Heart-focused anxiety in the general population

Abstract

Heart-focused anxiety is a common phenomenon that is related to psychological disorders and cardiac diseases. We investigated heart-focused anxiety in the general population and provided standard values using the Cardiac Anxiety Questionnaire (CAQ). Furthermore, we assessed the reliability of the CAQ and investigated the influence of social variables on heart-focused anxiety.
The questionnaire was applied to 2,396 individuals (age range: 18-92; mean age 49 ± 17, 50% male). Three aspects of heart-focused anxiety (fear, attention, and avoidance) were captured by the CAQ. To test the influence of age, gender, and social factors, we performed analyses of variance, correlative statistics, and regression analyses. Heart-focused anxiety showed a linear increase with age (P < 0.001). No gender differences were observed. The degree of anxiety was affected by relationship (P < 0.001), level of education (P < 0.001), employment (P < 0.001), and income (P < 0.001).
We evaluated heart-focused anxiety in the general population and validated the CAQ. Using percentiles based on a normative sample allows screening for heart-focused anxiety in patients with or without cardiac diseases and the measurement of therapy success after psychotherapeutic or pharmacological intervention.

Full text

ORIGINAL PAPER
Heart-focused anxiety in the general population
Denise Fischer •Ingrid Kindermann •Julia Karbach •Philipp Y. Herzberg •
Christian Ukena •Christine Barth •Matthias Lenski •Felix Mahfoud •
Franziska Einsle •Stephanie Dannemann •Michael Bo
¨hm •Volker Ko
¨llner
Received: 16 November 2010 / Accepted: 5 October 2011 / Published online: 21 October 2011
ÓSpringer-Verlag 2011
Abstract
Objective Heart-focused anxiety is a common phenome-
non that is related to psychological disorders and cardiac
diseases. We investigated heart-focused anxiety in the gen-
eral population and provided standard values using the
Cardiac Anxiety Questionnaire (CAQ). Furthermore, we
assessed the reliability of the CAQ and investigated the
influence of social variables on heart-focused anxiety.
Methods and results The questionnaire was applied to
2,396 individuals (age range: 18–92; mean age 49 ±17,
50% male). Three aspects of heart-focused anxiety (fear,
attention, and avoidance) were captured by the CAQ. To
test the influence of age, gender, and social factors, we
performed analyses of variance, correlative statistics, and
regression analyses. Heart-focused anxiety showed a linear
increase with age (P\0.001). No gender differences were
observed. The degree of anxiety was affected by relation-
ship (P\0.001), level of education (P\0.001),
employment (P\0.001), and income (P\0.001).
Conclusion We evaluated heart-focused anxiety in the
general population and validated the CAQ. Using percen-
tiles based on a normative sample allows screening for
heart-focused anxiety in patients with or without cardiac
diseases and the measurement of therapy success after
psychotherapeutic or pharmacological intervention.
Keywords Heart-focused anxiety General population 
Normative sample Anxiety questionnaire
Introduction
Since the end of the nineteenth century, heart-focused anx-
iety (HFA) has attracted attention in clinical research [1].
HFA refers to the fear of cardiac-related stimuli and sensa-
tions based on their perceived negative consequences [2].
Individuals with pronounced HFA with or without cardiac
diseases tend to overrate heart-focused sensations and to
consider them life threatening [3]. This fear results in
avoidance behavior for physical or sexual activity [4].
Therefore, HFA can result in frequent consultations of
physicians and constant demands for physical examinations
culminating in invasive diagnostic procedures in order to
ensure that no abnormalities have been missed. Up to 50% of
general medical consultations are based on heart related
D. Fischer and I. Kindermann contributed equally to this article.
M. Bo
¨hm and V. Ko
¨llner share senior authorship of this article.
