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To explore the long-term effect of anxiety and depression on outcome after cardiac surgery. To date, the relationship between psychosocial factors and future cardiac events has been investigated mainly in population-based studies, in patients after cardiac catheterization or myocardial infarction.In total, 180 patients who underwent cardiac surgery using cardiopulmonary bypass were prospectively studied and followed up for 4 years. Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI), living alone, and education level along with clinical risk factors and perioperative characteristics were assessed. Psychological self-report questionnaires were completed preoperatively and 6, 12, 24, 36, and 48 months after discharge. Clinical end-points were mortality and cardiac events requiring hospitalization during follow-up.Average preoperative STAI-T score was 44.6 ± 10. Kaplan-Meier analysis showed a significant effect of preoperative STAI-T >45 points (p = .008) on mortality. In multivariate models, postoperative congestive heart failure (OR: 10.8; 95% confidence interval [CI]:2.9–40.1; p = .009) and preoperative STAI-T (score OR: 1.07; 95% CI: 1.01–1.15; p = .05) were independently associated with mortality. The occurrence of cardiovascular hospitalization was independently associated with postoperative intensive care unit days (OR: 1.41; 95% CI: 1.01–1.96; p = .045) and post discharge 6th month STAI-T (OR: 1.06; 95% CI:1.01–1.13; p = .03).The results of the present study suggest that the assessment of psychosocial factors, particularly the ongoing assessment of anxiety, could help in risk stratification and identification of patients at risk of mortality and cardiovascular morbidity after cardiac surgery.BDI = Beck Depression Inventory; STAI-S = state anxiety subscale; STAI-T = trait anxiety subscale of Spielberger State-Trait Anxiety Inventory; CPB = cardiopulmonary bypass; CABG = coronary artery bypass grafting; CHF = congestive heart failure; CHD = coronary heart disease; ICU = intensive care unit; MI = myocardial infarction; PTSD = posttraumatic stress disorder.