Understanding Patients' Fears Before Heart Surgery: Addressing Death Anxiety in CABG Candidates

Abstract

Coronary artery bypass grafting (CABG) remains one of the most frequently performed and effective surgical interventions for patients with advanced coronary artery disease. Continuous advancements in surgical techniques, myocardial protection strategies, perioperative monitoring, and postoperative care have substantially improved procedural safety and long-term outcomes. Yet, while clinical attention is often directed toward optimizing physiological risk factors, the psychological burden experienced by patients awaiting cardiac surgery frequently remains underrecognized. In this issue of the Pakistan Heart Journal, Rizwan et al. [1] report that nearly two-thirds of patients awaiting CABG experienced significant death anxiety, highlighting an important but often overlooked dimension of preoperative cardiac care. Facing a major cardiac operation inevitably confronts patients with questions about mortality, uncertainty, and the future. Death anxiety—the distress and apprehension associated with the awareness of one's mortality—is a common psychological response among individuals facing life-threatening illness or invasive medical procedures [2,3]. For many patients, the prospect of open-heart surgery evokes concerns about survival, postoperative recovery, family responsibilities, financial security, and the possibility of an altered quality of life. The findings reported by Rizwan et al. suggest that these fears are not isolated experiences but represent a substantial psychological burden among CABG candidates. Importantly, the study identifies specific patient groups who appear particularly vulnerable to elevated levels of death anxiety. Women, older adults, individuals with limited education and health literacy, those from lower socioeconomic backgrounds, and patients with more severe coronary artery disease were significantly more likely to report heightened anxiety. These observations align with previous literature demonstrating that psychological responses to serious illness are shaped not only by disease severity but also by social, educational, cultural, and economic determinants of health [4-7]. Such findings underscore the importance of recognizing psychological vulnerability as a multidimensional construct that extends beyond traditional clinical risk assessment. The clinical relevance of preoperative anxiety extends far beyond emotional discomfort. A growing body of evidence suggests that psychological distress may adversely influence postoperative outcomes through both behavioral and biological mechanisms. Higher levels of anxiety have been associated with poorer treatment adherence, increased postoperative pain, delayed recovery, prolonged hospitalization, reduced participation in rehabilitation programs, and diminished quality of life [8]. Furthermore, anxiety can activate neuroendocrine stress responses and inflammatory pathways, potentially influencing perioperative physiological stability and recovery. Consequently, the assessment and management of death anxiety should be viewed as an integral component of comprehensive cardiac care rather than a secondary or optional consideration. The implications of these findings may be particularly important in low- and middle-income countries, including Pakistan, where preoperative evaluations predominantly focus on medical fitness while emotional wellbeing often receives limited attention. Integrating psychological assessment into routine preoperative care need not require substantial resources. Structured counseling sessions, patient education regarding the surgical procedure and expected outcomes, opportunities for patients to discuss concerns with healthcare providers, family-centered communication, and referral pathways for psychological support may significantly alleviate anxiety and improve preparedness for surgery. In South Asian societies, culturally sensitive interventions that acknowledge spiritual beliefs, family structures, and social support networks may further enhance patient engagement and emotional resilience. Although the study is limited by its cross-sectional design and single-center setting, it addresses a significant gap in regional literature and contributes valuable evidence regarding the psychological experiences of cardiac surgical patients. Future multicenter and longitudinal studies are warranted to determine whether targeted interventions aimed at reducing death anxiety can improve not only psychological wellbeing but also postoperative recovery, patient satisfaction, and clinical outcomes. As cardiac surgery continues to evolve, the definition of successful care must extend beyond technical excellence and procedural success. Equally important is the ability of healthcare teams to recognize and address the fears, uncertainties, and emotional needs of patients confronting major surgery. The work by Rizwan et al. serves as a timely reminder that truly patient-centered cardiac care requires attention to both the heart and the mind. By acknowledging and addressing death anxiety, clinicians may not only improve the surgical experience but also contribute to better overall outcomes for patients undergoing CABG. References Khan KA, Shah T, Shah HA, Shah SM, Rahim T, Khan MU, et al. 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