D. Fischer (&)I. Kindermann C. Ukena C. Barth 
M. Lenski F. Mahfoud M. Bo
¨hm
Universita
¨tsklinikum des Saarlandes, Klinik fu
¨r Innere Medizin
III (Kardiologie, Angiologie und Internistische Intensivmedizin),
Kirrberger Straße, 66421 Homburg/Saar, Germany
e-mail: denise.fischer@uks.eu
J. Karbach
Universita
¨t des Saarlandes, Fachrichtung Psychologie,
Saarbru
¨cken, Germany
P. Y. Herzberg
Institut fu
¨r Medizinische Psychologie und Soziologie,
Universita
¨t Leipzig, Leipzig, Germany
F. Einsle
Institut fu
¨r Klinische Psychologie und Psychotherapie,
TU Dresden, Germany
S. Dannemann
Klinik und Poliklinik fu
¨r Psychotherapie und Psychosomatik,
TU Dresden, Germany
V. Ko
¨llner
Mediclin Bliestal Kliniken, Fachklinik fu
¨r Psychosomatische
Medizin, Blieskastel, Germany
123
Clin Res Cardiol (2012) 101:109–116
DOI 10.1007/s00392-011-0371-7

somatic conditions like chest pain, dyspnoea or palpitations,
which may be associated with anxiety [5]. In patients suf-
fering from heart disease, HFA impairs recovery and quality
of life [6]. Comorbid psychological disorders, such as anx-
iety and depression, often result in chronic conditions and
additional costs for the health care system [5,7–9].
The cardiac anxiety questionnaire (CAQ), designed to
measure the level of HFA, has previously been applied to
patients with chest pain and patients undergoing cardiac
MRT diagnostic procedures [2]. There is a lack of data
regarding healthy individuals. Thus, prevalence and inci-
dence of HFA in the normal population are widely
unknown. In order to address the rate of HFA in the general
population as well as factors influencing HFA like social
variables (age, marital status, education, and gender), we
examined a sample of individuals representative for the
adult German population by means of the CAQ. Based on
these data, we calculated percentiles that can be used to
compare the CAQ scores of patients with or without car-
diac diseases to scores representative for the normal
population.
Methods
We applied the German version of the CAQ [2]. This
questionnaire includes 17 items referring to ‘‘fear’’
regarding individually perceived heart function (items 9,
10, 12, 13, 14, 15, 16, 17), heart-focused ‘‘attention’’ (items
1, 3, 4, 5, 7), and ‘‘avoidance’’ of activities that may cause
cardiac symptoms (items 2, 6, 8, 11) (see Table 1). Sub-
jects were instructed to rate the statements on a five-point
Likert-type scale (0 =never, 1 =rarely, 2 =sometimes,
3=often, 4 =always). The CAQ yields one total HFA
score as well as scores for each of the three subscales (fear,
avoidance, attention). Subscales were calculated as mean
item scores.
The Independent Service for Surveys, Methods and
Analyses (‘‘Unabha
¨ngiger Service fu
¨r Umfragen, Metho-
den und Analysen’’, USUMA Number: 060502) collected
the data for the present study. Target households were
chosen randomly. Within each one of them, a target person
over 14 years of age was also chosen by chance. The pool
of initially selected addresses yielded a quality neutral
dropout rate of 3.5% (no member of the target population
in the household or unoccupied residence). After correcting
the sample for these missing values, the study sample
yielded 37.9% non-responders (e.g., the target individual
did not consent to interview). Subjects were asked to pro-
vide specific sociodemographic information (details are
provided below) and to complete the CAQ.
