Association of Depression and Health Anxiety with 5-Year Mortality in Patients with ST-Elevation Myocardial Infarction: SEMI-CI study

Association of Depression and Health Anxiety with 5-Year Mortality in Patients with ST-Elevation Myocardial Infarction: SEMI-CI study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of Depression and Health Anxiety with 5-Year Mortality in Patients with ST-Elevation Myocardial Infarction: SEMI-CI study Yasaman Shojaei, Hamidreza Roohafza, Kamran Mehrabani, Azam Soleimani, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7155212/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND ST-elevation myocardial infarction (STEMI) is a leading cause of cardiovascular death worldwide. While acute treatment has improved, long-term outcomes are affected by non-biological factors like depression and health anxiety. Evidence from middle-income countries is limited. This study examines the link between baseline depression, health anxiety, and five-year mortality in STEMI patients. METHODS This secondary analysis utilized data from the fifth-year follow-up of the SEMI-CI cohort study, conducted in Isfahan, Iran. Patients with STEMI admitted between October 2015 and October 2016 to university-affiliated hospitals were followed for five years. Baseline psychological assessments included the PHQ-9 for depression and the Diagnostic Criteria for Psychosomatic Research (DCPR) for health anxiety. Patients with incomplete data or lost to follow-up were excluded. Five-year mortality was the primary outcome. Associations between psychological factors and mortality were analyzed using Chi-square and independent t-tests. RESULTS Out of 759 participants, 189 (24.9%) died due to cardiovascular causes over 5 years. Mortality was significantly associated with older age, female sex, diabetes, hypertension, reduced ejection fraction, anterior MI, and higher Killip class. Depression and health anxiety were more prevalent among deceased patients. In fully adjusted models, depression (HR: 2.23, 95% CI: 1.35–3.64) and health anxiety (HR: 1.11, 95% CI: 1.04–1.19) independently predicted cardiovascular mortality. CONCLUSION Depression and health anxiety influence five-year mortality in STEMI patients. Health anxiety is moderately associated with mortality and linked to higher smoking rates and increased depression. Depression shows a strong association with mortality, smoking, and hypercholesterolemia. These findings emphasize the critical need to incorporate psychological assessment and management into the long-term care of STEMI patients. Introduction Cardiovascular diseases (CVDs) continue to be the leading cause of death worldwide, responsible for more than 1.7 million deaths each year(1, 2). Among the various forms of CVD, acute coronary syndromes (ACS), especially ST-elevation myocardial infarction (STEMI), are critical conditions associated with high short- and long-term mortality rates(3). According to the “American Heart Association (AHA) Guideline for the Management of Patients With Acute Coronary Syndromes” Forecasts suggest that cardiovascular diseases will continue to rank among the leading causes of death worldwide by the year 2030 (4). The burden of CVDs is increasing rapidly, with the years of life lost due to these diseases expected to nearly double between 2005 and 2025(5, 6). Despite significant advances in ACS treatment, including revascularization procedures and pharmacotherapy, long-term outcomes are still influenced by a combination of biological (such as age and sex), behavioral (such as smoking status), and psychological factors(7). Psychological conditions such as depression and anxiety have gained attention as important comorbidities in patients with ischemic heart disease, with mounting evidence indicating their negative effect on prognosis(8). In particular, depression has been linked to increased mortality after myocardial infarction (MI) in many studies. (9, 10). This results vary across different cultural and healthcare settings in such a way that some studies have found no significant association between depression and cardiovascular mortality or even suggested potential protective effects in certain subgroups, highlighting the complexity of this relationship(11). Additionally, studies have shown that variations in sample characteristics, such as age, gender distribution, and other clinical factors, can influence the relationship between mortality rate and depression(12). Anxiety disorders have also been studied due to their potential to worsen cardiac outcomes(13). Meta-analyses have shown that anxiety can raise the risk of adverse cardiac events by up to 36%(14). Specifically, health anxiety as a form of anxiety that is described by the fear of having, acquiring, or potentially avoiding illness, is one of the factors influencing patient mortality(15). However, the diversity of anxiety types and the lack of focused research in middle-income countries limit the broader application of these findings. Given the high prevalence of depression and anxiety among cardiac patients and the need for better risk stratification in post-MI care, this study aims to evaluate five-year mortality in STEMI patients in relation to their baseline psychological status. Utilizing validated tools, this cohort study assesses whether depression and health anxiety are significant predictors of long-term mortality among middle-income countries patients enrolled in the SEMI-CI registry. The findings may offer valuable insights into the integration of mental health assessments into routine cardiac care and emphasize the role of psychosomatic factors in cardiovascular prognosis. Methodology Study Design and Setting : This study was developed as a continuation of analyses conducted on the fifth-year data of the SEMI-CI project. The SEMI-CI study began in 2015 in Isfahan, Iran. Patients who were admitted to university-affiliated hospitals, within 24 hours of experiencing symptoms of ST-Elevation Myocardial Infarction (STEMI) between October 2015 and October 2016 were included in the initial cohort. The study included four phases: pre-hospital data (symptoms, referral, early treatment), hospital phase (diagnosis, history, procedures, medications), discharge data (final diagnosis and prescriptions), and a 5-year follow-up (medication adherence, MACE, re-hospitalization, mortality)(16). In the third and fifth year of follow-up, only patients who had survived through these years and had not withdrawn from participation included. Patients who failed to respond or cooperate during the follow-up process were excluded. Data collected in the fifth year included information on patient deaths and hospitalizations, which were obtained through telephone interviews using a checklist. The present study is a secondary analysis of data collected during the fifth year of follow-up with the ethical approval number "IR.MED.REC.1402.265". Written informed consent was obtained from all individual participants included in the study. Considering the critical importance of preserving and respecting the confidentiality of patient information, along with adherence to the relevant ethical guidelines. All participants provided written informed consent prior to their inclusion in the study. All patient`s data previously enrolled and recorded in the SEMI-CI study were included. The exclusion criteria also include information from patients whose data was incomplete during the review process. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Measurement: Depression: Depression was assessed at the time of admission using the Patient Health Questionnaire-9 (PHQ-9), a validated 9-item self-report tool. Each item was scored from 0 to 3, and total scores ranged from 0 to 27. depression scores were categorized into two groups: those with a score greater than or equal to 10 were considered as having depression, and those with a score less than 10 were considered as not having depression(17). Health Anxiety: Health anxiety was measured as one of the clusters of the Diagnostic Criteria for Psychosomatic Research (DCPR), 4 questions of a 58-item yes/no questionnaire consisting of 12 psychosomatic syndrome clusters. The Kappa coefficient for the Persian version ranged from 0.617 to 0.784. based on the structure of the DCPR questionnaire, patients were classified into two groups for health anxiety: those with health anxiety and those without(18). Other variables: Mortality data and other variables were examined, including demographic characteristics (age and sex), past medical history (smoking, diabetes, hypertension, and hypercholesterolemia), psychological conditions (depression and anxiety) as well as relevant clinical data. Statistical Analysis: Data were analyzed using SPSS version 24. Continuous variables were reported as mean ± standard deviation, and categorical variables as frequencies and percentages. comparison between depression, health anxiety, and five-year mortality