Depression after coronary artery disease is associated with heart failure

Depressive Symptoms and Incident Heart Failure Risk in the Southern Community Cohort Study

OBJECTIVES

This study aims to examine whether greater frequency of depressive symptoms associates with increased risk of incident heart failure (HF).

BACKGROUND

Depressive symptoms associate with adverse prognosis in patients with prevalent HF. Their association with incident HF is less studied, particularly in low-income and minority individuals.

METHODS

We studied 23,937 Black or White Southern Community Cohort Study participants (median age: 53 years, 70% Black, 64% women) enrolled between 2002 and 2009, without prevalent HF, receiving Centers for Medicare and Medicaid Services coverage. Cox models adjusted for traditional HF risk factors, socioeconomic and behavioral factors, social support, and antidepressant medications were used to quantify the association between depressive symptoms assessed at enrollment via the Center for Epidemiologic Studies Depression Scale (CESD-10) and incident HF ascertained from Centers for Medicare and Medicaid Services International Classification of Diseases-9th Revision (ICD-9) (code: 428.x) and ICD-10 (codes: I50, I110) codes through December 31, 2016.

RESULTS

The median CESD-10 score was 9 (IQR: 5 to 13). Over a median 11-year follow-up, 6,081 (25%) participants developed HF. The strongest correlates of CESD-10 score were antidepressant medication use, age, and socioeconomic factors, rather than traditional HF risk factors. Greater frequency of depressive symptoms associated with increased incident HF risk (per 8-U higher CESD-10 HR: 1.04; 95% CI: 1.00 to 1.09; P = 0.038) without variation by race or sex. The association between depressive symptoms and incident HF varied by antidepressant use (interaction-P = 0.03) with increased risk among individuals not taking antidepressants.

CONCLUSIONS

In this high-risk, low-income, cohort of predominantly Black participants, greater frequency of depressive symptoms significantly associates with higher risk of incident HF.

Social Isolation and Incident Heart Failure Hospitalization in Older Women: Women's Health Initiative Study Findings

Background The association of social isolation or lack of social network ties in older adults is unknown. This knowledge gap is important since the risk of heart failure (HF) and social isolation increase with age. The study examines whether social isolation is associated with incident HF in older women, and examines depressive symptoms as a potential mediator and age and race and ethnicity as effect modifiers. Methods and Results This study included 44 174 postmenopausal women of diverse race and ethnicity from the WHI (Women's Health Initiative) study who underwent annual assessment for HF adjudication from baseline enrollment (1993-1998) through 2018. We conducted a mediation analysis to examine depressive symptoms as a potential mediator and further examined effect modification by age and race and ethnicity. Incident HF requiring hospitalization was the main outcome. Social isolation was a composite variable based on marital/partner status, religious ties, and community ties. Depressive symptoms were assessed using CES-D (Center for Epidemiology Studies-Depression). Over a median follow-up of 15.0 years, we analyzed data from 36 457 women, and 2364 (6.5%) incident HF cases occurred; 2510 (6.9%) participants were socially isolated. In multivariable analyses adjusted for sociodemographic, behavioral, clinical, and general health/functioning; socially isolated women had a higher risk of incident HF than nonisolated women (HR, 1.23; 95% CI, 1.08-1.41). Adding depressive symptoms in the model did not change this association (HR, 1.22; 95% CI, 1.07-1.40). Neither race and ethnicity nor age moderated the association between social isolation and incident HF. Conclusions Socially isolated older women are at increased risk for developing HF, independent of traditional HF risk factors. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT00000611.

Depressive Symptoms, Cardiac Structure and Function, and Risk of Incident Heart Failure With Preserved Ejection Fraction and Heart Failure With Reduced Ejection Fraction in Late Life

Background Depressive symptoms are associated with heightened risk of heart failure (HF), but their association with cardiac function and with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) in late life is unclear. We aimed to determine the prevalence of depression in HFpEF and in HFrEF in late life, and the association of depressive symptoms with cardiac function and incident HFpEF and HFrEF. Methods and Results We studied 6025 participants (age, 75.3±5.1 years; 59% women; 20% Black race) in the ARIC (Atherosclerosis Risk in Communities) study at visit 5 who underwent echocardiography and completed the Center for Epidemiologic Studies Depression Scale questionnaire. Among HF-free participants (n=5086), associations of Center for Epidemiologic Studies Depression Scale score with echocardiography and incident adjudicated HFpEF and HFrEF were assessed using multivariable linear and Cox proportional hazards regression. Prevalent HFpEF, but not HFrEF, was associated with a higher prevalence of depression compared with HF-free participants (P<0.001 and P=0.59, respectively). Among HF-free participants, Center for Epidemiologic Studies Depression Scale score was not associated with cardiac structure and function after adjusting for demographics and comorbidities (all P>0.05). Over 5.5-year follow-up, higher Center for Epidemiologic Studies Depression Scale score was associated with heightened risk of incident HFpEF (hazard ratio [HR] [95% CI], 1.06 [1.04-1.12]; P=0.02), but not HFrEF (HR [95% CI], 1.02 [0.96-1.08]; P=0.54), independent of echocardiographic measures, NT-proBNP (N-terminal pro-B-type natriuretic peptide), troponin, and hs-CRP (high-sensitivity C-reactive protein) (HR [95% CI], 1.06 [1.00-1.12]; P=0.04). Conclusions Worse depressive symptoms predict incident HFpEF in late life, independent of common comorbidities, cardiac structure and function, and prognostic biomarkers. Further studies are necessary to understand the mechanisms linking depression to risk of HFpEF.

Cognitive impairment and depression after acute myocardial infarction: associations with ejection fraction and demographic characteristics

Cognitive impairment and depression are often associated with acute myocardial infarction, however, the risk factors for their occurrence after myocardial infarction are still unclear. To determine the effect of reduced ejection fraction and demographic characteristics on the occurrence of cognitive impairment and depression after myocardial infarction. In the prospective study, the final sample consisted of 82 patients. Based on the value of the ejection fraction, the patients were divided into those with a value of < 40% and those having a value of ≥ 40%. Demographic data (age, gender, education), and data on comorbidities, were collected from the patients' medical history. The instruments of studies were: Mini-mental test and Beck depression inventory. The occurrence of cognitive impairment and depression was not, to a significant degree, associated with the level of ejection fraction. In contrast, demographics have shown positive predictive effects. Among demographic characteristics, the age of the patient proved to be a significant predictor for the occurrence of cognitive impairment (p = 0.004). The probability of cognitive impairment increases 1.16 times for each year of life. Significant depression predictor was female gender (p = 0.014). The probability of depression was 3.5 times greater for female gender. Cognitive impairment after acute myocardial infarction is more common in older patients, and depression in more common in women.