Data were saved anonymously and analyzed with SPSS
16 and LISREL 8.80. In order to examine the item factor
structure, we performed confirmatory factor analyses
Table 1 Cadiac Anxiety Questionnaire (CAQ, German version)
Niemals Selten Manchmal Oft Immer
Herzangstfragebogen (HAF)
1 Ich beachte aufmerksam meinen Herzschlag 0 1 2 3 4
2 Ich vermeide ko
¨rperliche Anstrengung 0 1 2 3 4
3 Ich werde nachts durch Herzrasen geweckt 0 1 2 3 4
4 Unangenehme Gefu
¨hle im Brustbereich wecken mich nachts auf 0 1 2 3 4
5 Ich messe meinen Puls 0 1 2 3 4
6 Ich vermeide ko
¨rperliche Arbeit 0 1 2 3 4
7 Ich kann mein Herz in meiner Brust spu
¨ren 0 1 2 3 4
8 Ich vermeide Aktivita
¨ten, die meinen Herzschlag beschleunigen 0 1 2 3 4
9 Wenn Untersuchungen normale Ergebnisse erbringen, mache ich mir trotzdem Sorgen
wegen meines Herzens
012 34
10 Ich fu
¨hle mich sicher, wenn ich in einer Klinik, bei einem Arzt oder in einer anderen
medizinischen Einrichtung bin
012 34
11 Ich vermeide Aktivita
¨ten, die mich ins Schwitzen bringen 0 1 2 3 4
12 Ich befu
¨rchte, die A
¨rzte glauben, meine Symptome seien nicht wirklich vorhanden 0 1 2 3 4
Wenn ich unangenehme Gefu
¨hle in der Brust habe oder mein Herz schneller schla
¨gt, dann
13 mache ich mir Sorgen, ich ko
¨nnte eine Herzattacke haben 0 1 2 3 4
14 habe ich Schwierigkeiten, micht auf etwas zu konzentrieren 0 1 2 3 4
15 bekomme ich Angst 0 1 2 3 4
16 mo
¨chte ich von einem Arzt untersucht warden 0 1 2 3 4
17 spreche ich mit meiner Familie oder Freunden daru
¨ber 0 1 2 3 4
110 Clin Res Cardiol (2012) 101:109–116
123

(CFA). Cronbach’s aserved as indicator for internal con-
sistency (reliability). The item analysis included descrip-
tive analyses and discriminative power analyses (corrected
item-total correlations) (Table 3). Finally, we subjected the
data to analyses of variance (ANOVA) and regression
analyses in order to analyze the influence of age, gender,
and social factors on the level of HFA. Based on calcula-
tion of percentiles, we provided cut-offs (Table 4).
Results
Statistical analyses are based on a total of 2,396 participants
(age range: 18–92 years; mean age: 49 ±17, 50% male)
representative for the adult German population. 13.6% of the
final sample was recruited in more rural areas and 86.4%
were inhabitants of larger cities. There was no difference
between responders and non-responders in terms of regional
provenance. All participants included into the study com-
pleted the CAQ questionnaire (i.e., there were no missing
values). Demographic information is provided in Table 2.
Psychometric quality
In order to test the factor structure of the CAQ, we per-
formed a confirmatory factor analysis (CFA) based on a
hierarchical model with four latent variables [12–14]:
Three subscale-specific first-order factors (the three CAQ
subscales: fear, attention, and avoidance) as well as one
common second-order factor representing general HFA.
Av
2
-test (Satorra–Bentler) compared the observed
covariance matrix with the model covariance matrix. The
Comparative Fit Index (CFI), the Tucker–Lewis Index
(TLI), and the Root Mean Square Error of Approximation
(RMSEA) including a 90% confidence interval (CI) will be
reported as indexes of incremental fit [note that according
to Hu and Bentler (1999), values B0.05 are desirable for
the RMSEA while values C0.10 are not acceptable. For
both CFI and TLI values between 0.90 and 0.95 are con-
sidered acceptable and values [0.95 are desirable].
The fit for the hierarchical four-factor model was good [v
2
(116) =493.43, P\0.001, CFI =1.00, TLI =1.00,
RMSEA =0.04, 90% CI of RMSEA =0.03–0.04], con-
firming the postulated factor structure of HFA including three
correlated [r(fear/avoidance) =0.67, P\0.0001; r(fear/
attention) =0.75, P\0.0001; r(attention/avoidance) =
0.69, P\0.0001] but separable higher-order factors. Factor
loadings ranged between 0.58 and 0.95 and the internal
consistencies were high for the total score (a=0.93) as well
as for the subscales fear (a=0.86), attention (a=0.83), and
avoidance (a=0.81) (see Table 3).
