We evaluated the association of symptoms of anxiety and depression with fatal and non-fatal cardiovascular disease events among patients with coronary heart disease and considered several potential underlying pathogenetic links.
Design
This was a prospective cohort study.
Methods
In this study, including coronary heart disease patients undergoing an in-patient rehabilitation program, symptoms of anxiety and depression were evaluated with the Hospital Anxiety and Depression Scale (HADS). Fatal and non-fatal cardiovascular disease events were determined during a 3-year follow-up.
Results
Of the 1052 patients with CHD 16.1% showed a borderline and 8.3% a manifest anxiety symptoms score, whereas 11.8 and 5.9% showed a borderline and manifest depressive symptoms score, respectively. During the 3-year follow-up fatal and non-fatal cardiovascular disease events were observed in 73 (6.9%) patients. After adjustment for covariates, patients having manifest anxiety symptoms had a statistically significant hazard ratio (HR) of 2.32 [95% confidence interval (CI) 1.14-4.74] for a cardiovascular disease event, and patients with depressive symptoms had an HR of 1.47 (95% CI 0.62-3.51) compared to other patients. In a model considering anxiety and depressive symptom scores simultaneously, the hazard ratio for a cardiovascular disease event associated with anxiety symptoms increased to 3.31 (95% CI 1.32-8.27), whereas the hazard ratio associated with depressive symptoms decreased (HR 0.62; 95% CI 0.20-1.87). We found a positive association of increased anxiety scores with body mass index and systolic blood pressure.
Conclusions
The study suggests an important role especially for symptoms of anxiety for long-term prognosis of patients with known coronary heart disease. It furthermore suggests that several pathogenetic links may partly explain the increased risk.
NationalHeart, Lung and Blood Institute. Morbidity and mortality: 1998 chartbook on cardiovascular, lung, and blood diseases. Rockville: US Department of Health and Human Services, National Institute of Health; 1998.
2.
RozanskiABlumenthalJAKaplanJ.Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation1999; 99:2191–2217.
3.
MelleJPde JongePSpijkermanTATijssenJGOrmelJvan VeldhuisenDJ. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosom Med2004; 66:814–822.
4.
MayouRAGillDThompsonDRDayAHicksNVolminkJ. Depression and anxiety as predictors of outcomes after myocardial infarction. Psychosom Med2000; 62:212–219.
5.
Pignay-DemariaVLesperanceFDemariaRGFrasure-SmithNPerraultLP.Depression and anxiety and outcomes of coronary artery bypass surgery. Ann Thorac Surg2003; 75:314–321.
6.
BlumenthalJALettHSBabyakMAWhiteWSmithPKMarkDB. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet2003; 362:604–609.
7.
Frasure-SmithNLesperanceFGravelGMassonAJuneauMTalajicM. Social support, depression, and mortality during the first year after myocardial infarction. Circulation2000; 101:1919–1924.
8.
LesperanceFFrasure-SmithNTalajicMBourassaMG.Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction. Circulation2002; 105:1049–1053.
9.
ZigmondASSnaithRP.The hospital anxiety and depression scale. Acta Psychiatr Scand1983; 67:361–370.
10.
HerrmannC.International experiences with the hospital anxiety and depression scale: a review of validation data and clinical results. J Psychosom Res1997; 42:17–41.
11.
BjellandIDahlAAHaugTTNeckelmannD.The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res2002; 52:69–77.
12.
BarthJSchumacherMHerrmann-LingenC.Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis. Psychosom Med2004; 66:802–813.
13.
SulsJBundeJ.Anger, anxiety, and depression as risk factors for cardiovascular disease: the problems and implications of overlapping affective dispositions. Psychol Bull2005; 131: 260–300.
14.
StewartRANorthFMWestTMSharplesKJSimesRJColquhounDM. Long-term intervention with pravastatin in ischaemic disease (LIPID) study investigators. Depression and cardiovascular morbidity and mortality: cause or consequence? Eur Heart J2003; 24:2027–2037.
KawachiIColditzGAAscgeruiARimmEB.Prospective study of phobic anxiety and risk of coronary artery heart disease in men. Circulation1994; 89:1992–1997.
17.
Frasure-SmithNLesperanceFTalajicMThe impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol1995; 14:388–398.
18.
StrikJJDenolletJLousbergRHonigA.Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. J Am Coll Cardiol2003; 42:1801–1807.
19.
CarneyRMRichMWteVeldeASainiJClarkKFreedlandKE.The relationship between heart rate, heart rate variability and depression in patients with coronary artery disease. J Psychosom Res1988; 32: 159–164.
20.
McGeeHMDoyleFConroyRMDe La HarpeDShelleyE.Impact of briefly-assessed depression on secondary prevention outcomes after acute coronary syndrome: a one-year longitudinal survey. BMC Health Serv Res2006; 6:9.
21.
DoyleFMcGeeHMDe La HarpeDShelleyEConroyR.The Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, identifies patients with acute coronary syndrome at elevated risk of 1-year mortality. J Psychosom Res2006; 60:461–467.
22.
Everson-Rose SA, House JS, Mero RP Depressive symptoms and mortality risk in a national sample: confounding effects of health status. Psychosom Med2004; 66:823–830.
MillerGEStetlerCACarneyRMFreedlandKEBanksWA.Clinical depression and inflammatory risk markers for coronary heart disease. Am J Cardiol2002; 90:1279–1283.
25.
FordDEErlingerTP.Depression and C-reactive Protein in US adults. Arch Int Med2004; 164:1010–1014.
26.
PanagiotakosDBPitsavosCChrysohoouCTsetsekouEPapageorgiouCChristodoulouG. Inflammation, coagulation, and depressive symptomatology in cardiovascular disease-free people; the ATTICA study. Eur Heart J2004; 25:492–499.