Comorbidity of depression and anxiety leads to a poor prognosis following angina pectoris patients: a prospective study

BACKGROUND

Depression and anxiety are two common mood problems among patients with cardiovascular disease (CVD) and are associated with poor cardiac prognoses. The comorbidity of depression and anxiety is considered to be a more severe psychological status than non-comorbid mood disorders. However, little is known about the relationship between depression or anxiety and noncardiac readmission. We conducted a prospective study on the prognostic impact of depression, anxiety, and the comorbidity of the two among angina pectoris (AP) patients.

METHOD

In this prospective study, 443 patients with AP were included in the analysis. Follow-up assessments were performed 1 year, and 2 years after patient discharges. Clinical outcomes of interest included noncardiac readmission, major adverse cardiovascular events (MACEs), and composite events. Depression and anxiety symptom scores derived from the patient health questionnaire-9 (PHQ-9) and generalised anxiety disorder-7 (GAD-7) questionnaire were used to assess mood symptoms at baseline. Participants with symptom scores of ≥10 on both the depression and anxiety questionnaires formed the clinical comorbidity subgroup. We used multivariable Cox proportional hazards models to evaluate the impact of individual mood symptom and comorbidity on clinical outcomes.

RESULTS

Among all the AP patients, 172 (38. 9%) were determined to have depression symptoms, 127 (28.7%) patients had anxiety symptoms and 71 (16.0%) patients suffered from their comorbidity. After controlling covariates, we found that patients who endured clinical depression (hazard ratio [HR] = 2.38, 95% confidence interval [CI] 1.06-5.33, p = 0.035) and anxiety ([HR] 2.85, 95% [CI] 1.10-7.45, p = 0.032) had a high risk of noncardiac readmission. Compared to participants with no mood symptoms, those with clinical comorbidity of depression and anxiety presented a greater risk of noncardiac readmission ([HR] 2.91, 95% [CI] 1.03-8.18, p = 0.043) MACEs ([HR] 2.38, 95% [CI] 1.11-5.10, p = 0.025) and composite event ([HR] 2.52, 95% [CI] 1.35-4.69, p = 0.004).

CONCLUSION

Depression and anxiety were found to have predictive value for noncardiac readmission among patients with AP. Furthermore, prognoses were found to be worse for patients with comorbidity of depression and anxiety than those with single mood symptom. Additional attention needs to be focused on the initial identification and long-term monitoring of mood symptom comorbidity.

Depression as a Risk Factor for Developing Heart Failure: A Meta-Analysis of Prospective Cohort Studies

BACKGROUND

The associations of depression with incident heart failure (HF) risk based on epidemiological studies have been inconsistent.

OBJECTIVE

We aimed to quantitatively estimate the relative effect of depression on the development of HF.

METHODS

We performed a systematic review and meta-analysis of cohort studies published between January 1, 1950, and August 31, 2019, from PubMed, Embase, and the Science Citation Index databases. We selected prospective cohort studies reporting the relationship between depression and incident HF. Maximally adjusted hazard ratios and their 95% confidence intervals were combined using a random-effects model. The heterogeneity across studies was calculated by the I statistic. This meta-analysis was registered in PROSPERO (number CRD42020149274).

RESULTS

Six population-based, prospective cohort studies with 4727 HF events among 131 282 participants were eligible for meta-analysis. Compared with participants reporting no depression, those with depression had a 23% increased risk of developing HF (pooled hazard ratio, 1.23; 95% confidence interval, 1.08-1.41). There was no significant heterogeneity across studies (χ = 7.75, df = 5, P = .17, I = 35.5%).

CONCLUSION

Published literature supports a significant association of depression with an increased incidence of HF in the general population.

Palliative Care in Patients with Advanced Heart Failure

The heart failure (HF) guidelines recommend palliative care; however, it can often be difficult to determine the timing of palliative care referral. Because HF with fluid retention and low-cardiac output may trigger several unpleasant symptoms, continuous HF treatment is required to alleviate these symptoms in advanced HF. The patients with HF often suffer from total pain; therefore, the support from a multidisciplinary team plays a crucial role to improve quality of life of the patients and their families not only in the terminal phase but also from the early stage.

Choosing among second-generation antidepressant treatments for depressed patients with cardiac diseases

Objectives: The present paper aimed to assist physicians in the accurate choice among second-generation agents (SGAs) for patients with cardiovascular disease (CVD). Methods: We reviewed the published pharmacokinetic (PK) and pharmacodynamic (PD) clinical data that report potential -or absence of- drug interactions between second-generation agents (SGAs) and CVD drugs most commonly used in cardiology, including antiplatelet drugs and anticoagulants, statins, beta-blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics and the antiarrhythmic drugs amiodarone and digoxin. We also reviewed the cardiovascular safety profile that has been published for each class of SGAs and side effects reported by patients with CVD. Results: Most relevant PK/PD data about SGAs and CVD drugs are based on small studies or detailed case reports. In many cases, the drug interactions are at most assessed in healthy volunteers so that the clinical relevance of findings needs further investigation in patients with CVD. Case reports of serious, sometimes fatal reactions due to concomitant administration of certain drugs require careful consideration. The major cardiac side effects of SGAs include HR increase, postural hypotension and slight prolongation of the intraventricular conduction time and QT interval. On normal dosage of antidepressants, both advanced heart block and ventricular arrhythmias could occur in patients with severe heart disease, together with clinically important loss of myocardial contractile force. Conclusions: Data reported in the present review should help physicians about their decision-making processes that govern SGAs use in CVD patients.

A randomized controlled trial on the impact of moderate-intensity continuous aerobic exercise on the depression status of middle-aged patients with congestive heart failure

BACKGROUND

Depression prevalence rates in congestive heart failure (CHF) patients have increased in the last few years. Depression is a leveled and independent risk factor for hospital readmission, decreased function, and patient mortality for patients with CHF. Major depressive disorder can be diagnosed in CHF patients who frequently suffer from sleeplessness, fatigue, and neurovegetative manifestations that extend to depressed patients.

