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• Response to: Health anxiety and risk of ischaemic heart disease: a prospective cohort study linking the Hordaland Health Study (HUSK) with the Cardiovascular Diseases in Norway (CVDNOR) project
  Karolyn E. Brebner
  Published on: 21 November 2016

• Published on: 21 November 2016

  Response to: Health anxiety and risk of ischaemic heart disease: a prospective cohort study linking the Hordaland Health Study (HUSK) with the Cardiovascular Diseases in Norway (CVDNOR) project

  • Karolyn E. Brebner, Registered Nurse

  The study, "Health Anxiety and Risk of Ischemic Heart Disease: a Prospective Cohort Study Linking the Hordaland Health Study (HUSK) with Cardiovascular Diseases in Norway (CVDNOR) Project" by Berge et al., demonstrates an important association between health anxiety levels and ischemic heart disease independent of known cardiovascular disease (CVD) risk factors. The rationale of the study is appropriate based on the lit...

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  The study, "Health Anxiety and Risk of Ischemic Heart Disease: a Prospective Cohort Study Linking the Hordaland Health Study (HUSK) with Cardiovascular Diseases in Norway (CVDNOR) Project" by Berge et al., demonstrates an important association between health anxiety levels and ischemic heart disease independent of known cardiovascular disease (CVD) risk factors. The rationale of the study is appropriate based on the literature review, which demonstrates that the majority of studies have only focused on general anxiety related to IHD. This results in a need to further explore the impacts of health anxiety, specifically, and it's association with IHD. The sample of participants was chosen through the use of already existing databases: Hordaland Health Study (HUSK) (1997- 1999) and Cardiovascular Diseases in Norway (CDNOR) (1994-2009). The HUSK study provides baseline data of participants based on a physical assessment (blood pressure, cholesterol levels, height and weight ect) and 2 questionnaires. The second questionnaire includes questions related to health anxiety (exposure data). Health anxiety was assessed through the Whitely Index (WI), described as "a widely used self-report instrument considered a classic screening tool for health anxiety and hypochondriasis."1 The CDNOR provided data retrospectively collected on hospital stays coded with CVD diagnosis and information on person's with CVD diagnosis on the death certificate (outcome data).

  One could argue that this study is not a prospective cohort design, rather, a retrospective cohort design, given that: baseline, exposure and outcome data are all collected from the past. There are potential sources of bias from data the HUSK study had gathered, potentially affecting the validity, reliability and generalizability of results. A number of these issues were well addressed in the limitations section of this article. Firstly, lack of appropriate methods were used to determine whether the participants had already started developing coronary artery disease at baseline. More invasive diagnostic procedures (coronary angiogram), would have contributed to a valid representation of baseline IHD. Secondly, in one of the questionnaires, neglect of content validity is present. The construct smoking was not adequately covered, as it was only categorized by: never, former and current. Thirdly, blood pressure was measured on one separate occasion, which does not offer a reliable result, given it's fluctuating nature. Lastly, WI questions were answered on one separate occasion. This affects reliability as well; given the way in which the participants answered the questions could have been affected by their current mood, potentially resulting in higher levels of reported health anxiety. This problem was addressed to some extent by the researchers "by excluding participants with prevalent and 12 month incident IHD."1 Nevertheless, the design used is appropriate for the study's research questions, given the time consuming and laborious nature of a classic prospective cohort study.

  The researchers did considerable work with the information they had available. Appropriate methods of analysis were used to answer the research questions. Preforming a Cox proportional regression analysis (4 different models), with the use of appropriate covariates (age, alcohol consumption, physical activity ect.), gave results regarding "whether a potential association can be explained by the presence or absence of established risk factors for CVD."1 Unfortunately, race was not included as a covariate as this could have enhanced generalizability of findings. The study demonstrated "person with health anxiety defined as scores on WI equal to or above the 90th centile had 70% increased risk of incident IHD."1 The researchers made these results far more convincing with the presentation of a biological gradient, evidenced by "a significant trend with increased strength of the association by increasing scores on WI."1

  Overall, this study provides an important perspective, regarding the inclusion of health anxiety as an important part of assessment of cardiac risk factors for IHD prevention. Working as a cardiology nurse, I find this study is of great importance to this field of health and applaud their work. In my experience, much of discharge and preventative teaching revolves around smoking cessation, weight loss, nutrition and physical activity. Anxiety, more specifically, health anxiety, is very seldom addressed. I for one will be incorporating this newfound knowledge in my future practice.

  References

  1. Berge, Line., et al. (2016). Health anxiety and risk of ischaemic heart disease: a prospective cohort study linking the Hordaland Health Study (HUSK) with the Cardiovascular Diseases in Norway (CVDNOR) project.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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