Cardiovascular neurosis refers to a clinical syndrome characterized by symptoms related to cardiovascular disease without evidence of organic heart disease. This condition predominantly occurs in middle-aged and young individuals, with a higher prevalence in females, particularly those in the perimenopausal period. Patients often present with variable and atypical symptoms, and despite extensive testing, objective evidence of organic disease is difficult to identify. Due to the frequent coexistence of psychological or psychiatric issues, patients often seek repeated medical consultations, which can severely disrupt daily life and work. This condition may also increase the risk of cardiovascular events, making it challenging to achieve true health.
Etiology and Pathogenesis
The exact cause of cardiovascular neurosis remains unclear. It is believed to be associated with personality type, environmental factors, genetic predisposition, and individual temperament. Affected individuals often exhibit depressive, anxious, or melancholic personality traits. The condition may be triggered by external stressors, work-related tension, or difficulty adapting to stressful environments. A family history of neurosis suggests that this condition may be linked to shared familial personality traits and similar external environmental influences. In some cases, the disorder may arise from excessive worry about suspected heart disease due to a lack of understanding about cardiac conditions.
During the disease process, dysfunction of the nervous and endocrine systems is often observed, including heightened sympathetic nervous system activity and an imbalance between sympathetic and parasympathetic functions. Patients frequently exhibit a significantly faster heart rate in response to intravenous isoproterenol compared to the general population. Features of a hyperdynamic circulatory state, such as enhanced arterial pulsations and increased left ventricular ejection velocity, may also be present. Additionally, abnormal responses to exercise, psychological stress, or painful stimuli can occur.
Psychological and psychiatric issues often lead to harmful behaviors, such as smoking, lack of physical activity, and poor adherence to treatment. These behaviors may exacerbate endothelial dysfunction, promote inflammatory responses, induce platelet aggregation and coagulation abnormalities, trigger arrhythmias, and accelerate the progression of atherosclerosis, ultimately increasing the risk of cardiovascular disease.
Clinical Manifestations
Patients with cardiovascular neurosis often report numerous and variable symptoms, with little internal correlation between them. The following symptoms may be observed:
Palpitations
A heightened awareness of the heartbeat is often exacerbated by tension or fatigue.
Dyspnea
Symptoms include chest tightness and difficulty breathing, often accompanied by a sensation of insufficient air, leading to a desire to open windows or request supplemental oxygen. Many patients frequently take deep breaths or sigh to alleviate symptoms, which can result in hyperventilation, respiratory alkalosis, and symptom exacerbation.
Precordial Pain
Unlike typical angina, the pain does not have a fixed location. It is often localized to a small area near the apex of the heart or beneath the left breast but may also occur under the sternum, in the right anterior chest, or in the chest and back. The pain is unrelated to physical exertion and typically occurs during rest. Patients often describe the pain as stabbing, pulling, or cutting in nature. The duration varies, often lasting longer than typical angina, and may persist for several days or longer, especially if triggered by work-related stress or emotional agitation. Sublingual nitroglycerin does not alleviate the pain.
Symptoms of Autonomic Nervous System Dysfunction
These include insomnia, vivid dreams, anxiety, loss of appetite, dizziness, tinnitus, excessive sweating, cold extremities, hand tremors, frequent urination, increased bowel movements, or constipation.
Despite the numerous symptoms, physical examination often reveals a lack of significant pathological findings. Tachycardia, accentuated heart sounds, short systolic murmurs, or premature contractions may be observed, along with mild blood pressure elevation and hyperactive tendon reflexes. However, cardiac-related auxiliary tests typically show no significant abnormalities. Electrocardiograms may indicate sinus tachycardia, atrial or ventricular premature contractions, or nonspecific ST-T changes.
Patients with cardiovascular disease combined with psychological or psychiatric conditions often exhibit clear clinical manifestations of cardiovascular disease, such as angina or heart failure, alongside unexplained somatic symptoms, including depression, suppression, restlessness, irritability, and fatigue. Acute episodes, such as panic attacks, may also occur, presenting with chest pain, palpitations, dyspnea, dizziness, headache, perspiration, and trembling. These symptoms usually peak within 10-20 minutes and lack evidence of organic abnormalities in the cardiac, respiratory, or nervous systems to support the clinical presentation.
Diagnosis and Differential Diagnosis
The diagnosis of cardiovascular neurosis is typically straightforward, based on its clinical manifestations, which include the presence of the aforementioned symptoms with minimal physical signs and no evidence of organic heart disease. It is essential to exclude organic cardiac conditions and differentiate cardiovascular neurosis from angina pectoris, hyperthyroidism, myocarditis, mitral valve prolapse syndrome, and pheochromocytoma.
Patients with organic cardiovascular diseases may also present with psychological or psychiatric issues. Clinicians should be vigilant in identifying these cases and consider the impact of psychological and psychiatric problems on the assessment of the severity of organic heart disease.
Treatment
The primary approach to managing cardiovascular neurosis involves psychological therapy, supplemented with pharmacological treatment when necessary. A thorough understanding of the patient’s history, potential triggers, and contributing factors is essential, along with careful physical examination and necessary laboratory tests. Explaining the nature of the condition in simple and understandable terms, combined with suggestive language, can help alleviate the patient’s concerns. Patients are encouraged to adopt a positive mindset, maintain a balanced schedule, and engage in appropriate recreational, travel, and physical activities. For patients with hyperventilation, diaphragmatic breathing relaxation techniques may be helpful. In cases where cardiovascular risk factors such as hypertension or hyperlipidemia coexist without clear evidence of organic disease, active intervention to address these risk factors is recommended.
For both cardiovascular neurosis and organic cardiovascular diseases complicated by psychological or psychiatric problems, a dual-heart medical treatment model is advocated.
In addition to the active and appropriate treatment of coexisting organic cardiovascular diseases, patients with significant anxiety symptoms may benefit from anxiolytic medications, such as benzodiazepines (e.g., clonazepam or lorazepam). For patients with depressive symptoms, tricyclic antidepressants (e.g., amitriptyline or doxepin) or selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine or sertraline) may be considered. SSRIs are currently regarded as having fewer cardiovascular side effects and greater safety compared to tricyclic antidepressants. However, SSRIs typically take around two weeks to become effective and are recommended as the first-line treatment for patients with depression.
Psychological and behavioral therapy, including counseling, behavior modification, and biofeedback therapy, should also be considered as part of the treatment plan.