Influence of age and gender
In order to investigate the effects of age on HFA, we
defined five age groups: 18–33, 34–43, 44–54, 55–66, and
67–92 years [12]. We observed a significant main effect for
age group (P\0.001). Subsequent analyses showed a
linear increase of HFA with age for the total CAQ score
(P\0.001) as well as for the three subscales (fear
P\0.001, avoidance P\0.001, and attention
P\0.001). Post hoc comparisons showed significant
Table 2 Descriptive statistics
Variable Total (N=2396) Male (N=1094) Female (N=1302)
Age (years) Mean ±SD 50 ±17 50 ±17 49 ±17
Range 18–92 18–92 18–91
Age group (years)
18–33 501 20.9% 226 20.7% 275 21.1%
34–43 455 19.0% 186 17.0% 269 20.7%
44–54 485 20.2% 228 20.8% 257 19.7%
55–66 478 19.9% 240 21.9% 238 18.3%
67–92 477 19.9% 214 19.6% 263 20.2%
Level of education
No degree 27 1.1% 10 0.9% 17 1.3%
Student 19 0.8% 8 0.7% 11 0.8%
CSE 1074 44.8% 515 47.1% 559 42.9%
O-levels 826 34.4% 329 30.1% 497 38.2%
A-levels 201 8.4% 92 8.4% 109 8.4%
Vocational diploma 75 3.1% 37 3.4% 38 2.9%
Academic degree 174 7.3% 103 9.4% 71 5.5%
SD standard deviation, CSE Certificate of secondary education
Clin Res Cardiol (2012) 101:109–116 111
123

differences in HFA between each of the age groups
(P\0.01) except for the two youngest groups (P=0.65).
We also observed a marginally significant effect of gender
(P\0.08), indicating that especially in younger age
groups, men showed lower levels of HFA than women
(P\0.01) (see Fig. 1).
Influence of social factors on the level of HFA
In order to determine the influence of social factors on the
level of HFA, we analyzed participant’s marital status
(single, married, divorced, widowed), employment (full
time, part time, by the hour, maternity leave, unemployed,
retired, seeking work, education, school), level of educa-
tion (‘‘University Graduate’’: yes or no), income (\1,250 €/
month, 1,250–2,500 €/month, [2,500 €/month) and their
area of residence (western and eastern parts of Germany).
Marital status
Widowed subjects showed higher levels of HFA than
single, married, and divorced individuals regarding the
total CAQ score as well as the three subscales
(P\0.001). However, given that marital status is cor-
related with age (P\0.001), we performed a hierarchi-
cal regression analysis to control for the effect of age.
Results revealed that age was a reliable predictor for the
CAQ total score (R
2
=0.15, F[1, 2,347] =412.65,
P\0.001, b=0.39), but there was no effect for the
marital status (P=0.14). Participants in a relationship
had lower total CAQ scores (P\0.001) and lower
scores on the three subscales (P\0.001). Results of a
hierarchical regression analysis showed that the effect of
relationship was still present after removing the contri-
bution of age (R
2
D=0.004, FD[1, 1,033] =4.70,
P\0.05).
Employment
We observed a main effect for the factor employment on the
total CAQ score (P\0.001) as well as on the three sub-
scales (P\0.001). Post hoc analyses revealed that retired
subjects showed more HFA than the remaining groups
(P\0.05), even when age had been accounted for
Table 3 Means (M), standard deviations (SD), range, distribution, skewness, discriminative power, and internal consistency for the CAQ items
and subscales
NM SD Range (0–4) Test for normal
distribution
Skewness Selectivity
Zvalue Significance
Fear Alpha =0.86
9. If tests come out normal, I still worry about my
heart
2,388 0.48 0.83 0–4 20.09 .00 1.78 0.64
10. I feel safe being around a hospital, physician or
other medical facility
2,379 1.13 1.40 0–4 12.59 .00 0.62 0.45
