Assessment of Preoperative Anxiety in Cardiac Surgery Patients Lacking a History of Anxiety: Contributing Factors and Postoperative Morbidity

Published:August 10, 2017DOI:


      The aim of this study was to measure the level of preoperative anxiety in patients scheduled for cardiac surgery, identify any influencing clinical factors, and assess the relationship between anxiety and postoperative morbidity.


      A prospective and consecutive study.


      A single university hospital.


      The study comprised 200 patients scheduled for cardiac surgery.


      Each patient was asked to grade his or her preoperative anxiety level using the Visual Analogue Scale for Anxiety, Amsterdam Preoperative Anxiety and Information Scale, and set of specific anxiety-related questions. Demographic data (age, sex, body mass index) and anesthetic and surgical data (American Society of Anesthesiologists physical status, EuroSCORE surgical risk, preoperative length of stay, and previous anesthetic experience) were registered. Also, postoperative morbidity was assessed.

      Measurements and Main Results

      Twenty-eight percent of the patients developed high preoperative anxiety. The mean Amsterdam Preoperative Anxiety and Information Scale score was 11.4 ± 4.3, and the mean Visual Analogue Scale for Anxiety score was 48 ± 21. Patients scheduled for coronary artery bypass surgery, who had no previous anesthetic experience, and who were hospitalized before surgery, had higher anxiety scores. Coronary bypass surgery (odds ratio 3.026; 1.509-6.067; p = 0.002) was associated independently with preoperative high-level anxiety. Anxiety most commonly was caused by waiting for surgery, not knowing what is happening, fearing not being able to awaken from anesthesia, and being at the mercy of staff. Anxiety did not modify the postoperative course.


      In patients waiting to undergo cardiac surgery, both fear of the unknown and lack of information, especially related to the surgery, are crucial factors in high levels of preoperative anxiety in cardiac surgery. Coronary bypass surgery is a determining factor for preoperative anxiety. The anxiety level did not modify the postoperative course in these patients.