were examined using Chi-square tests and independent t-tests. To estimate the hazard ratio (HR) and its corresponding confidence interval, Cox regression analysis was performed. Results A total of 759 participants were followed over a 5-year period, of whom 189 (24.9%) experienced cardiovascular mortality. Table 1 summarizes the baseline characteristics of participants based on survival status. Patients who died were significantly older (70.26 ± 12.45 vs. 58.32 ± 11.51 years, p < 0.05) and more likely to be female. Cardiovascular risk factors such as diabetes, hypertension, and reduced ejection fraction (were more prevalent in the deceased group. A higher Killip class, anterior myocardial infarction (MI), and multi-vessel disease (3-vessel: 39.1% vs. 20.5%) were also significantly associated with mortality. Psychological variables also showed significant associations: depression and health anxiety were more common in those who died (depression: 31.7% vs. 20.2%, p < 0.05; health anxiety: 9.5% vs. 4.2%, p = 0.012). In Table 2, participants with health anxiety were compared to those without. There was no significant difference in demographic or major clinical variables. However, a significantly higher prevalence of hypercholesterolemia ( p = 0.03) and depression (100% vs. 18.5%, p < 0.05) was observed among those with health anxiety. Table 3 presents comparisons based on the presence of depression. Participants with depression were younger on average and had higher smoking rates (46.3% vs. 37.3%, p = 0.01). There were no significant differences in EF or MI characteristics. Notably, 24% of depressed patients also exhibited health anxiety ( p < 0.05). Table 4 shows the crude and adjusted hazard ratios (HR) for 5-year cardiovascular mortality related to depression and health anxiety. Depression was a strong independent predictor across all models. After full adjustment (Model 3), depression was associated with a more than twofold increased risk of cardiovascular mortality (HR: 2.23, 95% CI: 1.35–3.64). Health anxiety was also independently associated with increased mortality risk in the fully adjusted model (HR: 1.11, 95% CI: 1.04–1.19). Table 1. Comparison of basic characteristics of risk factors of Study Participants on cardiovascular mortality after 5 years Variable Alive (n =570) Dead (n =189) p-value Demographic characteristics Age (mean+SD) 58.32±11.51 70.26±12.45 <0.05 Male 488(85.6) 133(70.4) <0.05 Past medical history Smoke 243(42.6) 52(27.5) <0.05 Diabetes 145(25.4) 75(39.7) <0.05 HTN 178(31.2) 85(45.0) <0.05 Hypercholesterolemia 174(30.5) 46(24.3) 0.06 Clinical data Killip Class On Admission (CLASS I) 547(96.0) 148(78.3) <0.05 Site of MI (anterior) 294(51.6) 117(61.9) 0.008 Number of Epicardial Territories (1) 233(45.9) 45(29.8) <0.05 (2) 161(31.7) 46(30.5) (3) 104(20.5) 59(39.1) EF <40% 287(58.2) 103(76.9) <0.05 Psychological factors Health anxiety 24 (4.2) 18(9.5) 0.012 Depression 115 (20.2) 60 (31.7) <0.05 Table 2. Comparison of basic characteristics of risk factors of Study Participants based on health anxiety Variable No health anxiety (n =717) Health anxiety (n =42) p-value Demographic characteristics Age(mean+SD) 60.28±12.6 59.30±10.6 0.64 male 594(82.8) 36(85.7) 0.37 Past medical history Smoke 290(40.5) 21(50.0) 0.12 Diabetes 206(28.7) 12(28.5) 0.51 HTN 252(35.1) 14(33.3) 0.43 Hypercholesterolemia 216(30.1) 19(45.2) 0.03 Clinical data Killip Class On Admission (CLASS I) 674(94.0) 39(92.8) 0.38 Site of MI (anterior) 393(54.8) 18(42.8) 0.11 Number of Epicardial Territories (1) 312(43.5) 23(54.8) 0.56 (2) 245(34.2) 13(30.9) (3) 160(22.3) 6(14.3) EF (<40%) 433(60.4) 25(59.5) 0.57 Psychological factors Depression 133(18.5) 42(100) <0.05 Table 3. Comparison of basic characteristics of risk factors of Study Participants based on depression Variable No depression (n =584) Depression (n =175) p-value Demographic characteristics Age(mean±SD) 62.12±13.0 57.70±11.54 <0.05 male 469(80.3) 148(84.6) 0.09 Past medical history Smoke 218(37.3) 81(46.3) 0.01 Diabetes 168(28.8) 55(31.4) 0.23 HTN 204(34.9) 54(30.8) 0.18 Hypercholesterolemia 169(29.3) 60(34.3) 0.05 Clinical data Killip Class On Admission (CLASS I) 531(91.0) 165(94.3) 0.06 Site of MI (anterior) 312(53.4) 99(56.6) 0.25 Number of Epicardial Territories (1) 235(40.2) 88(50.3) 0.09 (2) 197(33.7) 50(28.6) (3) 152(26.0) 37(21.1) EF (<40%) 370(63.3) 99(56.6) 0.07 Psychological factors Health anxiety 0(0) 42(24.0) <0.05 Table 4. Crude and Adjusted Hazard ratio (95% CI) of 5-years cardiovascular mortality for Depression and Health Anxiety Depression Health Anxiety HR 95%Cl HR 95%Cl Crude 1.65 (1.45-2.34) 1.05 (1.01_1.09) Model 1 1.98 (1.75-2.21) 1.06 (0.99_1.45) Model 2: 1.80 (1.59-2.89) 1.13 (1.05_1.25) Model 3 2.23 (1.35-3.64) 1.11 (1.04-1.19) Model 1: Adjusted for Demographic characteristics, Model 2: Model 1+ Adjusted for Past Medical history, Model 3: Model 2+Adjusted for clinical data, (Full adjusted). Discussion The current study aimed to investigate the influence of depression and health anxiety on the long-term mortality of patients with STEMI as a secondary analysis of the data from the SEMI-CI cohort. We identified depression and health anxiety as significant factors impacting patient mortality, which was more strongly affected by depression, highlighting the importance of early recognition and treatment. Consistent with previous studies, we found that patients with health anxiety exhibited higher long-term mortality rates(7). This association remained significant even after adjusting for demographic and clinical variables. Although several literatures have explored the relationship between depression and myocardial infarction (MI), the impact of anxiety following MI has received comparatively limited attention. This gap is mainly considering the high comorbidity between anxiety and depression(19). To date, only a small number of prospective studies have investigated anxiety in the post-MI context, that showed inconsistent findings(20-22). For instance, A nationwide registry study identified anxiety has been linked to a higher likelihood of mortality and recurrent cardiovascular events among individuals experiencing their first myocardial infarction(23), whereas other studies reported no such mortality association(21, 22, 24). Another study offered mixed results, indicating that anxiety predicted cardiac events but not mortality(20). In light of the limited research in this area, an observational work, provides this valuable contribution(25). This association may occur through mechanisms like autonomic nervous system dysregulation, decreased physical activity, and poor adherence to treatment(7). In addition, patients with health anxiety exhibit a higher prevalence of smoking compared to those without such anxiety. Few studies have examined this association in depth; however, one Australian population-based study reported that individuals with health anxiety were approximately twice as likely to be current smokers. A possible explanation for this finding is that smoking may serve as a means of alleviating tension and worry in these patients(26). Patients in the health anxiety group also showed a higher prevalence of hypercholesterolemia. According to our literature search, no studies to date have specifically examined this association or explored potential underlying mechanisms in this patient population(27). The variability in outcomes among studies examining the relationship between MI and anxiety may be attributed to several factors. Differences in sample characteristics play a role; some studies included patients with arrhythmias or significant left ventricular dysfunction, populations inherently at higher risk of mortality(24, 28). Timing also varied across studies in terms of when anxiety symptoms were assessed. Additionally, the use of diverse assessment tools and diagnostic measures for anxiety may have introduced inconsistencies in the reported outcomes. Methodological limitations such as small sample sizes and lack of multivariate analyses adjusting for confounding variables further undermine the reliability of some of the existing evidence(28). In our study, all of the patients with health anxiety demonstrated depression, a relationship that has also been explored in previous research. Following a myocardial infarction (MI), patients may develop various forms of health anxiety, these concerns can result in elevated psychological distress, reduced engagement in physical exercise, and diminished quality of life—all of which may increase the risk of developing depressive symptoms(29). A history of mental health disorders—especially previous episodes of anxiety, along with adverse events or complications during the hospital stay, are among the key elements associated with an increased vulnerability to post-MI depression(30). According to previous studies, depression was found to have a significant impact on patient mortality. In this regard, studies from various countries