11. I avoid activities that make me sweat 2,382 0.39 0.77 0–4 21.55 .00 2.60 0.52
When I have chest discomfort or when my heart is beating fast
13. I worry that I may have a heart attack 2,381 0.59 0.83 0–4 17.46 .00 1.30 0.73
14. I have difficulty concentrating on anything else 2,380 0.60 0.88 0–4 17.18 .00 1.23 0.68
15. I get frightened 2,380 0.60 0.84 0–4 17.16 .00 1.39 0.73
16. I like to be checked out by a doctor 2,379 0.86 0.98 0–4 13.94 .00 0.91 0.75
17. I tell my family or friends 2,380 0.92 1.06 0–4 13.39 .00 1.00 0.62
Avoidance Alpha =0.81
2. I avoid physical exertion 2,390 0.85 0.98 0–4 15.65 .00 0.99 0.81
6. I avoid exercise or other physical work 2,390 0.75 0.97 0–4 17.90 .00 1.18 0.83
8. I avoid activities that make my heart beat faster 2,390 0.63 0.95 0–4 16.65 .00 1.46 0.78
11. I avoid activities that make me sweat 2,388 0.73 1.02 0–4 10.18 .00 1.32 0.78
Attention Alpha =0.83
1. I pay attention to my heart beat 2,391 0.91 0.99 0–4 12.86 .00 0.86 0.71
3. My racing heart wakes me up at night 2,390 0.36 0.72 0–4 21.83 .00 2.24 0.64
4. Chest pain/discomfort wakes me up at night 2,389 0.32 0.71 0–4 22.53 .00 2.45 0.64
5. I check my pulse 2,390 0.77 1.03 0–4 16.10 .00 1.23 0.62
7. I can feel my heart in my chest 2,390 0.90 1.03 0–4 14.03 .00 0.95 0.60
aCronbach’s alpha. Discriminative power (r)=corrected item -total correlations
112 Clin Res Cardiol (2012) 101:109–116
123

(R
2
D=0.009, FD[1, 2346] =24.07, P\0.001). Unem-
ployment did not affect the level of HFA (P=0.22).
Income
Analyses confirmed linear trends, indicating that HFA
decreased with increasing income. This effect was present
for the total CAQ score and for the three subscales
(P\0.001).
Level of education
Results indicated that subjects with a higher level of edu-
cation showed a lower total CAQ score (P\0.001) and
lower scores on all three subscales (P\0.05).
Area of residence
A comparison between the habitants of the formerly east-
ern and western parts of Germany did not yield significant
differences in terms of HFA (P=0.87). There was no
difference between subjects living in cities or in rural areas
(P=0.94).
Standard values
Standard values for CAQ scores in the German general
population are provided in Table 4. Normative data were
calculated separately for each age group and for females
and males. Because no differences between the two
youngest age groups (18–33 and 34–43 years) were
observed (P=0.65) data were collapsed across these
groups. Percentiles serve as indicators of specificity and
can be used for the calculation of cut-offs.
Discussion
We investigated heart-focused anxiety (HFA) in the gen-
eral population by means of the German version of the
Cardiac Anxiety Questionnaire (CAQ). The association
between anxiety and cardiovascular diseases (coronary
heart disease, Tako-tsubo cardiomyopathy) has also been
discussed [15]. Patients with anxiety disorders tend to
excessively consult of physicians and oftentimes demand
unnecessary physical examinations. If patients suffering
from anxiety disorders are not treated adequately by psy-
chotherapy or medication, symptoms may chronify.
Therefore, health costs increase [5]. In patients with cor-
onary heart disease, anxiety and panic disorder have been
shown to increase the intensity of physical discomfort [6,
16–19] and to be associated with an increased mortality
[16,18]. Given that HFA is rather considered a symptom
than a diagnosis, it is neither included into the International
Classification of Diseases (ICD-10) nor the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV).