      Key Words

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        • Maranets I.
        • Kain Z.N.
        Preoperative anxiety and intraoperative anesthetic requirements.
        Anesth Analg. 1999; 89: 1346-1351
        • Rothenhausler H.B.
        • Grieser B.
        • Nollert G.
        • et al.
        Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: A prospective 12-month follow-up study.
        Gen Hosp Psychiatry. 2005; 27: 18-28
        • Caumo W.
        • Cardoso M.B.
        Perioperative anxiety: Psychobiology and effects in postoperative recovery.
        Pain Clin. 2003; 15: 87-101
        • Navarro-García M.A.
        • Marín-Fernández B.
        • de Carlos-Alegre V.
        • et al.
        Preoperative mood disorders in patients undergoing cardiac surgery: Risk factors and postoperative morbidity in the intensive care unit.
        Rev Esp Cardiol. 2011; 64: 1005-1010
        • Ai A.L.
        • Kronfol Z.
        • Seymour E.
        • et al.
        Effects of mood state and psychosocial functioning on plasma interleukin-6 in adult patient before cardiac surgery.
        Int J Psychiatry Med. 2005; 35: 363-376
        • Pearson S.
        • Maddern G.J.
        • Fitridge R.
        The role of pre-operative state-anxiety in the determination of intra-operative neuroendocrine responses and recovery.
        Br J Health Psychol. 2005; 10: 299-310
        • Székely A.
        • Balog P.
        • Benkö E.
        • et al.
        Anxiety predicts mortality and morbidity after coronary artery and valve surgery-a 4-year follow-up study.
        Psychosom Med. 2007; 69: 625-631
        • Ye S.
        • Shaffer J.A.
        • Rieckmann N.
        • et al.
        Long-term outcomes of enhanced depression treatment in patients with acute coronary syndromes.
        Am J Med. 2014; 127: 1012-1016
        • Burg M.M.
        • Meadows J.
        • Shimbo D.
        • et al.
        Confluence of depression and acute psychological stress among patients with stable coronary heart disease: Effects on myocardial perfusion.
        J Am Heart Assoc. 2014; 3: e000898
        • Maurice-Szamburski A.
        • Auquier P.
        • Viarre-Oreal V.
        • et al.
        Effect of sedative premedication on patient experience after general anesthesia: A randomized clinical trial.
        JAMA. 2015; 313: 916-925
        • Kindler C.H.
        • Harms C.
        • Amsler F.
        • et al.
        The visual analog scale allows effective measurement of preoperative anxiety and detection of patients’ anesthetic concerns.
        Anesth Analg. 2000; 90: 706-712
        • Spielberger C.D.
        • Auerbach S.M.
        • Wadsworth A.P.
        • et al.
        Emotional reactions to surgery.
        J Consult Clin Pshychol. 1973; 40: 33-38
        • Zigmond A.S.
        • Snaith R.P.
        Hospital Anxiety and Depression Scale.
        Acta Psychiatr Scand. 1983; 67: 361-370
        • Moerman N.
        • van Dam F.
        • Muller M.
        The Amsterdam Preoperative Anxiety and Information Scale (APAIS).
        Anesth Analg. 1996; 82: 445-451
        • Martin C.R.
        • Thompson D.R.
        • Chan D.S.
        An examination of the psychometric properties of the Hospital Anxiety and Depression Scale in Chinese patients with acute coronary syndrome.
        Psychiatry Res. 2004; 129: 279-288
        • Underwood M.J.
        • Firmin R.K.
        • Jehu D.
        Aspect of psychological and social morbidity in patients awaiting coronary artery bypass grafting.
        Br Heart J. 1993; 69: 382-384
        • Pochard F.
        • Bellivier F.
        • Squara P.
        Prevalence and prognostic value of anxiety and depression in patients undergoing cardiac surgery.
        Eur Psychiatry. 1996; 11: 326
        • Williams J.B.
        • Alexander K.P.
        • Morin J.F.
        • et al.
        Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery.
        Am J Cardiol. 2013; 111: 137-142
        • Maurice-Szamburski A.
        • Loundou A.
        • Capdevila X.
        • et al.
        Validation of the French version of the Amsterdam Preoperative Anxiety and Information Scale (APAIS).
        Health Qual Life Outcomes. 2013; 11: 166
        • Perks A.
        • Chakravarti S.
        • Manninen P.
        Preoperative anxiety in neurosurgical patients.
        J Neurosurg Anesthesiol. 2009; 21: 127-130
        • McCleane G.J.
        • Cooper R.
        The nature of pre-operative anxiety.
        Anaesthesia. 1990; 45: 153-155
        • Cortina J.M.
        What is coefficient alpha? An examination of theory and applications.
        J Appl Psychol. 1993; 78: 98-104
        • Lichtor J.L.
        • Johanson C.E.
        • Mhoon D.