investigated this effect in a large sample sizes, providing further evidence of the association(31). Given the rising prevalence of depression among cardiac patients, it is essential to explore this relationship in developing countries as well(32). Recent studies in the MENA (Middle East and North Africa) region have shown a high prevalence of depression among patients with MI; however, these studies have primarily focused on short-term mortality outcomes. Although a few studies conducted in these regions have noted similar effects on short-term prognosis, research examining the long-term implications of depression on cardiac outcomes remains limited(33, 34). One of the notable characteristics observed among individuals in the depression group was a higher prevalence of smoking. Large multicenter investigations conducted in Europe and Israel, have identified a link between post-MI depression and smoking behavior(35, 36). However, there has been a lack of large-scale, population-based data from the middle-income countries. This association may be partly explained by the use of smoking as a coping mechanism to alleviate psychological distress(37). Additionally, a greater proportion of patients in this group were found to have hypercholesterolemia. As demonstrated in recent studies, Individuals with depression tend to participate less in behaviors that support cardiovascular health after experiencing a myocardial infarction. This includes lower adherence to a balanced diet, reduced levels of physical activity, poor compliance with prescribed medications, limited engagement in stress management practices, and lower completion rates of cardiac rehabilitation programs. Additionally, these patients often face greater challenges in achieving optimal cholesterol levels post-MI(38). There were no significant differences between the two groups regarding other clinical and demographic data. Strengths and Limitations: Our study has several notable strengths, including a large sample size, a prospective design, and a long-term follow-up period. An additional strength of this study lies in its focus on patients from the MENA region. and enhance the reliability and validity of our findings. However, several limitations should be acknowledged in our study. The generalizability of our findings may be limited to the specific population studied. Additionally, reliance on medical records may result in missing or incomplete data. the sample population was derived from a cohort in Isfahan, Iran, which may limit the generalizability of the findings to broader populations with different ethnic and socio-economic backgrounds. Although multivariate adjustments were applied, residual confounding due to unmeasured variables such as medication adherence, dietary habits, and physical activity levels may have influenced the outcomes. Conclusion Given the increasing trend in the incidence of depression and anxiety among post-MI patients, it is essential to understand their impact on the long-term prognosis of these individuals. This knowledge can lead to significant improvements in patient care. Early identification of psychological disorders and the implementation of appropriate therapeutic interventions can positively influence patients' quality of life and, ultimately, reduce mortality rates . Declarations Ethics approval and consent to participate: The study was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MED.REC.1402.265). Written informed consent was obtained from all participants. Consent for publication: Not applicable. Clinical Trial Registration Number: Not applicable – this study is observational and was not registered as a clinical trial.) Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no conflict of interest. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions: Yasaman Shojaei: Conceptualization, Data collection, Data analysis, Draft writing. Hamidreza Roohafza: Study design, Methodology, Supervision. Kamran Mehrabani: Data validation, Statistical review. Azam Soleimani: Medical panel, Data validation. Safoura Yazdekhasti: Administrative coordination, Data entry support. Masoumeh Sadeghi: Principal investigator, Supervision, Correspondence. Mohammadamin Sadri: Data collection, Draft writing support. All authors reviewed and approved the final version of the manuscript References Mendis S, Puska P, Norrving B, World Health O, World Heart F, World Stroke O. Global atlas on cardiovascular disease prevention and control / edited by: Shanthi Mendis ... [et al.]. Geneva: World Health Organization; 2011. Di Cesare M, Perel P, Taylor S, Kabudula C, Bixby H, Gaziano TA, et al. The Heart of the World. Glob Heart. 2024;19(1):11. Rao SV, O’Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771–e862. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. مدل¬سازی تأثیر تغییر هرم سنی و جنسی بر بار بیماری¬های قلبی عروقی طی دو دهه آینده در ایران. مجله دانش و تندرستي در علوم پایه پزشکی. 2015;5 . Heidari-Foroozan M, Farshbafnadi M, Golestani A, Younesian S, Jafary H, Rashidi MM, et al. National and Subnational Burden of Cardiovascular Diseases in Iran from 1990 to 2021: Results from Global Burden of Diseases 2021 study. Glob Heart. 2025;20(1):43. Roohafza H, Shojaei Y, Azizian S, Zamani Z, Shafiei M, Masoumi G, et al. The Impact of Psychosomatic Factors on Treatment Adherence of Acute Myocardial Infarction Survivors; A Two-Year Follow-Up Study. Adv Biomed Res. 2023;12:251. Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J. 2006;27(23):2763–74. Hosseini SH, Yousefnejad K, Tabiban S, Nesarhoseyni V, Bagheri B, Kiasari AM, et al. Effects of depression and anxiety symptoms on cardiac mortality following myocardial infarction: a 2-year follow-up. Int J Psychiatry Clin Pract. 2011;15(2):91–6. Lin Y, Bai W, Liu H-H, Li Z-Z, Gao Z-Z, Han T, et al. Prevalence, correlates, and network analysis of depression and its association with quality of life in survivors with myocardial infarction during the COVID-19 pandemic. Journal of Affective Disorders. 2023;336:106–11. Whooley MA, de Jonge P, Vittinghoff E, Otte C, Moos R, Carney RM, et al. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. Jama. 2008;300(20):2379–88. Zeng J, Qiu Y, Yang C, Fan X, Zhou X, Zhang C, et al. Cardiovascular diseases and depression: A meta-analysis and Mendelian randomization analysis. Molecular Psychiatry. 2025. Johnsson A, Ljótsson B, Liliequist BE, Skúladóttir H, Maurex L, Boberg I, et al. Cognitive behavioural therapy targeting cardiac anxiety post-myocardial infarction: results from two sequential pilot studies. Eur Heart J Open. 2025;5(2):oeaf020. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med. 2010;72(6):563–9. Lebel S, Mutsaers B, Tomei C, Leclair CS, Jones G, Petricone-Westwood D, et al. Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates. PLoS One. 2020;15(7):e0234124. Sadeghi M, Soleimani A, Sarrafzadegan N, Askari M, Nouri F, Masoumi G, et al. Background and design of a 5-year ST Elevation Myocardial Infarction Cohort in Isfahan, Iran: SEMI-CI study. ARYA Atheroscler. 2021;17(3):1–7. Farrahi H, Gharraee B, Oghabian M, Zare R, Pirmoradi M, Najibi SM, et al. The Study of Psychometric Properties of the Persian Version of the Patient Health Questionnaire-9 (PHQ-9) Among Students of Guilan University of Medical Sciences in the Academic Year 2017-18. Iranian Journal of Psychiatry and Clinical Psychology. 2021;27. Goli F, Roohafza H, Khani A, Afshar H. Validation of Self-Assessed Form of Diagnostic Criteria for Psychosomatic Research Adapted from Diagnostic Criteria for Psychosomatic Research - Structured Interview. J Res Med Sci. 2022;27:11. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8–19. Frasure-Smith N, Lespérance F, Talajic M. The impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol. 1995;14(5):388–98. Lane D, Carroll D, Ring C, Beevers DG, Lip GY. Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Psychosom Med. 2001;63(2):221–30. Mayou RA, Gill D, Thompson DR, Day A, Hicks N, Volmink J, et al. Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med. 2000;62(2):212–9. Flygare O, Boberg J, Rück C, Hofmann R, Leosdottir M, Mataix-Cols D, et al. Association of anxiety or depression with risk of recurrent cardiovascular events and death after myocardial infarction: A nationwide registry study. Int J Cardiol. 2023;381:120–7. Ahern DK, Gorkin L, Anderson JL, Tierney C, Hallstrom A, Ewart C, et al. Biobehavioral variables and mortality or cardiac arrest in the Cardiac Arrhythmia Pilot Study (CAPS). Am J Cardiol. 1990;66(1):59–62. Strik JJ, Denollet J, Lousberg R, Honig A. Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. J Am Coll Cardiol. 2003;42(10):1801–7. Berge LI, Skogen JC, Sulo G, Igland J, Wilhelmsen I, Vollset SE, et al. 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. BMJ Open. 2016;6(11):e012914. Tembra S, Pegorini HJ, Reis LdLA. Diagnóstico, tratamento e impactos dos problemas de saúde mental no pós-infarto: uma revisão sistemática. Revista de Medicina. 