OBJECTIVES

The aim of this study was to investigate the influence of moderate-intensity continuous aerobic exercise (MICAE) on the depression status in patients with CHF.

METHODS

Between June and September 2017, 46 patients with CHF who suffered from depression were selected for this study. These patients aged 40 to 60 years, were medically diagnosed with CHF-related illnesses, and physical disabilities. The participating patients were selected from the psychological medicine unit of the University Hospitals. They were randomly classified into 2 groups, each group included 23 patients. The study group underwent MICAE (MICAE) 3 times weekly for 12 weeks, whereas the control group received traditional intervention without any physical exercise.

RESULTS

There were no significant differences between the 2 groups regarding baseline characteristics (P >.05). Patients in both groups had a significant decrease in their depression levels. The study group had a greater reduction of 80.9% (P <.05) when compared to a reduction in the control group 46.46% (P <.05).

CONCLUSIONS

According to the study outcomes, it was concluded that 12 weeks of MICAE has positive effects on the depression status in patients with CHF. The study group who underwent moderate-intensity aerobic exercise had a greater decrease in the depression status of CHF patients when compared to the control group.

Determinates of depressive disorder among adult patients with cardiovascular disease at outpatient cardiac clinic Jimma University Teaching Hospital, South West Ethiopia: cross-sectional study

BACKGROUND

Depression and heart disease are an important public-health problem. Depression is one of the most prevalent and disabling psychiatric disorders with more than three times increased risk among patients with cardiovascular disorders.

OBJECTIVE

To identify the prevalence and associated factors of depressive disorder among adult patients with cardiovascular disease.

METHODS

Institution based cross-sectional study design was used to conduct this study on 293 study participants attending an outpatient cardiac clinic at Jimma University Teaching Hospital. All eligible patients were recruited into the study consecutively. Depression was assessed using patient health questionnaire-9. The patient health questionnaire-9 had a total score of 27, from which 0-4: no/minimal depression, 5-9: mild depression, 10-14: moderately depression, 15-19: moderately severe depression and 20-27 severe depression. The data was feed into Epi-data version 3.1 and lastly exported to SPSS version 21 for analysis. Bivariate analysis was used to analyze the statistical association of covariates of interest with depressive disorder among patients with cardiovascular disease. Then, logistic regression analysis was used as a final model to control confounders. The strength of association was measured by a 95% confidence interval.

RESULTS

A total of 293 adult patients diagnosed with the cardiovascular disease were included in the study with 97% (n = 284) of response rate, 47.2% (n = 134) males and 52.8% (n = 150) females, making female to a male ratio around 1.1:1. The prevalence of depression was 52.8% (n = 150/284). Out of the subjects with depression 52.67% (n = 79), 36.0% (n = 54) and 11.33% (n = 17) were mild, moderate and severe depression, respectively. Variables such as employed, unemployed, physical activity, current cigarette user and poor social support were independently associated with depression in the final model.

CONCLUSIONS

In this study, depression was found to be highly prevalent psychiatric comorbidity in adult cardiovascular disease patients.

Prevalence and associations of depression among patients with cardiac diseases in a public health institute in Trinidad and Tobago

BACKGROUND

Psychosocial issues are major determinants as well as consequences of cardiovascular disease (CVD). This study sought to assess the prevalence and identify factors associated with depression among patients with cardiac disease in a public health institute in Trinidad and Tobago.

METHODS

A cross-sectional study was conducted with a convenience sample of 388 hospitalised, stable, adult patients with cardiac disease admitted in the only tertiary public health institute in South Trinidad. Patients were identified and interviewed 3 to 5 days after admission using a questionnaire comprising questions on demographic, medical, and lifestyle issues and the 9-item Patient Health Questionnaire (PHQ-9).

RESULTS

The prevalence of clinically significant depression (PHQ-9 > 9) among hospitalised patients with cardiac disease was 40.0%. However, the prevalence of non-minimal depression (PHQ-9 ≥ 5) in this study was 78.4%. It was greater among women (83.1%) than among men (72.9%). Non-minimal depression was associated with sex (p = 0.015), employment status (p = 0.007), hypertension (p = 0.017), stressful life (p ≤ 0.001), feelings of depression (p ≤ 0.001), regular exercise (p ≤ 0.001), and living alone (p = 0.006). Age, ethnicity, education level, income, or religious affiliations were not associated (p > 0.05) with depression. Participants diagnosed with depression commonly reported feeling tired (81.2%), having trouble sleeping (74.7%), and moving/speaking slowly (73.5%). Patients with self-claimed depression (past or current) were four times more likely to have depression and those with self-reported stress and loneliness were twice as likely to have depression. Employed patients and those who exercised regularly were approximately 50% less likely to have depression.

CONCLUSIONS

Clinical depression prevalence among hospitalised patients with cardiac disease was 40.0%. Approximately twice as many (78.4%) had non-minimal depression, with higher prevalence among women. Employment, sex, hypertension, stressful life, feelings of depression, regular exercise, and living alone were associated with non-minimal depression. Patients with self-claimed depression, stress, and those living alone had a much higher likelihood of having depression, while those who were employed and exercised regularly were approximately half as likely to have depression.

Clinical Impact of Subsequent Depression in Patients With a New Diagnosis of Stable Angina: A Population-Based Study

BACKGROUND

Depression is prevalent among patients with myocardial infarction and is associated with a worse prognosis. However, little is known about its importance in patients with chronic stable angina. We conducted a retrospective population-based cohort study to determine the occurrence and predictors of developing depression in patients with a new diagnosis of chronic stable angina. In addition, we sought to understand its impact on subsequent clinical outcomes.

METHODS AND RESULTS

Our cohort included patients in Ontario, Canada, with stable angina based on obstructive coronary artery disease found on angiogram. Depression was ascertained by physician billing codes and hospital admissions diagnostic codes. We first developed multivariable Cox proportional hazards models to determine predictors of developing depression. Clinical outcomes of interest included all-cause mortality, admission for myocardial infarction, and subsequent revascularization. Using hierarchical multivariable Cox proportional hazards models with occurrence of depression as a time-varying variable to control for potential immortal time bias, we evaluated the impact of depression on clinical outcomes. Our cohort consisted of 22 917 patients. The occurrence of depression after diagnosis of stable chronic angina was 18.8% over a mean follow-up of 1084 days. Predictors of depression included remote history of depression, female sex, and more symptomatic angina based on Canadian Cardiovascular Society class. Patients who developed depression had a higher risk of death (hazard ratio 1.83, 95% confidence interval 1.62-2.07) and admission for myocardial infarction (hazard ratio 1.36, 95% confidence interval 1.10-1.67) compared with nondepressed patients.

