Effects of antidepressant treatment following myocardial infarction

Depression and coronary heart disease

There are exciting findings in the field of depression and coronary heart disease. Whether diagnosed or simply self-reported, depression continues to mark very high risk for a recurrent acute coronary syndrome or for death in patients with coronary heart disease. Many intriguing mechanisms have been posited to be implicated in the association between depression and heart disease, and randomized controlled trials of depression treatment are beginning to delineate the types of depression management strategies that may benefit the many coronary heart disease patients with depression.

Mind and heart: heart rate variability in major depressive disorder and coronary heart disease - a review and recommendations

OBJECTIVE

There is a reciprocal association between major depressive disorder (MDD) and coronary heart disease (CHD). These conditions are linked by a causal network of mechanisms. This causal network should be quantitatively studied and it is hypothesised that the investigation of vagal function represents a promising starting point. Heart rate variability (HRV) has been used to investigate cardiac vagal control in the context of MDD and CHD. This review aims to examine the relationship of HRV to both MDD and CHD in the context of vagal function and to make recommendations for clinical practice and research.

METHODS

The search terms 'heart rate variability', 'depression' and 'heart disease' were entered into an electronic multiple database search engine. Abstracts were screened for their relevance and articles were individually selected and collated.

RESULTS

Decreased HRV is found in both MDD and CHD. Both diseases are theorized to disrupt autonomic control feedback loops on the heart and are linked to vagal function. Existing theories link vagal function to both mood and emotion as well as cardiac function. However, several factors can potentially confound HRV measures and would thus impact on a complete understanding of vagal mechanisms in the link between MDD and CHD.

CONCLUSIONS

The quantitative investigation of vagal function using HRV represents a reasonable starting point in the study of the relationship between MDD and CHD. Many psychotropic and cardiac medications have effects on HRV, which may have clinical importance. Future studies of HRV in MDD and CHD should consider antidepressant medication, as well as anxiety, as potential confounders.

Exercise and pharmacological treatment of depressive symptoms in patients with coronary heart disease: results from the UPBEAT (Understanding the Prognostic Benefits of Exercise and Antidepressant Therapy) study

OBJECTIVES

The aim of this study was to assess the efficacy of exercise and antidepressant medication in reducing depressive symptoms and improving cardiovascular biomarkers in depressed patients with coronary heart disease.

BACKGROUND

Although there is good evidence that clinical depression is associated with poor prognosis, optimal therapeutic strategies are currently not well defined.

METHODS

One hundred one outpatients with coronary heart disease and elevated depressive symptoms underwent assessment of depression, including a psychiatric interview and the Hamilton Rating Scale for Depression. Participants were randomized to 4 months of aerobic exercise (3 times/week), sertraline (50-200 mg/day), or placebo. Additional assessments of cardiovascular biomarkers included measures of heart rate variability, endothelial function, baroreflex sensitivity, inflammation, and platelet function.

RESULTS

After 16 weeks, all groups showed improvement on Hamilton Rating Scale for Depression scores. Participants in both the aerobic exercise (mean -7.5; 95% confidence interval: -9.8 to -5.0) and sertraline (mean -6.1; 95% confidence interval: -8.4 to -3.9) groups achieved larger reductions in depressive symptoms compared with those receiving placebo (mean -4.5; 95% confidence interval: -7.6 to -1.5; p = 0.034); exercise and sertraline were equally effective at reducing depressive symptoms (p = 0.607). Exercise and medication tended to result in greater improvements in heart rate variability compared with placebo (p = 0.052); exercise tended to result in greater improvements in heart rate variability compared with sertraline (p = 0.093).

CONCLUSIONS

Both exercise and sertraline resulted in greater reductions in depressive symptoms compared to placebo in patients with coronary heart disease. Evidence that active treatments may also improve cardiovascular biomarkers suggests that they may have a beneficial effect on clinical outcomes as well as on quality of life. (Exercise to Treat Depression in Individuals With Coronary Heart Disease; NCT00302068).

Depressive symptom clusters and 5-year incidence of coronary artery calcification: the coronary artery risk development in young adults study

BACKGROUND

Because depression is a multidimensional construct and few studies have compared the relative importance of its facets in predicting cardiovascular risk, we evaluated the utility of depressive symptom clusters in predicting the 5-year incidence of coronary artery calcification (CAC).

METHODS AND RESULTS

Participants were 2171 middle-aged adults (58% female; 43% black) from the Coronary Artery Risk Development in Young Adults (CARDIA) study who were free of cardiovascular disease. Depressive symptom clusters (z scores) were measured by questionnaires in 2000 to 2001, and CAC was measured by electron beam computed tomography in 2000 to 2001 and 2005 to 2006. There were 243 cases (11%) of incident CAC, defined as the absence of CAC at baseline and the presence of CAC at follow-up. Total depressive symptoms (odds ratio, 1.16; 95% confidence interval, 1.02-1.33; P=0.03) and the depressed affect cluster (odds ratio, 1.17; 95% confidence interval, 1.03-1.33; P=0.02) predicted incident CAC; however, the somatic, interpersonal distress, low positive affect, and pessimism clusters did not. The depressed affect-incident CAC relationship was independent of age, sex, race, education, and antidepressant use; was similar across sex and racial groups; and was partially accounted for by tobacco use and mean arterial pressure.

CONCLUSIONS

In contrast to recent results indicating that the somatic cluster is the most predictive of cardiovascular outcomes, we found that the prospective association between depressive symptoms and incident CAC was driven by the depressed affect cluster. Our findings raise the possibility that there may not be 1 facet of depression that is the most cardiotoxic across all contexts.

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).

Mood patterns based on momentary assessment of positive and negative moods over a day and coronary artery calcification in the CARDIA study

OBJECTIVE

Retrospective assessments of negative mood have predicted coronary artery disease development and progression. Using momentary assessment, we evaluated associations between average positive and negative mood states and diurnal mood patterns, with prevalent and incident coronary artery calcification (CAC), a measure of calcified atherosclerosis.

METHODS

In a prospective cohort study of 669 white and African American men and women, aged 33 to 45 years, from the Coronary Artery Risk Development in Young Adults Study, mood was assessed at Year 15 examination, six times over a weekday. Prevalent, progressive, and 5-year incident CAC (any detectable CAC [score >0]) and substantial CAC (CAC score ≥ 20) were assessed at examinations at Years 15 and 20 by electron-beam tomographic scans. We employed a modified Poisson regression approach for binary data with robust error estimation to quantify relative risk.

RESULTS

In multivariate-adjusted analyses, those with high-average positive mood that improved over a day had a lower risk of prevalent CAC higher than 0 (relative risk [RR] = 0.17 [95% confidence interval {CI} = 0.04-0.67]) and substantial CAC (RR = 0.25 [95% CI = 0.06-0.95]). In contrast, those with high-average, increasingly negative mood over a day had a higher risk of prevalent CAC (RR = 1.85 [95% CI = 0.86-3.99]) and substantial CAC (RR = 3.11 [95% CI = 1.29-7.49]). Findings were similar for progressive CAC at Year 20. This pattern of high/worsening negative mood (not positive mood) during the day was also predictive of 5-year incident CAC (RR = 2.99 [95% CI = 1.00-8.93]).

CONCLUSIONS

Diurnal mood patterns were associated with the progression of calcified atherosclerosis, with negative mood predicting greater progression and positive mood predicting lower progression.