2022;101(3):e–185514. Denollet J, Brutsaert DL. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation. 1998;97(2):167–73. Garrels E, Kainth T, Silva B, Yadav G, Gill G, Salehi M, et al. Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review. Frontiers in Psychiatry. 2023;Volume 14 - 2023. Strik JJ, Honig A, Lousberg R, van Os J, van den Berg EJ, van Praag HM. Clinical correlates of depression following myocardial infarction. Int J Psychiatry Med. 2001;31(3):255–64. Sabol RM, Sun CN, Gudenburr CA, Zou H, Fabian TJ, Xue Y. Impact of depression status and antidepressant use on mortality rates and clinical outcomes following acute myocardial infarction. J Psychiatr Res. 2025;186:57–63. Chong RJ, Hao Y, Tan EWQ, Mok GJL, Sia CH, Ho JSY, et al. Prevalence of Depression, Anxiety and Post-Traumatic Stress Disorder (PTSD) After Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. J Clin Med. 2025;14(6). Albasheer O, Al Ageeli E, Aljezani TI, Bakri KA, Jathmi SM, Maashi A, et al. Prevalence of depressive, anxiety, and stress symptoms and barriers to mental health services among medical students at Jazan University, Saudi Arabia: A cross-sectional study. Medicine. 2025;104(1):e41185. Shajrawi AM, Al-Akash HY, Al-Smadi AM, Masa'deh R, Aburuz ME, Khalil H, et al. Postacute Myocardial Infarction Differences in Physical Activity Behavior, Anxiety, and Depression Levels. SAGE Open Nurs. 2024;10:23779608241304478. Prugger C, Wellmann J, Heidrich J, De Bacquer D, De Backer G, Périer MC, et al. Readiness for smoking cessation in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey. Eur J Prev Cardiol. 2015;22(9):1212–9. Gerber Y, Rosen LJ, Goldbourt U, Benyamini Y, Drory Y. Smoking status and long-term survival after first acute myocardial infarction a population-based cohort study. J Am Coll Cardiol. 2009;54(25):2382–7. Parikh NS, Salehi Omran S, Kamel H, Elkind MSV, Willey J. Symptoms of depression and active smoking among survivors of stroke and myocardial infarction: An NHANES analysis. Prev Med. 2020;137:106131. Huffman JC, Celano CM, Beach SR, Motiwala SR, Januzzi JL. Depression and cardiac disease: epidemiology, mechanisms, and diagnosis. Cardiovasc Psychiatry Neurol. 2013;2013:695925. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7155212","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":511977898,"identity":"4d2ddb62-7566-48a4-86a0-3678ad37be85","order_by":0,"name":"Yasaman Shojaei","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Yasaman","middleName":"","lastName":"Shojaei","suffix":""},{"id":511977899,"identity":"db08012d-08b2-4ba7-9952-4dc70709a9f3","order_by":1,"name":"Hamidreza Roohafza","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hamidreza","middleName":"","lastName":"Roohafza","suffix":""},{"id":511977900,"identity":"ba88a9d6-a8af-4226-9b3b-02b8e97c6e5f","order_by":2,"name":"Kamran Mehrabani","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Kamran","middleName":"","lastName":"Mehrabani","suffix":""},{"id":511977901,"identity":"08053107-7ec6-4ad5-ad56-be06313043d7","order_by":3,"name":"Azam Soleimani","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Azam","middleName":"","lastName":"Soleimani","suffix":""},{"id":511977902,"identity":"d422c9a7-3e36-43b9-8072-f9d570fe0b03","order_by":4,"name":"Safoura Yazdekhasti","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Safoura","middleName":"","lastName":"Yazdekhasti","suffix":""},{"id":511977906,"identity":"12a82ecb-cb44-45d3-85ea-efd2a26167b6","order_by":5,"name":"Mohammadamin Sadri","email":"","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammadamin","middleName":"","lastName":"Sadri","suffix":""},{"id":511977907,"identity":"60ef33eb-013f-45fe-b186-217bceda5fc5","order_by":6,"name":"Masoumeh Sadeghi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYHACAwbGBgkY54AcmHxAihZjMJlAWAuccyARzManRb798MaHX3dYRPP3Hz4mdaPiTvr8sMMPgbbYyek2YNdicCat2Fj2jETujBtpadI5Z57lbrydZgDUkmxsdgCXq3LMpCXbJHIbbvCYSee2Hc7dODsBpOVA4jYcWuT735j/BmmZf/4MUMu/w+mGs9M/4NXCcCPHjPEjUMuGA0DrchsOJ8hL5+C3xeDGs2JpRqCWjTfSkq1zjh023CCdU3AgwQC3X+T7kzd+/NlWlzvv/OGDt3NqDsvLz07f/OFDhZ0cLi0gwMyDYu8BSLDgBYw/UOxtwK96FIyCUTAKRh4AAL5iayoOWvmHAAAAAElFTkSuQmCC","orcid":"","institution":"Isfahan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Masoumeh","middleName":"","lastName":"Sadeghi","suffix":""}],"badges":[],"createdAt":"2025-07-18 07:53:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7155212/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7155212/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90992496,"identity":"61d74b2e-fa8d-411e-9311-fcc54be356b4","added_by":"auto","created_at":"2025-09-10 11:38:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":536633,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7155212/v1/6e7872b2-eef8-4758-93e4-f9890ee2c661.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of Depression and Health Anxiety with 5-Year Mortality in Patients with ST-Elevation Myocardial Infarction: SEMI-CI study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiovascular diseases (CVDs) continue to be the leading cause of death worldwide, responsible for more than 1.7\u0026nbsp;million deaths each year(1, 2). Among the various forms of CVD, acute coronary syndromes (ACS), especially ST-elevation myocardial infarction (STEMI), are critical conditions associated with high short- and long-term mortality rates(3). According to the “American Heart Association (AHA) Guideline for the Management of Patients With Acute Coronary Syndromes” Forecasts suggest that cardiovascular diseases will continue to rank among the leading causes of death worldwide by the year 2030 (4). The burden of CVDs is increasing rapidly, with the years of life lost due to these diseases expected to nearly double between 2005 and 2025(5, 6).\u003c/p\u003e\u003cp\u003eDespite significant advances in ACS treatment, including revascularization procedures and pharmacotherapy, long-term outcomes are still influenced by a combination of biological (such as age and sex), behavioral (such as smoking status), and psychological factors(7). Psychological conditions such as depression and anxiety have gained attention as important comorbidities in patients with ischemic heart disease, with mounting evidence indicating their negative effect on prognosis(8).\u003c/p\u003e\u003cp\u003eIn particular, depression has been linked to increased mortality after myocardial infarction (MI) in many studies. (9, 10). This results vary across different cultural and healthcare settings in such a way that some studies have found no significant association between depression and cardiovascular mortality or even suggested potential protective effects in certain subgroups, highlighting the complexity of this relationship(11). Additionally, studies have shown that variations in sample characteristics, such as age, gender distribution, and other clinical factors, can influence the relationship between mortality rate and depression(12).\u003c/p\u003e\u003cp\u003eAnxiety disorders have also been studied due to their potential to worsen cardiac outcomes(13). Meta-analyses have shown that anxiety can raise the risk of adverse cardiac events by up to 36%(14). Specifically, health anxiety as a form of anxiety that is described by the fear of having, acquiring, or potentially avoiding illness, is one of the factors influencing patient mortality(15). However, the diversity of anxiety types and the lack of focused research in middle-income countries limit the broader application of these findings.\u003c/p\u003e\u003cp\u003eGiven the high prevalence of depression and anxiety among cardiac patients and the need for better risk stratification in post-MI care, this study aims to evaluate five-year mortality in STEMI patients in relation to their baseline psychological status. Utilizing validated tools, this cohort study assesses whether depression and health anxiety are significant predictors of long-term mortality among middle-income countries patients enrolled in the SEMI-CI registry. The findings may offer valuable insights into the integration of mental health assessments into routine cardiac care and emphasize the role of psychosomatic factors in cardiovascular prognosis.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cb\u003eStudy Design and Setting\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThis study was developed as a continuation of analyses conducted on the fifth-year data of the SEMI-CI project. The SEMI-CI study began in 2015 in Isfahan, Iran. Patients who were admitted to university-affiliated hospitals, within 24 hours of experiencing symptoms of ST-Elevation Myocardial Infarction (STEMI) between October 2015 and October 2016 were included in the initial cohort. The study included four phases: pre-hospital data (symptoms, referral, early treatment), hospital phase (diagnosis, history, procedures, medications), discharge data (final diagnosis and prescriptions), and a 5-year follow-up (medication adherence, MACE, re-hospitalization, mortality)(16). In the third and fifth year of follow-up, only patients who had survived through these years and had not withdrawn from participation included. Patients who failed to respond or cooperate during the follow-up process were excluded. Data collected in the fifth year included information on patient deaths and hospitalizations, which were obtained through telephone interviews using a checklist.