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
(mean)
Age group (Years)
male
female
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
Age group (Years)
(mean)
male
female
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
(mean)
Age group (Years)
male
female
0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
18-33 34-43 44-54 55-66 67-92
18-33 34-43 44-54 55-66 67-92
18-33 34-43 44-54 55-66 67-92
18-33 34-43 44-54 55-66 67-92
(mean)
Age group (Years)
male
female
Fig. 1 Total CAQ (Cardiac
Anxiety Questionnaire) score
(upper left) and CAQ subscale
scores [fear (upper right),
avoidance (lower left), and
attention (lower right)] as a
function of age group (18–33,
34–43, 44–54, 55–66,
67–92 years) and gender
(female, male). Error bars refer
to the standard error of the mean
Clin Res Cardiol (2012) 101:109–116 113
123

Table 4 Standard values for the CAQ Scores as a Function of Age and Gender
Variable Fear Avoidance Attention Overall Fear Avoidance Attention Overall
18-43 year old women 44-54 year old women
Mean 0.54 0.45 0.44 0.46 0.65 0.62 0.58 0.57
SD 0.62 0.66 0.56 0.50 0.62 0.79 0.61 0.54
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Maximum 3.5 4.00 3.00 2.82 2.88 3.50 3.00 2.65
Percentiles
25% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.12
50% 0.38 0.00 0.20 0.29 0.50 0.25 0.40 0.41
75% 0.88 0.75 0.6 0.71 1.00 1.25 1.00 0.94
90% 1.50 1.50 1.20 1.21 1.50 2.00 1.40 1.35
95% 1.88 1.96 1.60 1.47 1.93 2.25 2.00 1.70
99% 2.50 2.50 2.40 2.21 2.44 2.86 2.40 2.23
Variable Fear Avoidance Attention Overall Fear Avoidance Attention Overall
55-66 year old women 67-92 year old women
Mean 0.91 0.97 0.85 0.85 1.08 1.34 1.07 1.07
SD 0.73 0.89 0.74 0.66 0.76 1.04 0.79 0.70
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Maximum 3.63 4.00 4.00 3.59 3.50 4.00 4.00 3.24
Percentiles
25% 0.25 0.00 0.20 0.29 0.38 0.50 0.45 0.47
50% 0.81 1.00 0.80 0.76 1.00 1.25 1.00 1.00
75% 1.50 1.50 1.20 1.35 1.63 2.00 1.60 1.59
90% 2.00 2.00 1.82 1.82 2.13 2.75 2.20 2.00
95% 2.13 2.75 2.20 1.94 2.38 3.00 2.40 2.18
99% 2.63 3.41 3.00 2.49 2.88 4.00 3.63 3.13
Variable Fear Avoidance Attention Overall Fear Avoidance Attention Overall
18-43 year old men 44-54 year old men
Mean 0.43 0.35 0.33 0.36 0.68 0.62 0.62 0.60
SD 0.53 0.60 0.49 0.44 0.64 0.76 0.72 0.58
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Maximum 2.38 3.00 2.60 2.12 3.00 3.50 4.00 2.88
Percentiles
25% 0.00 0.00 0.00 0.00 0.13 0.00 0.00 0.18
50% 0.25 0.00 0.00 0.24 0.63 0.50 0.40 0.47
75% 0.75 0.50 0.60 0.59 1.00 1.00 1.00 0.88
90% 1.25 1.25 1.00 0.94 1.50 1.50 1.6 1.41
95% 1.59 1.75 1.40 1.24 1.96 2.15 2.00 1.76
99% 2.12 2.50 2.20 1.94 2.90 3.29 3.29 2.65
Variable Fear Avoidance Attention Overall Fear Avoidance Attention Overall
55-66 year old men 67-92 year old men
Mean 0.90 0.95 0.83 0.83 0.97 1.23 1.02 0.97
SD 0.69 0.83 0.72 0.61 0.71 1.05 0.80 0.69
Minimum 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Maximum 3.25 4.00 3.00 2.88 3.25 4.00 3.60 3.12
Percentiles
25% 0.25 0.25 0.20 0.35 0.38 0.25 0.40 0.41
114 Clin Res Cardiol (2012) 101:109–116
123

Therefore, patients suffering from HFA are oftentimes
diagnosed with panic disorder. Being able to measure HFA
by means of the CAQ allows the identification of specific
dysfunctional thinking and behavior and thereby facilitates
specific therapeutic interventions (e.g., exposition as an
efficient important method of cognitive behavioral
therapy).
In our study, HFA increased as a function of age: older
individuals showed higher levels of HFA than younger
individuals, a finding that may be explained by the increased
risk of cardiovascular diseases in older age. In addition,
similar findings have been reported with respect to anxiety
and depression: Hinz et al. [20]. investigated a sample rep-
resentative for the general population by means of the
Hospital Anxiety and Depression Scale (HADS), showing a
linear increase of anxiety and depression as a function of age
[20,21]. In line with previously published studies, younger
women were also more anxious than men [7,20].