CONCLUSIONS

Depression is common in patients with chronic stable angina and is associated with increased morbidity and mortality.

Depressive symptoms and functional decline following coronary interventions in older patients with coronary artery disease: a prospective cohort study

BACKGROUND

Depressive symptoms are prevalent in patients with coronary artery disease (CAD). It is unclear, however, how depressive symptoms change over time and the impact of these changes on long-term functional outcomes. We examined the association between different trajectories of depressive symptoms over 1 year and change in functional status over 30 months among patients undergoing coronary angiography.

METHODS

This was a prospective cohort study of 350 patients aged 60 and older undergoing non-emergent cardiac catheterization (October 2003-February 2007). A dynamic measure of significant depressive symptoms (i.e., Geriatric Depression Scale score 5+) capturing change over 12 months was derived that categorized patients into the following groups: (i) no clinically important depressive symptoms (at baseline, 6 and 12 months); (ii) baseline-only symptoms (at baseline but not at 6 and 12 months); (iii) new onset symptoms (not at baseline but present at either 6 or 12 months); and, (iv) persistent symptoms (at baseline and at either 6 or 12 month assessment). Primary outcomes were mean change in Older Americans Resources and Services (OARS) instrumental (IADL) and basic activities of daily living (BADL) scores (range 0-14 for each) across baseline (pre-procedure) and 6, 12, and 30 months post-procedure visits.

RESULTS

Estimates for the symptom categories were 71 % (none), 9 % (baseline only), 8 % (new onset) and 12 % (persistent). In adjusted models, patients with persistent symptoms showed a significant decrease in mean IADL and BADL scores from baseline to 6 months (-1.32 [95 % CI -1.78 to -0.86] and -0.63 [-0.97 to -0.30], respectively) and from 12 to 30 months (-0.79 [-1.27 to -0.31] and -1.00 [-1.35 to -0.65], respectively). New onset symptoms were associated with a significant decrease in mean IADL scores at 6 months and from 6 to 12 months. Patients with no depressive symptoms showed little change in scores whereas those with baseline only symptoms showed significant improvement in mean IADL at 6 months.

CONCLUSIONS

Patients with persistent depressive symptoms were at greatest risk for worse functional status 30 months following coronary interventions. Proactive screening and follow-up for depression in this population offers prognostic value and may facilitate the implementation of targeted interventions.

Psychosocial Factors and Risk of Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Heart failure (HF) is a major source of morbidity and mortality in the United States. Psychosocial factors have frequently been studied as risk factors for coronary heart disease but not for HF.

METHODS AND RESULTS

We examined the relationship between psychological status and incident HF among 6782 individuals from the Multi-Ethnic Study of Atherosclerosis (MESA). Anger, anxiety, chronic stress, depressive symptoms, and hostility were measured using validated scales, and physician reviewers adjudicated incident HF events. Cox proportional hazards models were used to adjust for relevant demographic, behavioral, and physiological covariates. Interactions by age, race, sex, and self-reported health were examined in exploratory analyses. During a mean follow-up of 9.3 years, 242 participants developed incident HF. There was no association between psychosocial factors and HF hazard ratios (95% confidence interval) for the highest versus lowest quartile: anger=1.14 (0.81-1.60), anxiety=0.74 (0.51-1.07), chronic stress=1.25 (0.90-1.72), depressive symptoms=1.19 (0.76-1.85), and hostility=0.95 (0.62-1.42). In exploratory analysis, among the participants reporting fair/poor health at baseline, those reporting high versus low levels of anxiety, chronic stress, and depressive symptoms had 2-fold higher risk of incident HF, but there was no association for those with good/very good/excellent self-reported health.

CONCLUSIONS

Overall, these psychosocial factors were not significantly associated with incident HF. However, for participants reporting poor health at baseline, there was evidence that anxiety, chronic stress, and depressive symptoms were associated with increased risk of HF. Future research with greater statistical power is necessary to replicate these findings and seek explanations.

Plasma mid-regional pro-adrenomedullin levels are inversely associated with anxiety but unrelated to depression: Results from the observational DIAST-CHF study in patients with cardiovascular risk factors

OBJECTIVES

It has been postulated that patients with heart failure have a high risk of ventricular arrhythmias and sudden cardiac death resulting from anxiety-induced autonomic arousal. In the prospective and multicenter DIAST-CHF (Diagnostic Trial on Prevalence and Clinical Course of Diastolic Dysfunction and Heart Failure) study, we therefore, tested the hypothesis that adrenomedullin (ADM), a well-established predictor for cardiovascular outcome, is associated with self-rated anxiety symptoms in patients at risk of suffering from or actually with overt heart failure.

PARTICIPANTS AND MEASURES

Study participants with risk factors for diastolic dysfunction were requested to complete the Hospital Anxiety and Depression Scale (HADS), and plasma mid-regional pro-adrenomedullin (MR-proADM) concentrations were measured.

RESULTS

In bivariate analysis, we found significantly lower plasma MR-proADM levels in patients with elevated HADS-anxiety scores above the clinically relevant cut-off level of ≥11 (n=118, 536pmol/l, interquartile range [IQR] 449-626) as compared to non-anxious study participants (n=1,292, 573pmol/l, IQR 486-702, p=0.001). A set of multivariate models adjusted for potential confounders confirmed the negative association between self-rated anxiety symptoms and plasma MR-proADM. In similar models, no significant association was detected between HADS-depression scores and MR-proADM.

CONCLUSIONS

The inverse relationship between plasma MR-proADM and anxiety observed in patients with cardiovascular risk factors supports a previous experimental study using a mutant mouse line with a brain-specific loss of ADM expression which displayed hyperactive and over-anxious behavior. Further experimental and clinical studies are warranted to test the hypothesis that also in humans ADM acts as a neuromodulator with anxiolytic properties.

Diabetes to cardiovascular disease: is depression the potential missing link?