\u003c/p\u003e\u003cp\u003e The present study is a secondary analysis of data collected during the fifth year of follow-up with the ethical approval number \"IR.MED.REC.1402.265\". Written informed consent was obtained from all individual participants included in the study. Considering the critical importance of preserving and respecting the confidentiality of patient information, along with adherence to the relevant ethical guidelines. All participants provided written informed consent prior to their inclusion in the study. All patient`s data previously enrolled and recorded in the SEMI-CI study were included. The exclusion criteria also include information from patients whose data was incomplete during the review process. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepression:\u003c/strong\u003e Depression was assessed at the time of admission using the Patient Health Questionnaire-9 (PHQ-9), a validated 9-item self-report tool. Each item was scored from 0 to 3, and total scores ranged from 0 to 27. depression scores were categorized into two groups: those with a score greater than or equal to 10 were considered as having depression, and those with a score less than 10 were considered as not having depression(17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth Anxiety:\u003c/strong\u003e Health anxiety was measured as one of the clusters of the Diagnostic Criteria for Psychosomatic Research (DCPR), 4 questions of a 58-item yes/no questionnaire consisting of 12 psychosomatic syndrome clusters. The Kappa coefficient for the Persian version ranged from 0.617 to 0.784. based on the structure of the DCPR questionnaire, patients were classified into two groups for health anxiety: those with health anxiety and those without(18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOther variables:\u003c/strong\u003e Mortality data and other variables were examined, including demographic characteristics (age and sex), past medical history (smoking, diabetes, hypertension, and hypercholesterolemia),\u0026nbsp;psychological conditions (depression and anxiety)\u0026nbsp;as well as relevant clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Data were analyzed using SPSS version 24. Continuous variables were reported as mean \u0026plusmn; standard deviation, and categorical variables as frequencies and percentages. comparison between depression, health anxiety, and five-year mortality were examined using Chi-square tests and independent t-tests. To estimate the hazard ratio (HR) and its corresponding confidence interval, Cox regression analysis was performed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 759 participants were followed over a 5-year period, of whom 189 (24.9%) experienced cardiovascular mortality. Table 1 summarizes the baseline characteristics of participants based on survival status. Patients who died were significantly older (70.26 \u0026plusmn; 12.45 vs. 58.32 \u0026plusmn; 11.51 years, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05) and more likely to be female. Cardiovascular risk factors such as diabetes, hypertension, and reduced ejection fraction (were more prevalent in the deceased group. A higher Killip class, anterior myocardial infarction (MI), and multi-vessel disease (3-vessel: 39.1% vs. 20.5%) were also significantly associated with mortality.\u003c/p\u003e\n\u003cp\u003ePsychological variables also showed significant associations: depression and health anxiety were more common in those who died (depression: 31.7% vs. 20.2%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05; health anxiety: 9.5% vs. 4.2%, \u003cem\u003ep\u003c/em\u003e = 0.012).\u003c/p\u003e\n\u003cp\u003eIn Table 2, participants with health anxiety were compared to those without. There was no significant difference in demographic or major clinical variables. However, a significantly higher prevalence of hypercholesterolemia (\u003cem\u003ep\u003c/em\u003e = 0.03) and depression (100% vs. 18.5%, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05) was observed among those with health anxiety.\u003c/p\u003e\n\u003cp\u003eTable 3 presents comparisons based on the presence of depression. Participants with depression were younger on average and had higher smoking rates (46.3% vs. 37.3%, \u003cem\u003ep\u003c/em\u003e = 0.01). There were no significant differences in EF or MI characteristics. Notably, 24% of depressed patients also exhibited health anxiety (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05).\u003c/p\u003e\n\u003cp\u003eTable 4 shows the crude and adjusted hazard ratios (HR) for 5-year cardiovascular mortality related to depression and health anxiety. Depression was a strong independent predictor across all models. After full adjustment (Model 3), depression was associated with a more than twofold increased risk of cardiovascular mortality (HR: 2.23, 95% CI: 1.35\u0026ndash;3.64). Health anxiety was also independently associated with increased mortality risk in the fully adjusted model (HR: 1.11, 95% CI: 1.04\u0026ndash;1.19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Comparison of basic characteristics of risk factors of Study Participants on cardiovascular mortality after 5 years\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAlive\u003c/p\u003e\n \u003cp\u003e(n =570)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDead\u003c/p\u003e\n \u003cp\u003e(n =189)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDemographic characteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eAge (mean+SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.32\u0026plusmn;11.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70.26\u0026plusmn;12.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eMale \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e488(85.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e133(70.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePast medical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eSmoke\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e243(42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52(27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDiabetes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e145(25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75(39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHTN\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e178(31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85(45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHypercholesterolemia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e174(30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46(24.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eClinical data\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eKillip Class On Admission (CLASS I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e547(96.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e148(78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eSite of MI (anterior)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e294(51.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e117(61.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eNumber of Epicardial Territories\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e233(45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45(29.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e161(31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46(30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e104(20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59(39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eEF \u0026lt;40%\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e287(58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e103(76.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePsychological factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHealth anxiety\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18(9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDepression\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e115 (20.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Comparison of basic characteristics of risk factors of Study Participants based on health anxiety\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo health anxiety\u003c/p\u003e\n \u003cp\u003e(n =717)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHealth anxiety\u003c/p\u003e\n \u003cp\u003e(n =42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDemographic characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eAge(mean+SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.28\u0026plusmn;12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.30\u0026plusmn;10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e594(82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePast medical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eSmoke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e290(40.