Depression and Cardiovascular Disease

Dr. dr. Starry H. Rampengan, SpJP(K), FIHA, MSi, CHt,

FICA, FACC, FAHA, FESC
Department Cardiology and Vascular Medicine/
Internal Medicine
Faculty of Medicine, Sam Ratulangi University
Manado
2013
A figurative interdependence between the heart
and sadness has long existed in language and
in literature.

In 1628, English physician William Harvey noted
every affection of the mind that is attended
either with pain or pleasure, hope or fear, is the
cause of an agitation whose influence extends to
the heart
1970s - epidemiologists start to
associate/correlate heart disease and
depression.

Global Burden of Disease


CAD & MDD will
be the 1 &2
contributors to the
burden of disease
by the year 2020.

Murray, CL Alterantive projections of mortality and disability by cause 1990-2020:Global Burden
Disease Study Lancet May 1997 vol. 349, pp 1498-1504


Global Burden of Disease
WHO 2002
MEN WOMEN
Objectives:
Review some of the literature regarding:
-the course of depression following cardiac events
-depression as a risk factor for cardiac events
-the links between depression and heart disease
Review evidence for treatment of depression in
pts with CHD
Review the ACC AHA guidelines
Discuss the professional recommendations with
ramifications relevant to local health care system
and evironment

Major depressive disorder (MDD)
DSM-IV requires that five of the following are present:
Depressed mood most of the day
Anhedonia
Significant change in weight
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or guilt
Impaired concentration, indecisiveness
Recurring thoughts of death or suicide

Further, one of the symptoms must be either
depressed mood or anhedonia.

The symptoms must be present nearly every day
for 2 weeks, and occur through most of the day.

Symptoms must cause impairment of functioning.

S sleep
I interest
G guilt or worthlessness
E energy
C concentration
A appetite
P psychomotor changes
S SI

AJC 1990;66:59-62
Biobehavioral variables and mortality or cardiac
arrest in the Cardiac Arrhythmia Pilot Study
(CAPS)
502 pts with >10PVC/hr or >5 NSVT episodes evaluated

Results indicated that higher levels of depression and
lower pulse rate reactivity were significant risk factors for
death or cardiac arrest, after adjusting statistically for a
set of known clinical predictors of disease severity.
JAMA 1993; 270(15) 1819-1825
Depression Following Myocardial Infarction:
Impact on 6-month Survival
To evaluate if MDD in patients hospitalized after MI
would have an independent impact on mortality during
6month follow-up
Prospective evaluation of 222 patients with MI using DIS
78% male. Ages 24-88. EF 12-76%. 82 pts with previous
MI.
Depression was a significant predictor of mortality with
HR 5.74, p=0.0006.
Controlling for LVEF, Killip class, previous MI, HR 4.29,
p=0.013
0
2
4
6
8
10
12
14
16
18
0 1 2 3 4 5 6
Months Post-MI
%

M
o
r
t
a
l
i
t
y
Depressed (n=35)
Nondepressed (n=187)
Circ 1995; 91:999-1005.
Depression and 18-Month Prognosis After
Myocardial Infarction
18month follow-up showed that both DIS and BDI scores
consistent with depression were significantly related to
18month cardiac mortality, after controlling for other
predictors of mortality including Killip class, PVCs,
previous MI. (OR 3.64, p=0.012 and OR 7.82, p=0.0002
with adjusted OR6.64, p=0.0026)

The deaths that occurred in 18month follow-up were
concentrated among depressed patients with PVCs
>10/hr.
0%
10%
20%
30%
40%
50%
60%
70%
%

C
a
r
d
i
a
c

M
o
r
t
a
l
i
t
y
BDI < 10 BDI 10
PVCs < 10/hour PVCs 10/hour
n = 112
n =56
n =16
n =10
Am J Cardiol 1996;78:613-617
Depression and Long-term Mortality Risk in
Patients with Coronary Artery Disease
1250 patients with CAD assessed for depression
and followed for 15.2 years to evaluate the long-
term mortality risk.

Pts were enrolled at the time of LHC and
followed at 6 and 12 months then annually with
SDS.

Higher depression scores were associated with
increased risk of subsequent cardiac death
(p=0.002) and total mortality (p<0.001) after
controlling for initial disease severity and
treatment.
Pts with moderate to severe depression had a
69% greater odds of cardiac death and a 78%
greater odds of mortality from all causes than
nondepressed patients.
Pts with higher scores had a higher risk of
cardiac death >5 yrs later (p<0.005)
Compared with nondepressed pts, those with
moderate to severe depression had an 84%
greater risk at 5-10yrs later and a 72% greater
risk after >10yrs.