The etiopathological consequences of diabetes and its imperative sequels have been explored extensively in the scientific arena of cardiovascular diabetology. Innumerable risk covariates and confounders have been delineated for the primary and secondary prevention of diabetes and cardiovascular diseases (CVD). However, an intricate interaction of depression on them has been largely overlooked. Depression influences and participates in each and every step that worsens the diabetic state for developing cardiovascular complications. The dilemma is that it coexists, remains silent and generally not considered as relevant clinical parameter amenable to intervention. In this review, it is highlighted that depression has strong association and linkages with both diabetes and CVD and it should be considered and diagnosed at every stage of the diabetes to CVD continuum. Careful attention to the diagnosis and management of these disease states would contribute in lessening the CVD burden of the society.

Effect of depression and sertraline treatment on cardiac function in female nonhuman primates

OBJECTIVE

Depression is a proposed risk factor for heart failure based largely on epidemiological data; few experimental data addressing this hypothesis are available.

METHODS

Depression was evaluated in relation to cardiac structural and functional phenotypes assessed by transthoracic echocardiography in 42 adult female cynomolgus monkeys that consumed a Western-like diet for 3 years. Half of the monkeys were treated with sertraline HCl for 18 months, and depressive behavior was assessed for 12 months before echocardiography.

RESULTS

Depressed monkeys (the 19/42 with depressive behavior rates above the mean rate) had higher heart rates (HRs; 171 [4.1[ versus 152 [6.1]) and smaller body surface area (0.13 [0.003] versus 0.15 [0.004]), left ventricular (LV) end-systolic dimension (0.75 [0.05] versus 0.89 [0.04]), LV systolic (0.76 [0.08] versus 1.2 [0.11]) and diastolic (2.4 [0.23] versus 3.4 [0.26]) volumes, and left atrial volumes (1.15 [0.14] versus 1.75 [0.12]; p values < .05). Doppler profiles of depressed monkeys indicated greater myocardial relaxation (higher e' and higher e'/a' ratio) and lower filling pressures (lower E/e') compared to nondepressed monkeys (p values < .05). Although sertraline treatment reduced HR (150 [5.8] versus 171 [4.8]) and modestly increased chamber dimensions (LV end-systolic dimension: 0.91 [0.05] versus 0.74 [0.03]; LV end-diastolic dimension, body surface area adjusted 1.69 [0.05] versus 1.47 [0.06]; p values < .05), it did not overtly affect systolic or diastolic function (p values > .10).

CONCLUSIONS

These data suggest that behavioral depression in female primates is accompanied by differences in cardiac function, although not in ways classically associated with subclinical heart failure. Selective serotonin reuptakes show promise in supporting heart function by reducing HR and perhaps improving LV filling; however, further investigation is needed.

Diagnosis and treatment of depression in patients with congestive heart failure: a review of the literature

CONTEXT

Major depressive disorder (MDD) can be challenging to diagnose in patients with congestive heart failure, who often suffer from fatigue, insomnia, weight changes, and other neurovegetative symptoms that overlap with those of depression. Pathophysiologic mechanisms (eg, inflammation, autonomic nervous system dysfunction, cardiac arrhythmias, and altered platelet function) connect depression and congestive heart failure.

OBJECTIVE

We sought to review the prevalence, diagnosis, neurobiology, and treatment of depression associated with congestive heart failure.

DATA SOURCES

A search of all English-language articles between January 2003 and January 2013 was conducted using the search terms congestive heart failure and depression.

STUDY SELECTION

We found 1,498 article abstracts and 19 articles (meta-analyses, systematic reviews, and original research articles) that were selected for inclusion, as they contained information about our focus on diagnosis, treatment, and pathophysiology of depression associated with congestive heart failure. The search was augmented with manual review of reference lists of articles from the initial search. Articles selected for review were determined by author consensus.

DATA EXTRACTION

The prevalence, diagnosis, neurobiology, and treatment of depression associated with congestive heart failure were reviewed. Particular attention was paid to the safety, efficacy, and tolerability of antidepressant medications commonly used to treat depression and how their side-effect profiles impact the pathophysiology of congestive heart failure. Drug-drug interactions between antidepressant medications and medications used to treat congestive heart failure were examined.

RESULTS

MDD is highly prevalent in patients with congestive heart failure. Moreover, the prevalence and severity of depression correlate with the degree of cardiac dysfunction and development of congestive heart failure. Depression increases the risk of congestive heart failure, particularly in those patients with coronary artery disease , and is associated with a poorer quality of life, increased use of health care resources, more frequent adverse clinical events and hospitalizations, and twice the risk of mortality.

CONCLUSIONS

At present, limited empirical data exist with regard to treatment of depression in the increasingly large population of patients with congestive heart failure. Evidence reveals that both psychotherapeutic treatment (eg, cognitive-behavioral therapy) and pharmacologic treatment (eg, use of the selective serotonin reuptake inhibitor sertraline) are safe and effective in reducing depression severity in patients with cardiovascular disease. Collaborative care programs featuring interventions that work to improve adherence to medical and psychiatric treatments improve both cardiovascular disease and depression outcomes. Depression rating scales such as the 9-item Patient Health Questionnaire should be used to monitor therapeutic efficacy.

The effects of apoptosis vulnerability markers on the myocardium in depression after myocardial infarction

BACKGROUND

There is an increased incidence of major depressive disorder (MDD) in individuals after myocardial infarction (MI), but the pathophysiological processes mediating this association are unclear. Our previous study demonstrated an increase in pro-apoptotic pathways in the myocardium and hippocampus in MDD, which was reversed by venlafaxine. This study aimed to attempt to confirm the effects of apoptosis vulnerability markers on the myocardium in a model of depression after myocardial infarction.

METHODS

Rats were divided into four groups: sham (N = 8), depression (N = 8, chronic mild unpredictable stress and separation were used in the depression group), MI (N = 13) and post-MI depression (N = 7). The rats in all four groups underwent the same open field and sucrose preference behavioral tests. Evan Blue staining was used to determine the area at risk of myocardial infarction in the left ventricle, and 2,3,5-triphenyl tetrazolium chloride (1.5% TTC) dye was used to detect the size of the myocardial infarction. The expression of bax and bcl-2 protein in the myocardium was investigated by immunohistochemistry, and the mRNA expression of bax, bcl-2 and caspase-3 in the myocardium was investigated by real time RT-PCR. Apoptosis was estimated in the myocardium by measuring the Bax:Bcl-2 ratio.

