Depression, Anxiety and Heart Disease

dr_paul_rosch_131By Dr. Paul J. Rosch, M.D., M.A., F.A.C.P.

Most stress research has focused on depression, which is a significant risk factor for coronary events, as well as congestive heart failure and premature death following a heart attack.

Some of the reasons for this include: an increase in sympathetic tone as evidenced by elevated levels of circulating catecholamines and reduced heart rate variability; elevated levels of cortisol, free fatty acids and inflammatory cytokines that promote atherosclerosis; elevated levels of platelet factor 4 and beta-thromboglobulin that indicate prothrombotic platelet activation that leads to clots and vascular damage; dysfunctional serotonin signaling.

Prinzmetal's angina, also known as variant angina, is characterized by severe chest pain occurring at rest that tends to come in cycles. It is often seen in young women and is caused by vasospasm of the coronary arteries without atherosclerosis.

While it is not associated with any acute stressful event, it is much more common in depressed patients and may be related to increased platelet aggregation. Depressed patients may also be less likely to exercise or eat well, or to adhere to medication or other treatments to prevent heart disease. 

Recent research has also started to focus on anxiety. An article in the May 2010 issue of the American Heart Journal that reviewed the medical records of 97,000 U.S. veterans reported that "When the researchers accounted for a number of other factors related to heart attack risk, people with anxiety disorders were anywhere from 25 percent to 43 percent more likely to suffer a heart attack than those with no anxiety disorders."

Two papers in the June 2010 issue of the Journal of the American College of Cardiology, also firmly established anxiety as an independent predictor for future coronary heart disease. The first was a meta-analysis on the association of anxiety with coronary heart disease in initially healthy people using data from the US, Europe, and Asia.

Even after adjustment for other influences, anxious people had a 25% greater risk of coronary disease and an almost 50% higher risk of cardiac death over a mean follow-up period of 11.2 years.

In the second study, 50,000 Swedish men who were thoroughly examined for military service were followed for an average of 37 years. Sweden has universal health coverage and maintains detailed ongoing records, and all the men classified as having anxiety or depression had been diagnosed by a psychiatrist.

Although depression was not a predictor for subsequent coronary disease as in most studies, those having an anxiety disorder were twice as likely to suffer from coronary disease or to have had a myocardial infarction. No females were included, but prior studies have shown that women are much more likely than men to suffer from anxiety and depression.

An accompanying editorial emphasized that these new risk factors for coronary disease "need to be carefully scrutinized for clinical utility...
Anxiety disorders are as prevalent as hypertension and are a major affliction of the young, with a lifetime prevalence of around 28%, and when anxiety coexists with depression, the corresponding impact on quality of life is even worse." The editorial also noted "Physicians are frequently timid about assessing emotional symptoms. It is odd that we thread catheters, ablate lesions, and give rectal exams but are uncomfortable asking patients about their lives."

Heightened interest in anxiety is also reflected in two articles in the June 2010 issue of Psychosomatic Medicine entitled "A Randomized Controlled Trial of Secondary Prevention of Anxiety and Distress in a German Sample of Patients With an Implantable Cardioverter Defibrillator" and "Heart Rate and Blood Pressure Changes During Autonomic Nervous System Challenge in Panic Disorder Patients", showing significant changes in heart rate variability parameters.

The July/August 2010 issue contains three pertinent articles. "Prognostic Association of Anxiety Post Myocardial Infarction With Mortality and New Cardiac Events" was a meta-analysis of available studies, which concluded that post-MI anxiety was associated with a 36% increased risk of adverse cardiac outcomes. "Hostility, Anger Control, and Anger Expression as Predictors of Cardiovascular Disease" showed that low anger control scores had better predictive value than other assessment measures.

In "Prolonged Cardiac Effects of Momentary Assessed Stressful Events and Worry Episodes", ambulatory heart rate and heart rate variability were recorded for four days, during which participants reported occurrence and duration of worry episodes and stressful events on an hourly basis. It found that stressful events had little or only transient effects, but that worrying about them produced significant changes over the next one or two hours.

Excerpted, with permission, from: Health and Stress, The Newsletter of The American Institute of Stress. ( )

Paul J. Rosch, M.D., M.A., F.A.C.P.
President of The American Institute of Stress,
Clinical Professor of Medicine and Psychiatry at New York Medical College,
Honorary Vice President of the International Stress Management Association and Chairman of its U.S. branch.

August 2010


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