-0.5
0
0.5
1
R
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l
a
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i
v
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R
i
s
k
Mild Moderate/Severe
2
1.5
1
0.5
1 2-5 6-10 11+
Years of Follow-up
AJC 2008;101:602-606
Effect of Depression on Late (8 years)
Mortality After Myocardial Infarction
Prospective observational study of 284 patients
hospitalized with MI

Any depression at the time of MI was not associated with
mortality at 8 years.

However, increased mortality was statistically significant
in the short term (4 months).
No Depression
Any Depression
Years
Number at risk
Any Depression
No Depression
2
229
60
169
0
184
76
208
4
200
50
150
6
169
41
128
8
147
34
113
P
e
r
c
e
n
t
a
g
e

S
u
r
v
i
v
i
n
g

0
%

5
0
%

1
0
0
%

Of note, this was a small observational study of
284 hospitalized pts over age 63 with multiple
comorbidities.
AJC 2008;101:15-19
Usefulness of Persistent Symptoms of Depression
to Predict Physical Health Status 12 Months After
an Acute Coronary Syndrome
425 pts hospitalized for ACS completed the BDI and SF-
12 in hospital, 6- and 12 months later.

Only patients with persistent symptoms of depression
were at risk for poorer physical health.

Patients with newly developed depressive symptoms
after ACS had a trend toward worse physical health,
whereas patients with transient depressive symptoms
were not at increased risk.

What about patients with
no history of heart
disease?
Arch Int Med 1998;158:1422-1426
Depression Is a Risk Factor for Coronary Artery
Disease in Men: The Precursors Study
Observational study of 1190 male medical students enrolled from
1948 to 1964 followed for 40 years
Incidence of depression was 12%. In multivariate analyses, these
men were at greater risk for subsequent CAD (RR 2.12) and MI (RR
2.12).
The increased risk associated with depression was present even for
MIs occurring 10 yrs after the first MDE (RR 2.1)
The association did not change when time-dependent smoking,
EtOH, and coffee use were added to models, nor when BMI, FH of
MI, baseline cholesterol, and time-dependent HL were added.
In a model with the strongest RF, the risk of CHD from depression
was still significant with RR of 1.7
Clinical depression was associated with a greater risk of
total mortality according to both unadjusted and adjusted
analyses.
Clinical depression was significantly related to CVD
mortality in unadjusted analyses, with a trend toward
increased CVD mortality in adjusted analyses.
The association of clinical depression with CVD mortality
was stronger than the association of clinical depression
with other causes of death, exclusive of suicide.

Arch Int Med 2000;160:1261-1268
Depression as an Antecedent to Heart Disease
Among Women and Men in the NHANES I Study
5006 women and 2888 men who completed the
CES-D were followed over 10 years.
17.5% of women were depressed and 9.7% of
men were depressed.
The mean poverty index was lower in depressed
patients.
Women had 187 nonfatal and 137 fatal events.
Men had 187 nonfatal and 129 fatal events.

The RR of nonfatal CHD among women
with scores of 23 or higher on CES-D was
2.09

Adjusted RR with final model taking into
consideration poverty, DM, HTN, smoking,
and BMI was 1.73.

The adjusted RR for nonfatal CHD in depressed
men was 1.71.

Adjusted RR for CHD mortality was 2.34.

Adjusted all-cause mortality RR was 1.69.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
0 5 10 15 20 25
CES-D Score
R
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R
i
s
k

o
f

F
a
t
a
l

E
v
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n
t
Men
Women

What is the connection between depression
and cardiac events?
Pathophysiologic changes

Behavioral issues

Medication Adherence

Medication Side Effects
Candidate Mechanisms Linking Depression To
Cardiovascular Morbidity & Mortality
Physiological pathways
Cardiovascular autonomic dysregulation
E.g., low heart rate variability (HRV)
Pro-inflammatory processes
E.g., elevated CRP, IL-6
Pro-coagulant processes
E.g., elevated fibrinogen, PF4, BTG
Shared genetic factors
E.g., TNFA, IL1B, 5-HTT, 5-HT2A, 5-HT2B
Hypothalamic-Pituitary-Adrenal
(HPA) axis in depression
Endothelium-Teflon Resistant
Tunica adventitia
Tunica media
Tunica intima
Endothelium
Subendothelial connective
tissue
Internal elastic membrane
Smooth muscle cells
Elastic/collagen fibers
External elastic membrane
Ross, R. Nature, 1993; 362: 801-809. 1993;362:801-809.
LDL-small dense particles
LDL
Mackness MI et al. Biochem J 1993;294:829-834.
Endothelium
Vessel Lumen-Teflon Resistent
Monocyte
oxidized LDL
Macrophages
engulf LDL
Adhesion Modules-
increase monocytes
adherence