RESULTS

In the depression and post-MI depression rats, there were significantly decreased movements and total sucrose consumption, modeling behavioral deficits and an anhedonic-like state. In terms of myocardial infarction size, no difference was seen between the MI and post-MI depression groups. There was an up-regulated Bax:Bcl-2 ratio in the depression, MI and post-MI depression groups. Furthermore, in the latter group, there was a greater up-regulated Bax:Bcl-2 ratio. However, caspase-3 did not differ among the four groups.

CONCLUSIONS

These results of this animal model suggest that active pro-apoptotic pathways may be involved in the nexus between myocardial infarction and depression. This mechanism may be germane to understanding this relationship in humans.

The impact of premorbid and postmorbid depression onset on mortality and cardiac morbidity among patients with coronary heart disease: meta-analysis

BACKGROUND

Depression is associated with increased cardiac morbidity and mortality in the general population and in patients with coronary heart disease (CHD). Recent evidence suggests that patients with new-onset depression post-CHD diagnosis have worse outcomes than do those who had previous or recurrent depression. This meta-analysis investigated the timing of depression onset in established CHD and CHD-free cohorts to determine what time frame is associated with greater mortality and cardiac morbidity.

METHODOLOGY/PRINCIPAL FINDINGS

The MEDLINE, EMBASE, and PsycINFO databases were searched systematically to identify articles examining a depression time frame that specified an end point of all-cause mortality, cardiac mortality, rehospitalization, or major adverse cardiac events. A meta-analysis was conducted to estimate effect sizes by time frame of depression. Twenty-two prospective cohort studies were identified. Nine studies investigated premorbid depression in CHD-free cohorts in relation to cardiac death. Thirteen studies in patient samples with CHD examined new-onset depression in comparison with previous or recurrent depression. The pooled effect size (risk ratio) was 0.76 (95% confidence interval (CI) = 0.48-1.19) for history of depression only, 1.79 (95% CI = 1.45-2.21) for premorbid depression onset, 2.11 (95% CI = 1.66-2.68) for postmorbid or new depression onset, and 1.59 (95% CI = 1.08-2.34) for recurrent depression.

CONCLUSIONS/SIGNIFICANCE

Both premorbid and postmorbid depression onsets are potentially hazardous, and the question of timing may be irrelevant with respect to adverse cardiac outcomes. However, the combination of premorbid depression with the absence of depression at the time of a cardiac event (i.e., historical depression only) is not associated with such outcomes and deserves further investigation.

Dysthymia and depression increase risk of dementia and mortality among older veterans

OBJECTIVE

To determine whether less severe depression spectrum diagnoses such as dysthymia, as well as depression, are associated with risk of developing dementia and mortality in a "real-world" setting.

DESIGN

Retrospective cohort study conducted using the Department of Veterans Affairs (VA) National Patient Care Database (1997-2007).

SETTING

VA medical centers in the United States.

PARTICIPANTS

A total of 281,540 veterans aged 55 years and older without dementia at study baseline (1997-2000).

MEASUREMENTS

Depression status and incident dementia were ascertained from International Classification of Diseases, Ninth Revision codes during study baseline (1997-2000) and follow-up (2001-2007), respectively. Mortality was ascertained by time of death dates in the VA Vital Status File.

RESULTS

Ten percent of veterans had baseline diagnosis of depression and nearly 1% had dysthymia. The unadjusted incidence of dementia was 11.2% in veterans with depression, 10.2% with dysthymia and 6.4% with neither. After adjusting for demographics and comorbidities, patients diagnosed with dysthymia or depression were twice as likely to develop incident dementia compared with those with no dysthymia/depression (adjusted dysthymia hazard ratio [HR]: 1.96, 95% confidence interval [CI]: 1.71-2.25; and depression HR: 2.18, 95% CI: 2.08-2.28). Dysthymia and depression also were associated with increased risk of death (31.6% dysthymia and 32.9% depression versus 28.5% neither; adjusted dysthymia HR: 1.41, 95% CI: 1.31-1.53; and depression HR: 1.47, 95% CI: 1.43-1.51).

CONCLUSIONS

Findings suggest that older adults with dysthymia or depression need to be monitored closely for adverse outcomes. Future studies should determine whether treatment of depression spectrum disorders may reduce risk of these outcomes.

Heartache and heartbreak--the link between depression and cardiovascular disease

The close, bidirectional relationship between depression and cardiovascular disease is well established. Major depression is associated with an increased risk of coronary artery disease and acute cardiovascular sequelae, such as myocardial infarction, congestive heart failure, and isolated systolic hypertension. Morbidity and mortality in patients with cardiovascular disease and depression are significantly higher than in patients with cardiovascular disease who are not depressed. Various pathophysiological mechanisms might underlie the risk of cardiovascular disease in patients with depression: increased inflammation; increased susceptibility to blood clotting (owing to alterations in multiple steps of the clotting cascade, including platelet activation and aggregation); oxidative stress; subclinical hypothyroidism; hyperactivity of the sympatho-adrenomedullary system and the hypothalamic-pituitary-adrenal axis; reductions in numbers of circulating endothelial progenitor cells and associated arterial repair processes; decreased heart rate variability; and the presence of genetic factors. Early identification of patients with depression who are at risk of cardiovascular disease, as well as prevention and appropriate treatment of cardiovascular disease in these patients, is an important and attainable goal. However, adequately powered studies are required to determine the optimal treatment regimen for patients with both depression and cardiovascular disorders.

Depression and the heart

Cardio Vascular disease (CVD) as well as depression are both highly prevalent disorders and both of them cause a significant decrease in quality of life and increase the economic burden for the patient. Depressed individuals are more likely to develop angina, fatal or non-fatal myocardial infarction, than those who are not depressed. Over the past decade, evidence has accumulated to suggest that depression may be a risk factor for cardiac mortality in patients with established coronary artery disease (CAD). The 'vicious cycle' linking CVD to major depression and depression to CVD, deserves greater attention from both cardio-vascular and psychiatric investigators.(1).

Depression predicts repeated heart failure hospitalizations

OBJECTIVE

Management of depression, if it is independently associated with repeated hospitalizations for heart failure (HF), offers promise as a viable and cost-effective strategy to improve health outcomes and reduce health care costs for HF. The objective of this study was to assess the association between depression and the number of HF-related hospitalizations in patients with low-to-moderate systolic or diastolic dysfunction, after controlling for illness severity, socioeconomic factors, physician adherence to evidence-based medications, patient adherence to HF drug therapy, and patient adherence to salt restrictions.

