of Mental Health.¹ Sometimes these disorders can cause symptoms that mirror cardiovascular concerns, from increased heart rate (or a perception of one) to shortness of breath and chest pain, notes the Anxiety and Depression Association of America.²

Additionally, some manifestations of anxiety disorders can lead to abnormal ECG readings. When false positives occur for rhythm irregularities or other concerns, preexisting anxiety or even test-invoked nervousness may be factors.

So how can providers discern underlying cardiac issues from changes due to underlying or temporary anxiety? While the research is mixed, several case studies point to the importance of increased diligence with ECG readings and assessing patient history for relevant risk factors when possible.

Because many Americans are experiencing economic and other stressors tied to the pandemic—all while battling a public health threat known to cause lasting heart damage—remaining vigilant with ECG interpretation may be more important than ever.

Abnormal ECG Findings Caused by Anxiety

Whether it is due to short-term test nervousness or a chronic condition, anxiety may be associated with certain ECG abnormalities, including T-wave inversion. Inversions are commonly discussed in studies analyzing patients diagnosed with mental health conditions, and in one study from the American Journal of Cardiology, authors noted that anxiety and depression affected T-wave inversion in opposite ways: depression made a person more likely to have inversions in the T-wave, while anxiety made them less likely to experience an inversion.³

Additionally, certain high-dose or regular-dose anxiety treatments may induce QT prolongation, which has led Archives in Medical Science authors to recommend routine surveillance of patients being treated with tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and other therapies.⁴

In patients without a known clinical history of anxiety or other mental health concerns, short-term nervousness can also disrupt ECG readings. In one case study from the Egyptian Journal of Critical Care Medicine, such apprehension led to reported quadrigeminy in all ECG leads.⁵ The patient, an otherwise healthy 28-year-old male, was reportedly afraid of being shocked by the leads. Once the operator advised the patient to remain calm, a follow-up ECG conducted one minute later showed completely normal readings.

However, as important as it is for clinicians to become familiar with these potential irregularities, it's also crucial to understand which ECG changes are less likely to be due to preexisting or short-term anxiety. As the authors in a Frontiers in Neuroscience article emphasized, there's little evidence that either anxiety or depression can generate abnormalities in T-wave amplitude or QT-interval corrected for heart rate (QTc).⁶

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To learn more about the power of the ECG in today's clinical landscape, browse our Diagnostic ECG Clinical Insights Center.

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The Rise of Smart ECG Devices

Wearable ECGs, such as those found in smartwatches and mobile apps, have recently become popular among patients. These ECGs can be applied to manage patients with anxiety, as they have been used to detect, monitor, and reduce symptoms of anxiety disorders.

However, one literature review in Brain Sciences that analyzed research involving these devices revealed mixed and unreliable evidence in support of their use.⁷ The authors emphasized that more research is needed in this area.

If patients use wearable ECGs, the results may have mixed bearing on the actuality of waveform changes. These devices could be helpful, but they might not be entirely clinically relevant until more is known about their applications in anxiety and cardiac response.

Mitigating the Risks of Variable Readings

When possible, medical history, including mental health history, should be assessed along with a physical exam and a 12-lead ECG. If a history of anxiety or depression is known, close surveillance is essential, particularly (but not solely) for patients taking medications.

Additionally, providers should be conscious of how ECG testing can emotionally impact patients at the point-of-care, especially when stress is already high due to COVID-19. Leads may be frightening for some people and—as with the Egyptian patient—could lead to concerns of electric shock or other fears. Physicians should work to provide a reassuring presence to help offset any temporary cardiac measures that could influence diagnosis, and re-run the ECG if abnormalities linked to short-term stressors are suspected.

Most importantly, anxiety might be the root cause of the symptoms and the ECG reading, but it might not be. With instances of missed STEMI and other diagnoses being passed off as mere worry (particularly among women who are most prone to anxiety), diligence matters—especially now.

 

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References:

1. National Institute of Mental Health, Mental Health Information Statistics. Prevalence of Any Anxiety Disorder Among Adults. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder
2. Anxiety & Depression Association of American. Am I having a panic attack or a heart attack? https://adaa.org/living-with-anxiety/ask-and-learn/ask-expert/how-can-i-tell-if-i%E2%80%99m-having-panic-attack-or-heart-atta
3. Whang W et al. Relations between depressive symptoms, anxiety, and T wave abnormalities in subjects without clinically-apparent cardiovascular disease (from the multi-ethnic study of atherosclerosis [MESA]). American Journal of Cardiology. Dec 2014; vol. 114 (iss. 12): 1917-1922. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4270832/
4. Aronow W and Shamliyan T. Effects of antidepressants on QT interval in people with mental disorders. Archives of Medical Science. May 2020; vol. 16 (iss. 4): 727-741. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286318/
5. Elsayed Y M H. An electrocardiographic anxiety-induced quadrigeminy and re-assurance. The Egyptian Journal of Critical Care Medicine. Apr 2018; vol. 6 (iss. 3): 21-23. https://www.sciencedirect.com/science/article/pii/S2090730318300082
6. Hu M X et al. Association between depression, anxiety, and antidepressant use with T-wave amplitude and QT-interval. Frontiers in Neuroscience. Jun 2018; vol. 12: 375. https://www.frontiersin.org/articles/10.3389/fnins.2018.00375/full
7. Elgendi M and Menon C. Assessing anxiety disorders using wearable devices: Challenges and future directions. Brain Sciences. Mar 2019; vol. 9 (iss. 3): 50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6468793/