27.
HinzASchwarzR.Anxiety and depression in the general popülation [in German]. Psychother Psychosom Med Psychol2001; 51: 193–200.
28.
CarneyRMFreedlandKEVeithRCJaffeAS.Can treating depression redüce mortality after an acüte myocardial infarction? Psychosom Med1999; 61:666–675.
29.
GlassmanAHRooseSPBiggerJTJr.The safety of tricyclic antidepressants in cardiac patients: risk-benefit reconsidered. JAMA1993; 269:2673–2675.
30.
AlbüsCJordanJHerrmann-LinegnC.Screening for psychosocial risk factors in patients with coronary heart disease-recommendations for clinical practice? Eur J Cardiovasc Prev Rehabil2004; 111:75–79.
31.
NationalHeart, Lung and Blood Institute. Morbidity and mortality: 1998 chartbook on cardiovascular, lung, and blood diseases. Rockville: US Department of Health and Human Services, National Institute of Health; 1998.
32.
RozanskiABlumenthalJAKaplanJ.Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation1999; 99:2191–2217.
33.
MelleJPde JongePSpijkermanTATijssenJGOrmelJvan VeldhuisenDJ. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosom Med2004; 66:814–822.
34.
MayouRAGillDThompsonDRDayAHicksNVolminkJ. Depression and anxiety as predictors of outcomes after myocardial infarction. Psychosom Med2000; 62:212–219.
35.
Pignay-DemariaVLesperanceFDemariaRGFrasure-SmithNPerraultLP.Depression and anxiety and outcomes of coronary artery bypass surgery. Ann Thorac Surg2003; 75:314–321.
36.
BlumenthalJALettHSBabyakMAWhiteWSmithPKMarkDB. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet2003; 362:604–609.
37.
Frasure-SmithNLesperanceFGravelGMassonAJuneauMTalajicM. Social support, depression, and mortality during the first year after myocardial infarction. Circulation2000; 101:1919–1924.
38.
LesperanceFFrasure-SmithNTalajicMBourassaMG.Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction. Circulation2002; 105:1049–1053.
39.
ZigmondASSnaithRP.The hospital anxiety and depression scale. Acta Psychiatr Scand1983; 67:361–370.
40.
HerrmannC.International experiences with the hospital anxiety and depression scale: a review of validation data and clinical results. J Psychosom Res1997; 42:17–41.
41.
BjellandIDahlAAHaugTTNeckelmannD.The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res2002; 52:69–77.
42.
BarthJSchumacherMHerrmann-LingenC.Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis. Psychosom Med2004; 66:802–813.
43.
SulsJBundeJ.Anger, anxiety, and depression as risk factors for cardiovascular disease: the problems and implications of overlapping affective dispositions. Psychol Bull2005; 131: 260–300.
44.
StewartRANorthFMWestTMSharplesKJSimesRJColquhounDM. Long-term intervention with pravastatin in ischaemic disease (LIPID) study investigators. Depression and cardiovascular morbidity and mortality: cause or consequence? Eur Heart J2003; 24:2027–2037.
KawachiIColditzGAAscgeruiARimmEB.Prospective study of phobic anxiety and risk of coronary artery heart disease in men. Circulation1994; 89:1992–1997.
47.
Frasure-SmithNLesperanceFTalajicMThe impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol1995; 14:388–398.
48.
StrikJJDenolletJLousbergRHonigA.Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. J Am Coll Cardiol2003; 42:1801–1807.
49.
CarneyRMRichMWteVeldeASainiJClarkKFreedlandKE.The relationship between heart rate, heart rate variability and depression in patients with coronary artery disease. J Psychosom Res1988; 32: 159–164.
50.
McGeeHMDoyleFConroyRMDe La HarpeDShelleyE.Impact of briefly-assessed depression on secondary prevention outcomes after acute coronary syndrome: a one-year longitudinal survey. BMC Health Serv Res2006; 6:9.
51.
DoyleFMcGeeHMDe La HarpeDShelleyEConroyR.The Hospital Anxiety and Depression Scale depression subscale, but not the Beck Depression Inventory-Fast Scale, identifies patients with acute coronary syndrome at elevated risk of 1-year mortality. J Psychosom Res2006; 60:461–467.
52.
Everson-Rose SA, House JS, Mero RP Depressive symptoms and mortality risk in a national sample: confounding effects of health status. Psychosom Med2004; 66:823–830.
MillerGEStetlerCACarneyRMFreedlandKEBanksWA.Clinical depression and inflammatory risk markers for coronary heart disease. Am J Cardiol2002; 90:1279–1283.
55.
FordDEErlingerTP.Depression and C-reactive Protein in US adults. Arch Int Med2004; 164:1010–1014.
56.
PanagiotakosDBPitsavosCChrysohoouCTsetsekouEPapageorgiouCChristodoulouG. Inflammation, coagulation, and depressive symptomatology in cardiovascular disease-free people; the ATTICA study. Eur Heart J2004; 25:492–499.
57.
HinzASchwarzR.Anxiety and depression in the general popülation [in German]. Psychother Psychosom Med Psychol2001; 51: 193–200.
58.
CarneyRMFreedlandKEVeithRCJaffeAS.Can treating depression redüce mortality after an acüte myocardial infarction? Psychosom Med1999; 61:666–675.
59.
GlassmanAHRooseSPBiggerJTJr.The safety of tricyclic antidepressants in cardiac patients: risk-benefit reconsidered. JAMA1993; 269:2673–2675.
60.
AlbüsCJordanJHerrmann-LinegnC.Screening for psychosocial risk factors in patients with coronary heart disease-recommendations for clinical practice? Eur J Cardiovasc Prev Rehabil2004; 111:75–79.