METHODS AND RESULTS

The Heart Failure Adherence and Retention Trial (HART) was a randomized behavioral trial to evaluate whether patient self-management skills coupled with HF education improved patient outcomes. Depression was measured at baseline with the Geriatric Depression Scale (GDS). The number of hospitalizations was analyzed with a negative binomial regression model that included an offset term to account for the differential duration of follow-up for individual subjects. The average unadjusted number of hospitalizations per year was 0.40 in the depressed group (GDS ≥10) and 0.33 in the nondepressed group (GDS <10). Depression was a strong predictor (incident rate ratio 1.45; P = .006) after adjusting for physician adherence to evidence-based medication use, patient adherence to HF drug therapy, patient adherence to salt restriction, illness severity, HF severity (6-minute walk <620 feet), and socioeconomic factors.

CONCLUSIONS

Depression is a strong psychosocial predictor of repeated hospitalizations for HF. Compared with nondepressed individuals, those with depression were hospitalized for HF 1.45 times more often, even after controlling for physician adherence to evidence-based medications and patient adherence to HF drug therapy and salt restrictions. This finding suggests that clinicians should screen for depression early in the course of HF management.

Lifestyle interventions for cardiovascular risk reduction in women with breast cancer

PURPOSE

The purpose of this paper is to identify risk factors for cardiovascular disease in women with breast cancer and review healthy lifestyle behaviors as essential risk reduction strategies.

FINDINGS

Women with breast cancer account for 22% of the 12 million cancer survivors. Women diagnosed with breast cancer often present with modifiable and non-modifiable cardiovascular risk factors and/or pre-existing co-morbid illness. Any one or a combination of these factors may increase the risk of cardiovascular disease. There is strong evidence that healthy eating and routine physical activity can reduce cardiovascular disease. Exercise improves cardiovascular fitness, body composition and quality of life in breast cancer survivors and observational studies suggest a survival benefit.

CLINICAL IMPLICATIONS

Lifestyle interventions including a healthy diet, regular physical activity, weight management and smoking cessation should be integrated into a survivorship care plan to reduce cardiovascular disease risk and promote better health for women with breast cancer.

Chronic heart failure: current evidence, challenges to therapy, and future directions

Heart failure (HF) is a complex syndrome characterized by the inability of the heart to maintain a normal cardiac output without elevated intracardiac filling pressures, resulting in signs of pulmonary and peripheral edema and symptoms of dyspnea and fatigue. Central to the management of HF is a multifaceted pharmacological intervention to abate the harmful counter-regulatory effects of neurohormonal activation and avid salt and water retention. Whereas up to 40 years ago HF was managed with diuretics and leaf of digitalis, the cornerstones of therapy for HF patients with systolic dysfunction now include ACE inhibitors or angiotensin II type 1 receptor antagonists (angiotensin receptor blockers), β-adrenoceptor antagonists (β-blockers), and aldosterone antagonists, which have significantly improved survival. However, with the increasing number of beneficial therapies, there are challenges to implementing all of them. Specific cardiomyopathies also merit specific considerations with respect to treatment, and - unfortunately - there is no therapy for HF with preserved left ventricular ejection fraction that has been shown to improve survival. Although mortality has improved in HF, the biggest challenge to treatment lies in addressing the morbidity of this disease, which is now the most common reason for hospital admission in our aged population. As such, there are many therapies that may serve to improve the quality of life of HF patients. Future HF treatment regimens may include direct cellular therapy via hormone and cytokine signaling or cardiac regeneration through growth factors or cell therapy.

Psychosocial risk factors and heart failure hospitalization: a prospective cohort study

Prospective studies on the role of psychosocial factors in heart failure development are virtually nonexistent. The authors aimed to address the effect of psychosocial factors on the risk of heart failure hospitalization in men and women free of cardiovascular disease. In 1991-1993, the 8,670 participants of the Copenhagen City Heart Study (Denmark) were asked comprehensive questions on major life events, work-related stress, social network, vital exhaustion, and sleep medication and were followed in nationwide registries until 2007, with less than 0.2% loss to follow-up. Almost one-fourth of the population reported some degree of vital exhaustion. The vital exhaustion score was associated with a higher risk of heart failure in a dose-response manner (P < 0.002), with high vital exhaustion being associated with a 2-fold higher risk of heart failure in both men (hazard ratio = 1.93, 95% confidence interval: 1.20, 3.10) and women (hazard ratio = 2.56, 95% confidence interval: 1.80, 3.65). Contrary to expectation, major life events, social network, and sleeping medication did not play an individual role for heart failure hospitalization. Because of the high prevalence of vital exhaustion in the population, even a modestly higher risk of heart failure associated with vital exhaustion may be of importance in the planning of future preventive strategies for heart failure.

Review of major measuring instruments in comorbid depression and coronary heart disease

Depression and coronary heart disease (CHD) are common comorbid conditions in which each may be a risk factor for the other condition. However, treating depression does not appear to favorably alter cardiac outcome when depression and CHD are comorbid. The National Heart Lung and Blood Institute working group convened in August, 2004 reviewed and recommended instruments to assess and treat depression in subjects with CHD. This paper focuses on these instruments and their limitations when compared and contrasted with the robust instruments available to assess CHD. As a result of our observations about the limitations of instruments and scales available to assess depression and depressive symptoms in subjects with comorbid CHD, we propose using the objectivity of CHD parameters to assess the efficacy of psychiatric interventions in patients with comorbid depression and to better define the link between depression and these cardiac conditions.

Does Depression Screening Have an Effect on the Diagnosis and Treatment of Mood Disorders in General Medical Settings? An Instrumental Variable Analysis of the National Ambulatory Medical Care Survey

This study examined the association of depression screening with the diagnoses of mood disorders and prescription of antidepressants in 73,712 visits to nonpsychiatrist physician offices drawn from the 2005-2007 U.S. National Ambulatory Medical Care Survey. Physicians used depression screening selectively for patients whom they perceived as more likely to have a mood disorder. In bivariate probit analyses with instrumental variables, depression screening did not increase the prevalence of either mood disorder diagnoses or prescription of antidepressants. However, screening was associated with lower rates of antidepressants prescription without a diagnosis of a mood disorder. In visits in which antidepressants were prescribed, 47.4% of the screened visits compared with 16.3% of nonscreened visits had a mood disorder diagnosis. As currently practiced in medical settings, depression screening may help improve targeting and appropriate use of antidepressant medications. Wider use of depression screening may help curb the growing trend of off-label antidepressant prescriptions.