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21(50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e206(28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12(28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e252(35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHypercholesterolemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e216(30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19(45.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eClinical data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eKillip Class On Admission (CLASS I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e674(94.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e39(92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;Site of MI (anterior)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e393(54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18(42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eNumber of Epicardial Territories\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e312(43.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23(54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e245(34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13(30.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e160(22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eEF (\u0026lt;40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e433(60.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25(59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePsychological factors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e133(18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. Comparison of basic characteristics of risk factors of Study Participants based on depression\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo depression\u003c/p\u003e\n \u003cp\u003e(n =584)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003e(n =175)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDemographic characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eAge(mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.12\u0026plusmn;13.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.70\u0026plusmn;11.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e469(80.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e148(84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePast medical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eSmoke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e218(37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81(46.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e168(28.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55(31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHTN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e204(34.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54(30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHypercholesterolemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e169(29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60(34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eClinical data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eKillip Class On Admission (CLASS I)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e531(91.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e165(94.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u0026nbsp;Site of MI (anterior)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e312(53.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e99(56.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eNumber of Epicardial Territories\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e235(40.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88(50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e197(33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e(3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e152(26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37(21.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eEF (\u0026lt;40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e370(63.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e99(56.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003ePsychological factors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHealth anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42(24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4. Crude and Adjusted Hazard ratio (95% CI) of 5-years cardiovascular mortality for Depression and Health Anxiety\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003eHealth Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95%Cl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e95%Cl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCrude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.45-2.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.01_1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.75-2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(0.99_1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModel 2:\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.59-2.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.05_1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eModel 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.35-3.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e(1.04-1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eModel 1: Adjusted for Demographic characteristics, Model 2: Model 1+ Adjusted for Past Medical history, Model 3: Model 2+Adjusted for clinical data, (Full adjusted).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study aimed to investigate the influence of depression and health anxiety on the long-term mortality of patients with STEMI as a secondary analysis of the data from the SEMI-CI cohort. We identified depression and health anxiety as significant factors impacting patient mortality, which was more strongly affected by depression, highlighting the importance of early recognition and treatment.\u003c/p\u003e\n\u003cp\u003eConsistent with previous studies, we found that patients with health anxiety exhibited higher long-term mortality rates(7). This association remained significant even after adjusting for demographic and clinical variables. Although several literatures have explored the relationship between depression and myocardial infarction (MI), the impact of anxiety following MI has received comparatively limited attention. This gap is mainly considering the high comorbidity between anxiety and depression(19). To date, only a small number of prospective studies have investigated anxiety in the post-MI context, that showed inconsistent findings(20-22). For instance, A nationwide registry study identified anxiety has been linked to a higher likelihood of mortality and recurrent cardiovascular events among individuals experiencing their first myocardial infarction(23), whereas other studies reported no such mortality association(21, 22, 24). Another study offered mixed results, indicating that anxiety predicted cardiac events but not mortality(20). In light of the limited research in this area, an observational work, provides this valuable contribution(25). This association may occur through mechanisms like autonomic nervous system dysregulation, decreased physical activity, and poor adherence to treatment(7). \u003c/p\u003e\n\u003cp\u003eIn addition, patients with health anxiety exhibit a higher prevalence of smoking compared to those without such anxiety. Few studies have examined this association in depth; however, one Australian population-based study reported that individuals with health anxiety were approximately twice as likely to be current smokers. A possible explanation for this finding is that smoking may serve as a means of alleviating tension and worry in these patients(26). Patients in the health anxiety group also showed a higher prevalence of hypercholesterolemia. According to our literature search, no studies to date have specifically examined this association or explored potential underlying mechanisms in this patient population(27). \u003c/p\u003e\n\u003cp\u003eThe variability in outcomes among studies examining the relationship between MI and anxiety may be attributed to several factors. Differences in sample characteristics play a role; some studies included patients with arrhythmias or significant left ventricular dysfunction, populations inherently at higher risk of mortality(24, 28). Timing also varied across studies in terms of when anxiety symptoms were assessed. Additionally, the use of diverse assessment tools and diagnostic measures for anxiety may have introduced inconsistencies in the reported outcomes. Methodological limitations such as small sample sizes and lack of multivariate analyses adjusting for confounding variables further undermine the reliability of some of the existing evidence(28). \u003c/p\u003e\n\u003cp\u003eIn our study, all of the patients with health anxiety demonstrated depression, a relationship that has also been explored in previous research. Following a myocardial infarction (MI), patients may develop various forms of health anxiety,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003ethese concerns can result in elevated psychological distress, reduced engagement in physical exercise, and diminished quality of life\u0026mdash;all of which may increase the risk of developing depressive symptoms(29). A history of mental health disorders\u0026mdash;especially previous episodes of anxiety,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003ealong with adverse events or complications during the hospital stay, are among the key elements associated with an increased vulnerability to post-MI depression(30).