Cytokines
Atherosclerosis is an Inflammatory Disease
LDL pro-inflammatory & HDL anti-inflammatory
Foam Cell-increase
ANGIOTENSIN II,
PAI, -pro-
thrombotic state &
decrease NO
HDL Promote Cholesterol Efflux
HDL Inhibit
Oxidation
of LDL
Libby, P. et al. Circulation 2005;111:3481-3488
Plaque Morphology and Ischemic
Impact
Pathophysiology in Motion
Psychosom Med 2005;67:S1:S29-33.
Autonomic dysregulation in depression
sympathetic; parasympathetic activity: increased
catecholamines (e.g. NE)
lower threshold for ischemia, ventricular tachycardia,
ventricular fibrillation, sudden death in CHD pts and may
contribute to endothelial injury
resting heart rate; heart rate variability
baroreceptor sensitivity
QT interval/impaired repolarization, variable repol


Psychosom Med 2005;67:S1:S34-36.
Procoagulant effects of depression
Elevated catecholamines may also promote
procoagulant processes by potentiating platelet
activation through agonist effects, by increasing
hemodynamic stress on vascular walls, or by inhibiting
vascular eicosanoid synthesis.


Schwarz . Dialogues in Clin
Neurosciences 2003; 5: 139-153
Immunologic response
Cytokines may lead to sickness-behavior (lethargia,
anorexia, paresthesia, irritability, social withdrawal, impaired
concentration, sleep problems, decreased libido; particularly TNF-
alfa and IL-6 may induce depression, anxiety and memory
impairment)
In non-melancholic depression elevated levels of
-IL-6 (mediates activation of the HPA axis),
-NK cells (acute stage)
-leucocytes/lymphocytes (acute stage)

In melancholic depression:
- decreased (in vitro) production of IL-2; IFN-g; IL-10 (acute stage),
but normal cell counts

Kop: Psychosom Med 2005; 67 [Suppl
1]: s37-s41

The relationship between central nervous system correlates of depression and
immune system parameters is bidirectional, mediated by neurohormonal and
parasympathetic pathways. Depressive symptoms primarily affect the transition
from stable CAD to acute coronary syndromes via plaque activation and
prothrombotic processes (solid line) and may adversely affect the initial response
to injury at early stages of coronary atherosclerosis (dashed line).
Jiang W, Davidson JRT. Am Heart J
2005; 150: 871-881
SSRI therapy in patients with ischemic
heart disease

SSRIs reduce platelet activity. SSRI
(sertraline) was associated with
substantially less release of
platelet/endothelial biomarkers: PF4, TG,
platelet/endothelial cell adhesion molecule
1, P selectin, thromboxane B
2
, 6-keto
prostaglandin F
1a
, vascular cell adhesion
molecule 1, and E selectin.

Barton et al. J Hypertens. 2007
Oct;25(10):2117-2124.
Sympathetic activity in
major depressive disorder

SSRI therapy abolished the excessive
sympathetic activation, with whole body
noradrenaline spillover falling from 518 +/- 83 to
290 +/- 41 ng/min (P = 0.008).
Copyright restrictions may apply.
Glassman, A. H. et al. Arch Gen Psychiatry 2007;64:1025-1031.
Heart rate variability (HRV) recovery following myocardial infarction in the Sertraline
Antidepressant Heart Attack Randomized Trial (SADHART) and studies by Jokinen et al and
McFarlane et al
-20
-10
0
10
20
30
40
C
h
a
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g
e

i
n

H
R
V
,

%
n=416 n=11
n=12
n=125
n=133 n=15
Patients Without
Depression
Prescribed
Sertraline
Given
Placebo
Patients With Depression
A
B
Jokinen et al
SADHART
McFarlane et al
Candidate Mechanisms Linking Depression To
Cardiovascular Morbidity & Mortality
Behavioral pathways
Smoking
High prevalence of smoking in depression & vice versa
Depression decreases smoking cessation rates.
Physical inactivity
Depression is inversely associated with exercise, participation
in cardiac rehabilitation
Poor diet and obesity
Nonadherence to prescribed medications
Archives 2005;165:2508-2513
Depression and Medication Adherence in
Outpatients With Coronary Heart Disease
Findings From the Heart and Soul Study
14% of depressed pts vs 9% of nondepressed pts
reported not taking their medications as prescribed (OR
2.8, p<0.001)