Predictive value of depressive symptoms and B-type natriuretic peptide for new-onset heart failure and mortality

Depression and natriuretic peptides predict heart failure (HF) progression, but the unique contributions of depression and biomarkers associated with HF outcomes are not known. The present study determined the additive predictive value of depression and aminoterminal pro-B-type natriuretic peptide (NT-proBNP) for new-onset HF in HF-free subjects and mortality in patients with HF. The participants in the Cardiovascular Health Study were assessed for depressive symptoms using the Center for Epidemiologic Studies Depression Scale and NT-proBNP using an electrochemiluminescence immunoassay. The validated cutoff values for depression (Center for Epidemiologic Studies Depression Scale ≥8) and NT-proBNP (≥190 pg/ml) were used. The risks of incident HF and mortality (cardiovascular disease-related and all-cause) were examined during a median follow-up of 11 years, adjusting for demographics, clinical factors, and health behaviors. In patients with HF (n = 208), depression was associated with an elevated risk of cardiovascular disease mortality (hazard ratios [HR] 2.07, 95% confidence interval [CI] 1.31 to 3.27) and all-cause mortality (HR 1.49, 95% CI 1.05 to 2.11), independent of the NT-proBNP level and covariates. The combined presence of depression and elevated NT-proBNP was associated with substantially elevated covariate-adjusted risks of cardiovascular disease mortality (HR 5.42, 95% CI 2.38 to 12.36) and all-cause mortality (HR 3.72, 95% CI 2.20 to 6.37). In the 4,114 HF-free subjects, new-onset HF was independently predicted by an elevated NT-proBNP level (HR 2.27, 95% CI 1.97 to 2.62) but not depression (HR 1.08, 95% CI 0.92 to 1.26) in covariate-adjusted analysis. In conclusion, depression and NT-proBNP displayed additive predictive value for mortality in patients with HF. These associations can be explained by complementary pathophysiologic mechanisms. The presence of both elevated depression and NT-proBNP levels might improve the identification of patients with HF with a high risk of mortality.

Assessing the presence and severity of depression in subjects with comorbid coronary heart disease

Our understanding of how depression alters the origin and course of coronary heart disease is derived from subjective methodologies. Many psychiatric instruments were not tested for reliability and validity in subjects with comorbid medical illness, particularly coronary heart disease. They largely use scales of categoric or ordinal variables. Instruments used to assess coronary heart disease are considerably more objective and often use interval variables. By searching the websites of Circulation and the Journal of the American College of Cardiology, we entered the word "depression" on August 28, 2009. We ignored articles using "depression" in the context of cardiovascular concepts such as "ST-segment depression." By searching articles dating back to 1995, we selected publications that studied the prognostic association of depression and coronary heart disease. There were 5 relevant publications: 3 from Circulation and 2 from the Journal of the American College of Cardiology. The methods used to assess coronary heart disease (specifically, myocardial infarction) are largely homogenous across the studies, but the methods used to assess depression are heterogeneous. Parameters used to diagnose myocardial infarction and determine its severity are precise, objective, and reliable, whereas those used to assess depression and its severity exhibit less precision and lack comparable objectivity and reliability. This mismatch may compromise our understanding of the link between coronary heart disease and depression in depressed patients with comorbid coronary heart disease. We propose using precise instruments to identify and quantitate coronary heart disease as outcome variables to assess psychiatric interventions and to better define depression in depressed patients with comorbid coronary heart disease. This should lead to a better understanding of the link between depression and comorbid coronary heart disease.

Social work practitioner knowledge and assessment of late-life depression

Late-life depression has attracted considerable attention in the social work literature. This study examined levels of knowledge and self-efficacy (confidence) in evaluation of depression in late life among a random sample of social workers (N = 168) from the National Association of Social Workers. Relationships among knowledge on aging, job-related variables, and predictors of knowledge of geriatric depression were examined. Participants ranked depression as one of the most frequent clinical problems seen in practice, scored at the lower end on knowledge about aging, and experienced great difficulty on the items pertaining to suicide in the older adults.

Depression and cardiovascular disease: selected findings, controversies, and clinical implications from 2009

We systematically searched published empirical research on depression and cardiovascular disease (CVD) and found 494 unique articles published in 2009. Several particularly notable and provocative findings and controversies emerged from this survey of the 2009 literature. First, multiple large observational studies found that antidepressant use was associated with increased risk of incident stroke, CVD, or sudden cardiac death. Second, four randomized controlled trials on depression interventions in CVD patients reported important efficacy results that should guide future trials. Finally, the vigorous debate on whether patients with CVD should be routinely screened (and subsequently treated) for depression continued in 2009 even as some observed that routine screening for CVD in depressed patients is more evidence-based and appropriate. This article reviews these selected provocative findings and controversies from our search and explores their clinical implications.

The inextricable nature of mental and physical health: implications for integrative care

There is growing evidence that physical health problems are caused and exacerbated by psychological factors. Research indicates that psychological distress leads to physical disease through impairment of the neuroendocrine system and its interface with the body's immune response. However, the current health care delivery system splinters care into "psychiatric" and "physical" health silos. New approaches are needed to assure adequate professional knowledge of behavioral health at basic licensure, to increase the use of advanced practice psychiatric-mental health nurses in primary care settings, to identify and teach behavioral competencies for primary care providers, and to fund the design and evaluation of integrative models of care.

Broken-Hearted Women: The Complex Relationship between Depression and Cardiovascular Disease

The importance of mind–body health relationships has been recognized for decades, but only recently has the wider medical and cardiovascular community become engaged in understanding and addressing the complex, bidirectional risk relationship between cardiovascular disease (CVD) and depression. Furthermore, it has become increasingly clear that there are incompletely understood sex differences in incidence and outcomes for both conditions that should guide treatment and future research efforts. This review will explore the role of depression in women as a risk factor for incident CVD, its impact on women already suffering from CVD, proposed psychobiologic mechanisms and links, and the implications of sex differences on diagnosis and treatment.