\u003c/p\u003e\n\u003cp\u003eAccording to previous studies, depression was found to have a significant impact on patient mortality. In this regard, studies from various countries investigated this effect in a large sample sizes, providing further evidence of the association(31). Given the rising prevalence of depression among cardiac patients, it is essential to explore this relationship in developing countries as well(32). Recent studies in the MENA (Middle East and North Africa) region have shown a high prevalence of depression among patients with MI; however, these studies have primarily focused on short-term mortality outcomes.\u003cspan dir=\"RTL\"\u003e \u003c/span\u003eAlthough a few studies conducted in these regions have noted similar effects on short-term prognosis, research examining the long-term implications of depression on cardiac outcomes remains limited(33, 34).\u003c/p\u003e\n\u003cp\u003eOne of the notable characteristics observed among individuals in the depression group was a higher prevalence of smoking. Large multicenter investigations conducted in Europe and Israel, have identified a link between post-MI depression and smoking behavior(35, 36). However, there has been a lack of large-scale, population-based data from the middle-income countries. This association may be partly explained by the use of smoking as a coping mechanism to alleviate psychological distress(37). \u003c/p\u003e\n\u003cp\u003eAdditionally, a greater proportion of patients in this group were found to have hypercholesterolemia. As demonstrated in recent studies,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003eIndividuals with depression tend to participate less in behaviors that support cardiovascular health after experiencing a myocardial infarction. This includes lower adherence to a balanced diet,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003ereduced levels of physical activity,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003epoor compliance with prescribed medications, limited engagement in stress management practices,\u003cspan dir=\"RTL\"\u003e \u003c/span\u003eand lower completion rates of cardiac rehabilitation programs. Additionally, these patients often face greater challenges in achieving optimal cholesterol levels post-MI(38). There were no significant differences between the two groups regarding other clinical and demographic data. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eand Limitations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study has several notable strengths, including a large sample size, a prospective design, and a long-term follow-up period. An additional strength of this study lies in its focus on patients from the MENA region. and enhance the reliability and validity of our findings. However, several limitations should be acknowledged in our study. The generalizability of our findings may be limited to the specific population studied. Additionally, reliance on medical records may result in missing or incomplete data. the sample population was derived from a cohort in Isfahan, Iran, which may limit the generalizability of the findings to broader populations with different ethnic and socio-economic backgrounds. Although multivariate adjustments were applied, residual confounding due to unmeasured variables such as medication adherence, dietary habits, and physical activity levels may have influenced the outcomes. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eGiven the increasing trend in the incidence of depression and anxiety among post-MI patients, it is essential to understand their impact on the long-term prognosis of these individuals. This knowledge can lead to significant improvements in patient care. Early identification of psychological disorders and the implementation of appropriate therapeutic interventions can positively influence patients\u0026apos; quality of life and, ultimately, reduce mortality rates\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: The study was conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MED.REC.1402.265). Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eClinical Trial Registration Number: Not applicable \u0026ndash; this study is observational and was not registered as a clinical trial.)\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u0026nbsp;The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u0026nbsp;The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contributions:\u003c/p\u003e\n\u003cp\u003eYasaman Shojaei: Conceptualization, Data collection, Data analysis, Draft writing.\u003c/p\u003e\n\u003cp\u003eHamidreza Roohafza: Study design, Methodology, Supervision.\u003c/p\u003e\n\u003cp\u003eKamran Mehrabani: Data validation, Statistical review.\u003c/p\u003e\n\u003cp\u003eAzam Soleimani: Medical panel, Data validation.\u003c/p\u003e\n\u003cp\u003eSafoura Yazdekhasti: Administrative coordination, Data entry support.\u003c/p\u003e\n\u003cp\u003eMasoumeh Sadeghi: Principal investigator, Supervision, Correspondence.\u003c/p\u003e\n\u003cp\u003eMohammadamin Sadri: Data collection, Draft writing support.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMendis S, Puska P, Norrving B, World Health O, World Heart F, World Stroke O. Global atlas on cardiovascular disease prevention and control / edited by: Shanthi Mendis ... [et al.]. Geneva: World Health Organization; 2011.\u003c/li\u003e\n\u003cli\u003eDi Cesare M, Perel P, Taylor S, Kabudula C, Bixby H, Gaziano TA, et al. The Heart of the World. Glob Heart. 2024;19(1):11.\u003c/li\u003e\n\u003cli\u003eRao SV, O\u0026rsquo;Donoghue ML, Ruel M, Rab T, Tamis-Holland JE, Alexander JH, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025;151(13):e771\u0026ndash;e862.\u003c/li\u003e\n\u003cli\u003eMathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442.\u003c/li\u003e\n\u003cli\u003e\u003cspan dir=\"RTL\"\u003eمدل\u0026not;سازی تأثیر تغییر هرم سنی و جنسی بر بار بیماری\u0026not;های قلبی عروقی طی دو دهه آینده در ایران. مجله دانش و تندرستي در علوم پایه پزشکی. 2015;5\u003c/span\u003e.\u003c/li\u003e\n\u003cli\u003eHeidari-Foroozan M, Farshbafnadi M, Golestani A, Younesian S, Jafary H, Rashidi MM, et al. National and Subnational Burden of Cardiovascular Diseases in Iran from 1990 to 2021: Results from Global Burden of Diseases 2021 study. Glob Heart. 2025;20(1):43.\u003c/li\u003e\n\u003cli\u003eRoohafza H, Shojaei Y, Azizian S, Zamani Z, Shafiei M, Masoumi G, et al. The Impact of Psychosomatic Factors on Treatment Adherence of Acute Myocardial Infarction Survivors; A Two-Year Follow-Up Study. Adv Biomed Res. 2023;12:251.\u003c/li\u003e\n\u003cli\u003eNicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J. 2006;27(23):2763\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eHosseini SH, Yousefnejad K, Tabiban S, Nesarhoseyni V, Bagheri B, Kiasari AM, et al. Effects of depression and anxiety symptoms on cardiac mortality following myocardial infarction: a 2-year follow-up. Int J Psychiatry Clin Pract. 2011;15(2):91\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eLin Y, Bai W, Liu H-H, Li Z-Z, Gao Z-Z, Han T, et al. Prevalence, correlates, and network analysis of depression and its association with quality of life in survivors with myocardial infarction during the COVID-19 pandemic. Journal of Affective Disorders. 2023;336:106\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eWhooley MA, de Jonge P, Vittinghoff E, Otte C, Moos R, Carney RM, et al. Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. Jama. 2008;300(20):2379\u0026ndash;88.\u003c/li\u003e\n\u003cli\u003eZeng J, Qiu Y, Yang C, Fan X, Zhou X, Zhang C, et al. Cardiovascular diseases and depression: A meta-analysis and Mendelian randomization analysis. Molecular Psychiatry. 2025.