        • et al.
        Preoperative anxiety: Does anxiety level the afternoon before surgery predict anxiety level just before surgery?.
        Anesthesiology. 1987; 67: 595-599
        • Boker A.
        • Brownell L.
        • Donen N.
        The Amsterdam Preoperative Anxiety and Information Scale provides a simple and reliable measure of preoperative anxiety.
        Can J Anesth. 2002; 49: 792-798
        • Shafer A.
        • Fish M.P.
        • Gregg K.M.
        • et al.
        Preoperative anxiety and fear: A comparison of assessments by patients and anesthesia and surgery residents.
        Anesth Analg. 1996; 83: 1285-1291
        • Millar K.
        • Jelicic M.
        • Bonke B.
        • et al.
        Assessment of preoperative anxiety: Comparison of measures in patients awaiting surgery for breast cancer.
        Br J Anaesth. 1995; 74: 180-183
        • Oddershede L.
        • Andreasen J.J.
        • Ehlers L.
        Estimation of utility values from visual analogue scale measures of health in patients undergoing cardiac surgery.
        Clinicoecon Outcomes Res. 2014; 6: 21-27
        • Salzwedel C.
        • Petersen C.
        • Blanc I.
        • et al.
        The effect of detailed, video assisted anesthesia risk education on patient anxiety and the duration of the preanesthetic interview: A randomized controlled trial.
        Anesth Analg. 2008; 106: 202-209
        • Crockett J.K.
        • Gumley A.
        • Longmate A.
        The development and validation of the Pre-operative Intrusive Thoughts Inventory (PITI).
        Anaesthesia. 2007; 62: 683-689
        • Ehsan-ul-Haq M.
        Role of pre-anesthesia outpatient clinic in reducing pre-operative anxiety.
        J Coll Physicians Surg Pak. 2004; 14: 202-204
        • Klopfenstein C.E.
        • Forster A.
        • Van Gessel E.
        Anesthetic assessment in an outpatient consultation clinic reduces preoperative anxiety.
        Can J Anaesth. 2000; 47: 511-515
        • Koivula M.
        • Paunonen-Ilmonen M.
        • Tarkka M.T.
        • et al.
        Fear and anxiety in patient awaiting coronary artery bypass grafting.
        Heart Lung. 2001; 30: 302-311
        • Vingerhoets G.
        Perioperative anxiety and depression in open-heart surgery.
        Psychosomatics. 1998; 39: 30-37
        • Burg M.M.
        • Benedetto M.C.
        • Rosenberg R.
        • et al.
        Presurgical depression predicts medical morbidity 6 months after coronary artery bypass graft.
        Psychosom Med. 2003; 65: 111-118
        • Fitzsimons D.
        • Parahoo K.
        • Richardson S.G.
        • et al.
        Patient anxiety while on a waiting list for coronary artery bypass surgery: A qualitative and quantitative analysis.
        Heart Lung. 2003; 32: 23-31
        • Rymaszewska J.
        • Kiejna A.
        • Hadryś T.
        Depression and anxiety in coronary artery bypass grafting patients.
        Eur Psychiatry. 2003; 18: 155-160
        • Gu G.
        • Zhou Y.
        • Zhang Y.
        • et al.
        Increased prevalence of anxiety and depression symptoms in patients with coronary artery disease before and after percutaneous coronary intervention treatment.
        BMC Psychiatry. 2016; 22: 259
        • Domar A.D.
        • Everett L.L.
        • Keller M.G.
        Preoperative anxiety: Is it a predictable entity?.
        Anesth Analg. 1989; 69: 763-767
        • Caumo W.
        • Schmidt A.P.
        • Schneider C.N.
        • et al.
        Risk factors for postoperative anxiety in adults.
        Anaesthesia. 2001; 56: 720-728
        • Badner N.H.
        • Nielson W.R.
        • Munk S.
        • et al.
        Preoperative anxiety: Detection and contributing factors.
        Can J Anaesth. 1990; 37: 444-447
        • Oxlad M.
        • Stubberfield J.
        • Stuklis R.
        • et al.
        Psychological risk factors for cardiac-related hospital readmission within 6 months of coronary artery bypass graft surgery.
        J Psychosom Res. 2006; 61: 775-781
        • Stengrevics S.
        • Sirois C.
        • Schwartz C.E.
        • et al.
        The prediction of cardiac surgery outcome based upon preoperative psychological factors.
        Psychol Health. 1996; 11: 471-477
        • Poole L.
        • Kidd T.
        • Leigh E.
        • et al.
        Psychological distress and intensive care unit stay after cardiac surgery: The role of illness concern.
        Health Psychol. 2015; 34: 283-287
        • Aldea G.S.
        • Gaudiani J.M.
        • Shapira O.M.
        • et al.
        Effect of gender on postoperative outcomes and hospital stays after coronary artery bypass grafting.
        Ann Thorac Surg. 1999; 67: 1097-1103