Furthermore, we examined the role of several social
factors on the degree of HFA. HFA seems to be related to
marital status: Widowed subjects are characterized by
higher levels of HFA than single, married, and divorced
participants. When adjusting for age, this effect was no
longer significant. Nevertheless, individuals being in a
relationship generally showed less HFA. It seems likely
that sharing emotional events and physiological discomfort
with a partner can improve a person’s evaluation process as
well as the individual arousal level. The level of education
modulates the degree of HFA in the general population.
University graduates experience less HFA than individuals
without college degree. This effect might be due to dif-
ferences in cognitive evaluation strategies and to better
knowledge regarding their health care behavior.
The CAQ can be considered as a standardized instru-
ment for the assessment of HFA [2,10]. Einsle et al. (2009)
examined the psychometric criteria of the German version
of the CAQ in patients with cardiac diseases. The factor
analysis confirmed the postulated three-factor structure.
Internal consistencies were satisfactory (a=0.69–0.92).
Construct validity was investigated by correlations
between the CAQ and the Hospital Anxiety and Depression
Scale (HADS) as well as quality of life (SF12).
Correlations between general anxiety and heart focused
anxiety were moderate. Hoyer et al. (2008) investigated
heart focused anxiety before and after cardiac surgery. The
correlation between HFA and general anxiety corroborates
the convergent validity of the CAQ. Furthermore, the
findings of the present study provide important information
about the quality and the relevance of the CAQ as a
diagnostic screening tool and its application in clinical
practice. Providing standard values and diagnostic cut-offs
allows the comparison of HFA in patients with cardiac
symptoms in whom cardiac diseases are ruled out by
appropriate technical examinations to those in the general
population. In physically healthy people with inadequate
levels of HFA, psychotherapy may be helpful to improve
the patients’ well-being and to help to save costs. The use
of the cut-offs calculated based on the normal population
can also be useful in identifying patients with cardiac
diseases that show a high tendency to denial. Lower CFA
values in patients with cardiac diseases (compared to the
age and gender matched general population) may point to
ineffective coping strategies. Increased values on the total
CAQ score may give reason for further therapeutic inter-
ventions (psychotherapy, pharmacological treatments). [1]
But it has to be mentioned that a questionnaire cannot
replace a diagnostic interview by expert staff. Neverthe-
less, the application of the CAQ in clinical settings has the
potential to help reducing redundant diagnostics, inefficient
treatment, and health care costs. The questionnaire may
also be applied to investigate the effects of psychotherapy,
pharmacological or invasive treatment [e.g., implantable
cardioverter defibrillator implantation (ICD)]. Further
studies should also investigate the influence of age and
social variables on HFA in patients with different cardiac
diseases, such as coronary heart disease, cardiomyopathy
or valvular heart disease. In addition, it seem worth
investigating which level of HFA is typical for patients
successfully coping with different types of heart disease
and at which point HFA may be protective or constitute as
a risk factor, respectively. Future research should focus on
specific cognitive behavioral interventions aimed to reduce
heart focused anxiety and to examine changes in coping
strategies and quality of life.
Table 4 continued
Variable Fear Avoidance Attention Overall Fear Avoidance Attention Overall
50% 0.88 0.75 0.70 0.71 0.88 1.00 1.00 0.88
75% 1.50 1.50 1.20 1.24 1.50 2.00 1.60 1.51
90% 1.88 2.00 2.00 1.70 1.96 2.75 2.10 1.92
95% 2.00 2.50 2.20 1.94 2.25 3.25 2.45 2.16
99% 2.90 3.15 2.80 2.80 2.88 3.96 3.37 2.87
Note: 0never, 1rarely, 2sometimes, 3often, 4always
Clin Res Cardiol (2012) 101:109–116 115
123

Conclusion
Screening of heart focused anxiety by means of the CAQ in
patients with or without cardiac diseases may help to
reduce redundant diagnostics, health care costs and may
help to introduce the adequate therapy options of affected
patients.
Acknowledgments This study was funded by the German Heart
Foundation and the Saarland Ministry for Education and Science.
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