\u003c/li\u003e\n\u003cli\u003eJohnsson A, Lj\u0026oacute;tsson B, Liliequist BE, Sk\u0026uacute;lad\u0026oacute;ttir H, Maurex L, Boberg I, et al. Cognitive behavioural therapy targeting cardiac anxiety post-myocardial infarction: results from two sequential pilot studies. Eur Heart J Open. 2025;5(2):oeaf020.\u003c/li\u003e\n\u003cli\u003eRoest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med. 2010;72(6):563\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLebel S, Mutsaers B, Tomei C, Leclair CS, Jones G, Petricone-Westwood D, et al. Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates. PLoS One. 2020;15(7):e0234124.\u003c/li\u003e\n\u003cli\u003eSadeghi M, Soleimani A, Sarrafzadegan N, Askari M, Nouri F, Masoumi G, et al. Background and design of a 5-year ST Elevation Myocardial Infarction Cohort in Isfahan, Iran: SEMI-CI study. ARYA Atheroscler. 2021;17(3):1\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eFarrahi H, Gharraee B, Oghabian M, Zare R, Pirmoradi M, Najibi SM, et al. The Study of Psychometric Properties of the Persian Version of the Patient Health Questionnaire-9 (PHQ-9) Among Students of Guilan University of Medical Sciences in the Academic Year 2017-18. Iranian Journal of Psychiatry and Clinical Psychology. 2021;27.\u003c/li\u003e\n\u003cli\u003eGoli F, Roohafza H, Khani A, Afshar H. Validation of Self-Assessed Form of Diagnostic Criteria for Psychosomatic Research Adapted from Diagnostic Criteria for Psychosomatic Research - Structured Interview. J Res Med Sci. 2022;27:11.\u003c/li\u003e\n\u003cli\u003eKessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8\u0026ndash;19.\u003c/li\u003e\n\u003cli\u003eFrasure-Smith N, Lesp\u0026eacute;rance F, Talajic M. The impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol. 1995;14(5):388\u0026ndash;98.\u003c/li\u003e\n\u003cli\u003eLane D, Carroll D, Ring C, Beevers DG, Lip GY. Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Psychosom Med. 2001;63(2):221\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eMayou RA, Gill D, Thompson DR, Day A, Hicks N, Volmink J, et al. Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med. 2000;62(2):212\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eFlygare O, Boberg J, R\u0026uuml;ck C, Hofmann R, Leosdottir M, Mataix-Cols D, et al. Association of anxiety or depression with risk of recurrent cardiovascular events and death after myocardial infarction: A nationwide registry study. Int J Cardiol. 2023;381:120\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eAhern DK, Gorkin L, Anderson JL, Tierney C, Hallstrom A, Ewart C, et al. Biobehavioral variables and mortality or cardiac arrest in the Cardiac Arrhythmia Pilot Study (CAPS). Am J Cardiol. 1990;66(1):59\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eStrik JJ, Denollet J, Lousberg R, Honig A. Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. J Am Coll Cardiol. 2003;42(10):1801\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eBerge LI, Skogen JC, Sulo G, Igland J, Wilhelmsen I, Vollset SE, et al. 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. BMJ Open. 2016;6(11):e012914.\u003c/li\u003e\n\u003cli\u003eTembra S, Pegorini HJ, Reis LdLA. Diagn\u0026oacute;stico, tratamento e impactos dos problemas de sa\u0026uacute;de mental no p\u0026oacute;s-infarto: uma revis\u0026atilde;o sistem\u0026aacute;tica. Revista de Medicina. 2022;101(3):e\u0026ndash;185514.\u003c/li\u003e\n\u003cli\u003eDenollet J, Brutsaert DL. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation. 1998;97(2):167\u0026ndash;73.\u003c/li\u003e\n\u003cli\u003eGarrels E, Kainth T, Silva B, Yadav G, Gill G, Salehi M, et al. Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review. Frontiers in Psychiatry. 2023;Volume 14 - 2023.\u003c/li\u003e\n\u003cli\u003eStrik JJ, Honig A, Lousberg R, van Os J, van den Berg EJ, van Praag HM. Clinical correlates of depression following myocardial infarction. Int J Psychiatry Med. 2001;31(3):255\u0026ndash;64.\u003c/li\u003e\n\u003cli\u003eSabol RM, Sun CN, Gudenburr CA, Zou H, Fabian TJ, Xue Y. Impact of depression status and antidepressant use on mortality rates and clinical outcomes following acute myocardial infarction. J Psychiatr Res. 2025;186:57\u0026ndash;63.\u003c/li\u003e\n\u003cli\u003eChong RJ, Hao Y, Tan EWQ, Mok GJL, Sia CH, Ho JSY, et al. Prevalence of Depression, Anxiety and Post-Traumatic Stress Disorder (PTSD) After Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. J Clin Med. 2025;14(6).\u003c/li\u003e\n\u003cli\u003eAlbasheer O, Al Ageeli E, Aljezani TI, Bakri KA, Jathmi SM, Maashi A, et al. Prevalence of depressive, anxiety, and stress symptoms and barriers to mental health services among medical students at Jazan University, Saudi Arabia: A cross-sectional study. Medicine. 2025;104(1):e41185.\u003c/li\u003e\n\u003cli\u003eShajrawi AM, Al-Akash HY, Al-Smadi AM, Masa\u0026apos;deh R, Aburuz ME, Khalil H, et al. Postacute Myocardial Infarction Differences in Physical Activity Behavior, Anxiety, and Depression Levels. SAGE Open Nurs. 2024;10:23779608241304478.\u003c/li\u003e\n\u003cli\u003ePrugger C, Wellmann J, Heidrich J, De Bacquer D, De Backer G, P\u0026eacute;rier MC, et al. Readiness for smoking cessation in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey. Eur J Prev Cardiol. 2015;22(9):1212\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eGerber Y, Rosen LJ, Goldbourt U, Benyamini Y, Drory Y. Smoking status and long-term survival after first acute myocardial infarction a population-based cohort study. J Am Coll Cardiol. 2009;54(25):2382\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eParikh NS, Salehi Omran S, Kamel H, Elkind MSV, Willey J. Symptoms of depression and active smoking among survivors of stroke and myocardial infarction: An NHANES analysis. Prev Med. 2020;137:106131.\u003c/li\u003e\n\u003cli\u003eHuffman JC, Celano CM, Beach SR, Motiwala SR, Januzzi JL. Depression and cardiac disease: epidemiology, mechanisms, and diagnosis. Cardiovasc Psychiatry Neurol. 2013;2013:695925.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7155212/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7155212/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e\u003cp\u003eST-elevation myocardial infarction (STEMI) is a leading cause of cardiovascular death worldwide. While acute treatment has improved, long-term outcomes are affected by non-biological factors like depression and health anxiety. Evidence from middle-income countries is limited. This study examines the link between baseline depression, health anxiety, and five-year mortality in STEMI patients.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e\u003cp\u003eThis secondary analysis utilized data from the fifth-year follow-up of the SEMI-CI cohort study, conducted in Isfahan, Iran. Patients with STEMI admitted between October 2015 and October 2016 to university-affiliated hospitals were followed for five years. Baseline psychological assessments included the PHQ-9 for depression and the Diagnostic Criteria for Psychosomatic Research (DCPR) for health anxiety. Patients with incomplete data or lost to follow-up were excluded. Five-year mortality was the primary outcome. Associations between psychological factors and mortality were analyzed using Chi-square and independent t-tests.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e\u003cp\u003eOut of 759 participants, 189 (24.9%) died due to cardiovascular causes over 5 years. Mortality was significantly associated with older age, female sex, diabetes, hypertension, reduced ejection fraction, anterior MI, and higher Killip class. Depression and health anxiety were more prevalent among deceased patients. In fully adjusted models, depression (HR: 2.23, 95% CI: 1.35\u0026ndash;3.64) and health anxiety (HR: 1.11, 95% CI: 1.04\u0026ndash;1.19) independently predicted cardiovascular mortality.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e\u003cp\u003eDepression and health anxiety influence five-year mortality in STEMI patients. Health anxiety is moderately associated with mortality and linked to higher smoking rates and increased depression. Depression shows a strong association with mortality, smoking, and hypercholesterolemia. These findings emphasize the critical need to incorporate psychological assessment and management into the long-term care of STEMI patients.\u003c/p\u003e","manuscriptTitle":"Association of Depression and Health Anxiety with 5-Year Mortality in Patients with ST-Elevation Myocardial Infarction: SEMI-CI study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:12:08","doi":"10.21203/rs.3.rs-7155212/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6aa92db8-be07-4cdd-ad6d-9c1e7607a48b","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-10T11:38:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 11:12:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7155212","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7155212","identity":"rs-7155212","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}