Twice as many depressed pts as nondepressed pts
reported forgetting to take their medications (OR2.4,
p<0.001)

9% depressed pts and 4% nondepressed pts reported
deciding to skip their medications (OR 2.2 p=0.009)

0
2
4
6
8
10
12
14
16
18
20
P
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o
f

P
a
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t
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c
i
p
a
n
t
s
Depressed (n=204) Not Depressed (n=736)
Not as Prescribed
(P<.001)
Forgot to Take
(P<.001)
Decided to Skip
(P<.01)
Reason for Nonadherence
JACC 2006;48:2218-22
Course of Depressive Symptoms and Medication
Adherence After Acute Coronary Syndromes
Depression was associated with medication
nonadherence in a gradient fashion.

15% of nondepressed pts, 29% of mildly
depressed pts, and 37% of mod-severely
depressed pts took ASA <80% of the time.

Change in depressive symptoms over the study
period were linearly related to changes in
adherence.

JACC 2006;48:2209-14
Beta-Blockers and Depression After
Myocardial Infarction
381 pts, 127 without BB and 254 matched
pts with BB at discharge after MI
There were no significant differences in
BDI at baseline, 3, 6, or 12 months after
MI.
Does treatment of depression, then,
improve outcomes in patients with CAD?
JAMA 2002;288(6) 701-709
Sertraline Treatment of Major Depression in
Patients With Acute MI or Unstable Angina
SADHART
369 pts with MDD randomized to sertraline (50-
200mg/day) or placebo for 24 weeks
Pts were hospitalized with ACS in the past 30
days and met DSM-IV criteria for MDD.
The study involved 7 countries from 04/1997-
04/2001.
Primary outcome was change from baseline EF.
Secondary measures included cardiovascular
adverse events, HAM-D scores, CGI-I scores
SADHART: Safety Outcomes
No difference between drug and placebo in:
LVEF
Blood pressure
Resting ECG (HR, QRS, QT)
24-Hour Holter ECG
VPCs
HRV (time & frequency domain)

SADHART: Efficacy
All Randomized Patients
Outcome
Sertraline
(n=186)
Placebo
(n=183) p
HAM-D, mean (SD) -8.4 (0.4) -7.6 (0.4) .14
HAM-D: Hamilton Rating Scale for Depression

* 2 prior episodes plus HAM-D score 18.
Severe Recurrent MDD Subgroup*
Outcome
Sertraline
(n=50)
Placebo
(n=40) p
HAM-D, mean (SD) -12.3 (0.9) -8.9 (1.0) .01
SADHART
Sertraline had no significant effect on mean
LVEF, incidence of PVCs, or QTc interval.

The incidence of severe CV adverse events was
14.5% with sertraline and 22.4% with placebo.

CGI-I but not HAM-D favored sertraline.

In the groups with preexisting depression, both
CGI-I and HAM-D measures were significantly
better in those assigned to sertraline.
SADHART
Sertraline appears to be a safe medication for
use following ACS.

In patients with recurrent depression and CAD,
sertraline was efficacious in the treatment of
depression.
JAMA 2003;289(23) 3106-3116.
Effects of Treating Depression and Low
Perceived Social Support on Clinical Events
After Myocardial Infarction
ENRICHD
2481 MI patients at 8 centers enrolled from
10/1996 to 04/2001.

Pts had major or minor depression by DSM IV
criteria.

Randomized to usual medical care or CBT
based therapy with primary endpoints of death
or nonfatal MI.

