Social emotional learning and autonomic regulation enhance social connectedness in female adolescents with extensive exposure to adverse childhood experiences.

Nearly half of patients with cardiovascular disease (CVD) experience increased levels of depression and anxiety. Furthermore, depression can be a risk factor for adverse cardiovascular outcomes in patients with CVD. Although the link between depression and CVD outcomes is well-established, the underlying psychological pathways – specifically how anxiety subcomponents bridge depression and health-related quality of life (HRQoL) – remain a critical knowledge gap. Evidence about the relationships among depression, anxiety, and HRQoL has been inconsistent. Whereas some studies suggest a strong correlation, others report no significant associations. Crucially, although previous studies have shown evidence of associations, they have primarily established simple relationships without elucidating the distinct pathways through which specific anxiety traits influence outcomes. This study uses the Cardiac Anxiety Questionnaire (CAQ) to analyze anxiety through its three dimensions—fear, attention, and avoidance. Rather than merely confirming a relationship between anxiety and health outcomes, it examines the underlying mechanisms by which these dimensions mediate the effects of depression on HRQoL. In this study, cardiac anxiety is conceptualized as a broad construct comprising three subdomains – fear, attention, and avoidance. This approach clarifies not only whether anxiety is associated with HRQoL, but also which specific anxiety-related responses explain this pathway. Previous studies have not fully elucidated the relationships among HRQoL, depression, and anxiety in patients with CVD, and few studies have explored whether anxiety mediates the relationship between depression and HRQoL in patients with CVD. Although current CVD prevention guidelines recommend screening for both anxiety and depression to identify the individuals at greatest risk, the role of anxiety as a risk factor for CVD has not been established as definitively as that of depression. Suls and Bunde pointed out that the relationship between anxiety and CVD remains inconclusive, highlighting the complexities of differentiating the effects of specific negative affective states on cardiovascular risk. Since then, researchers have increasingly emphasized the importance of clarifying the role of anxiety in cardiovascular outcomes beyond its association with depression. However, few studies have examined how anxiety – particularly its specific components of fear, attention, and avoidance – might function as a mediator in the relationship between depression and HRQoL in patients with CVD. Therefore, it is necessary to analyze both depression and anxiety to determine whether and how they directly and indirectly affect the HRQoL of patients with CVD.