Depression and coronary heart disease: 2018 ESC position paper of the working group of coronary pathophysiology and microcirculation developed under the auspices of the ESC Committee for Practice Guidelines ... Show more European Heart Journal, ehy913, https://doi.org/10.1093/eurheartj/ehy913 Published: 28 January 2019 Article history PDF Cite Permissions Share by Rapovets V.A. Introduction Major depression is a highly prevalent condition, affecting approximately 10% of the population.1 It is also a growing global problem,2 and has been consistently associated with increased risk of coronary heart disease (CHD).3 It is therefore not surprising that depression is highly comorbid with CHD, being two to three times more common among patients with CHD than in the general population. The prevalence of depression is 15–30% in patients with CHD,4 and is approximately twice as high in women than men, especially affecting young women in the aftermath of acute myocardial infarction (MI).5 Depression as a risk factor for CHD has been characterized from mild depressive symptoms to a clinical diagnosis of major depression. As defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), clinical depression, or major depression, is characterized by depressed mood or anhedonia (loss of interest or pleasure) for at least 2 weeks accompanied by significant functional impairment and additional somatic or cognitive symptoms.6 Most epidemiological studies of depression and incidence of CHD have used depressive symptom scales, and have frequently demonstrated a dose–response pattern, with higher levels of depressive symptoms being associated with higher risk.3 The exact mechanisms linking depression to increased CHD risk are complex and multifactorial, and still incompletely understood.7 Although adverse lifestyle behaviours and traditional CHD risk factors, such as smoking and sedentary lifestyle, largely contribute to the risk, they do not explain it entirely. In CHD patients, depression is also associated with severity of functional impairment, lower adherence to therapy and lower participation in cardiac rehabilitation. Whether and to what extent these factors explain the relationship between depression and CHD deserves future study. The present paper summarizes key aspects in our current knowledge linking depression and CHD within the intersecting fields of neuroscience, cardiovascular physiology, and behavioural medicine, with the objective of bringing attention to this area and stimulating interdisciplinary research, clinical awareness, and improved care. Epidemiological aspects Depression and coronary heart disease Many studies have shown a relationship between major depression, or depressive symptoms, and CHD.3,8,9 This literature has been summarized by a number of meta-analyses,8–10 all providing evidence for an association between clinical depression (or depressive symptoms) and CHD. This link is seen in individuals initially free of CHD and in a variety of CHD patient populations, including patients with acute coronary syndromes (ACS), heart failure, stable CHD, and post-coronary bypass surgery. However, individual studies have produced heterogeneous risk estimates and have varied in their ability to adjust for other factors such as smoking, physical inactivity, other risk factors, and severity of CHD. Indeed, depression is associated with several CHD risk factors and health behaviours as described above. In statistical models that adjust for these risk factors, depression usually remains an independent risk factor for CHD, suggesting a biological relationship between these two disease states that remains in part unexplained by an increase in traditional risk factors or lifestyle behaviours. In one of the relatively recent meta-analyses, which included 30 prospective cohort studies of individuals initially free of CHD, depression was associated with a 30% increased risk of future coronary events.9 The association remained significant in the group of studies that adjusted for socio-demographic factors and lifestyle behaviours.8 In community samples and in general practice clinics, the rate of depression is about, 10%11 but it goes up to about 15–30% in patients with CHD.11,12 Studies have also suggested that specific subtypes of depression may be more strongly associated with CHD risk than others. For instance, patients with a new-onset of depression after ACS, with treatment resistant depression, or with somatic depressive symptoms as opposed to cognitive symptoms, are all at increased risk of developing adverse CHD outcomes. However, there is no clear consensus on whether these different phenotypes carry variations in risk.13 Gender differences Among women, depression is approximately twice as prevalent as in men and has shown some of the most robust associations with CHD.14 Depression in women is also on average more severe than in men and has an earlier age of onset. Women with CHD similarly have twice the rates of depression as men with CHD.15–17 The condition is especially common in young women who have survived a MI15,16,18; about half of women younger than 60 years with a previous MI have a history of major depression.16–18 Of note, young women are more likely to die MI than men.19Depression is linked to early life adversities and psychological trauma, which tend to be more common in girls than boys and may result in chronic dysregulation of neurohormonal stress systems. This may begin at an early age, setting the stage for an increase in cardiovascular risk in women many years before CHD becomes manifest.5 Among women, depression increases their risk for CHD between 30% and two-fold depending on depression measures and CHD endpoints.20,21 Two follow-up studies of young community samples (<40 years old) found that the impact of depression on CHD risk was higher among women than men.22,23 In the Third National Health and Nutrition Examination Survey (NHANES III), a history of major depression or suicide attempt was associated with almost 15-fold increased risk of ischaemic heart disease among women, and 3.5 in men.22 In the prospective Community Mental Health Epidemiology Study of Washington County, MD, women younger than 40 years with depression had a six-fold increased risk of CHD compared with women of the same age without depression, while depression was not associated with CHD in men or older individuals.23 Even among patients referred for coronary angiography, depression is more predictive of adverse cardiovascular outcomes in young women than in other groups.24 After an acute MI, however, depression seems to affect prognosis to a similar extent in women and men.25 Overall, the evidence suggests that depression is more closely associated with CHD for women than for men, with the strongest effects for younger women. Clinical and prognostic considerations Depression as a prognostic factor in acute cor