ENRICHD: Intervention
Cognitive behavior therapy
Behavioral activation, cognitive restructuring, social skills
training, social network.
Up to 6 months of CBT with trained therapist

Sertraline added for severely depressed patients
and for those who did not respond sufficiently to
CBT within 6 weeks
ENRICHD: Overall Effects on
Depression and Social Support
5.1
-10.1
3.4
-8.4
-15
-10
-5
0
5
10
ESSI score Hamilton depression
score
Intervention
Usual care
ENRICHD Social Support Instrument (ESSI) scores reported for patients with low social
support only; Hamilton depression scores reported for depressed patients only.
The Efficacy of the ENRICHD Intervention
Depended on Initial Severity of Depression
0
10
20
30
40
50
60
70
80
BDI 10-15 BDI 16-23 BDI 24+
%

R
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D
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s
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Usual Care
Intervention
RL*=1.35
p<0.006
RL=1.80
p<0.0008
RL=2.58
p<0.0015
(N=346) (N=313) (N=200)
*Relative Likelihood of Remission
The ENRICHD Intervention Did Not
Improve Reinfarction-Free Survival
The ENRICHD Intervention Did
Improve Late Survival (>6 Months)
Late survival
depended on
whether depression
improved over the
course of the
intervention.
Carney et al., Psychosom Med 2004;66(4):466-474.
ENRICHD
Improvements in psychosocial outcomes favored
treatment at 6 months.

There was no difference in event-free survival.

Of note, treatment with anti-depressants was
4.8% to 20.6% in the usual care group and 9.1%
to 28% in the treatment arm.
JAMA 2007;297(4) 367-379
Effects of Citalopram and Interpersonal
Psychotherapy on Depression in Patients With
Coronary Artery Disease
CREATE

284 patients with CAD and DSM-IV criteria
for MDD with HAM-D scores >20.

Pts randomized to (1) 12 weekly sessions
of interpersonal psychotherapy plus
clinical mgmt vs clinical mgmt only and (2)
12 weeks citalopram or matching placebo

CREATE
Citalopram was superior to placebo in reducing
12 week HAM-D scores (p=0.005)

No benefit was seen of IPT over clinical mgmt
(p=0.06)

Similar to the results of SADHART, response to
SSRI was more pronounced in pts with a history
of recurrent depression.
AJM 2007;120:799-806
Impact of Cardiac Rehabilitation on
Depression and Its Associated Mortality
522 patients enrolled in cardiac rehab and a
control group not enrolled evaluated over 4
years
Effect of Cardiac Rehab on Depression in 552 patients
17%
6%
15%
20%
10%
0
P
r
e
v
a
l
e
n
c
e

Before After
5%
Milani RV, Am J Med 2007
Before
After
Cardiac Rehab Improves Depression
Actuarial cumulative hazard plot for survival time
based on depression status upon completion of cardiac rehabilitation

Milani RV, Am J Med 2007
Depressed
Non-
depressed 0
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0 1 2 3 4 5
Time (Years)
C
u
m
u
l
a
t
i
v
e

H
a
z
a
r
d

Depression is Associated with Decreased
Survival
Prevalence of Depression Before and After Cardiac Rehab
23%
19%
30
20
0
P
r
e
v
a
l
e
n
c
e

(
%
)

Young Elderly
10
6%
4%
Before
After
Lavie CF, Arch Int Med, 2006
Psychological Distress is Common
Evidence for Depression as an
Independent Risk factor for CAD
GOOD
1. Strength of
Association
2. Prediction
3. Consistency
4. Dose-response Effect
FAIR
5. Specificity
6. Biological Plausibility

INSUFFICIENT EVIDENCE
7. Cardiac risk reduction in
response to treatment for
depression.
Wulsin, L.R; Harv Rev Psychiatry. March/April 2004
Criteria for Major Depression
Depressed mood
Diminished interest or pleasure
5 or more of the following Sx present for > 2
weeks:
Fatigue or loss of energy
Diminished ability to concentrate
Insomnia or hypersomnia
Weight loss or weight gain
Feelings of worthlessness or excessive guilt
Psychomotor agitation or retardation
Recurrent thoughts of death or suicidal
ideation or attempt
One or the
other required
When to suspect depression in cardiac
pts
Symptoms: chronic tiredness, wt loss,
insomnia, recent onset of irritability or
anger
Impairment: reduced social contact, poor
ADLs, reduced interest, difficulty coping
with recent losses and stresses
Medical Management Problems: chronic
anxiety, poor medication compliance or
risk factor modification
What are the treatment
recommendations
regarding depression in
patients with CHD?
Tools for Assessment of
Depression in Clinical Practice
Patient Health Questionnaire
(PHQ-9) and (PHQ-2)

Beck Depression Inventory
(Self-report)

Zung Self-rating Depression Scale
(self report)

Center for Epidemiologic Studies-
Depression (self report)

Hamilton Depression Scale
(Administered)





Depression and Coronary Heart Disease
Recommendations for Screening, Referral,
and Treatment: A Science Advisory From
the American Heart Association
Lichtman JH, Bigger JT, Blumenthal JA,
Frasure-Smith N, Kaufmann PG, Lesprance
F, Mark DB, Sheps DS, Taylor CB, Froelicher
ES.

Circulation 2008;118;1768-1775
AHA Recommendations
Routine screening for depression in
patients with CHD in various settings,
including the hospital, physicians office,
clinic, and cardiac rehabilitation center.
The opportunity to screen for and treat
depression in cardiac patients should not
be missed, as effective depression
treatment may improve health outcomes.
Lichtman et al., Circulation 2008;118;1768-1775
Patient Health Questionnaire (PHQ-2)
Over the past 2 weeks, how often have you been bothered
by any of the following problems?

(1) Little interest or pleasure in doing things.
(2) Feeling down, depressed, or hopeless.

Positive screen = yes to either question.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression
severity measure. J Gen Intern Med. 2001;16:606613.
Patient Health Questionnaire (PHQ-9)
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression
severity measure. J Gen Intern Med. 2001;16:606613.
Over the past 2 weeks, how often have you been bothered by any of the
following problems?

(1) Little interest or pleasure in doing things.
(2) Feeling down, depressed, or hopeless.
(3) Trouble falling asleep, staying asleep, or sleeping too much.
(4) Feeling tired or having little energy.
(5) Poor appetite or overeating.
(6) Feeling bad about yourself, feeling that you are a failure, or feeling
that you have let yourself or your family down.
(7) Trouble concentrating on things such as reading the newspaper or
watching television.
(8) Moving or speaking so slowly that other people could have noticed.
Or being so fidgety or restless that you have been moving around a
lot more than usual.
(9) Thinking that you would be better off dead or that you want to hurt
yourself in some way.
AHA Recommendations
Patients with positive screens should be
evaluated by a professional qualified in the
diagnosis and management of depression.
Patients with cardiac disease who are
under treatment for depression should be
carefully monitored for adherence to their
medical care, drug efficacy, and safety
with respect to their cardiovascular as well
as mental health.
Lichtman et al., Circulation 2008;118;1768-1775
AHA Recommendations
Monitoring mental health may include, but
is not limited to, the assessment of
patients receiving antidepressants for
possible worsening of depression or
suicidality, especially during initial
treatment when doses may be adjusted,
changed, or discontinued.

Lichtman et al., Circulation 2008;118;1768-1775
AHA Screening Guideline
Meta-Analysis of the Adverse
Effect of Depression on
Patient Adherence
Compared to
nondepressed patients,
the odds are 3 times
greater that depressed
patients would be
nonadherent with
medical treatment
recommendations
DiMatteo MR, et al. Arch Intern Med. 2000;160(14):2101-2107.
Depression Is Associated
With % Smoking
0
5
10
15
20
None Minor Major
Depression Group
%

S
m
o
k
i
n
g

p<0.001; Major>None
p<0.01; Minor>None
N=4225
Adjusted for demographics, medical comorbidity, diabetes severity,diabetes type and duration, treatment type,
HbA1c and clinic.
Katon et al, Diabetes Care, 2004
Summary
MDD occurs in 15-23% of patients with coronary disease
and is an independent RF for morbidity and mortality.
RCTs in the 1990s and 2000s show RR of MI and CV
mortality of 1.5-2 in pts with preexisting depression.
In persons with established IHD, depression is
associated with a 3-4 fold increase in the risk of
subsequent CV morbidity and mortality.
Treatment of depression in patients with CAD is safe and
somewhat efficacious
Rehabilitation is associated with a 50% decrease in
depressive symptoms in pts with CHD
Bi-Directional Conclusions
PSYCHIATRY
Depression is associated with
an increase in cardiac risk
Recurrent depression worsens
cardiac outcomes
CBT improves mood but does
not improve cardiovascular
outcomes in depressed cardiac
patients
SSRIs improves mood and
appears safe in the cardiac
patient
CARDIOLOGY/PRIMARY CARE
20% of patients post MI will have
symptoms of depression
Understand the potential
mechanisms of how depression
may increase the risk for CHD
events
Treatment of depression leads
to better clinical outcomes after
a cardiac event
Wulsin, L.R; Harv Rev Psychiatry. March/April 2004

MDD is an independent predictor of
all cause mortality and CV death after
AMI complicated by heart failure
Insanity:
Doing the same thing
over and over again
and expecting different results.


Albert Einstein