Relation between psychological strain and carotid atherosclerosis in a general population

Association between metabolic score of visceral fat and carotid atherosclerosis in Chinese health screening population: a cross-sectional study

BACKGROUND

The metabolic score for visceral fat (METS-VF) quantifies the cumulative burden of visceral and intra-abdominal adipose tissues. However, the relationship between the METS-VF and carotid atherosclerosis (CAS) has not been extensively explored. Therefore, this study aimed to investigate the association between the METS-VF and CAS.

METHODS

This cross-sectional study enrolled 7089 Chinese adults who underwent physical examinations at the Zhenhai Lianhua Hospital, Zhejiang, China, in 2020. Multivariable logistic regression analysis was used to explore the linear relationship between METS-VF and CAS. Generalised additive models (GAM) were employed to evaluate potential nonlinear associations. The inflection points of METS-VF were determined using segmented logistic regression analysis optimised for maximum likelihood ratios and recursive algorithms.

RESULTS

Multivariable logistic regression analysis revealed a positive correlation between METS-VF and CAS (odds ratio [OR]: 1.824, 95% confidence interval [CI]: 1.753-1.899; P < 0.001). The GAM analysis confirmed a nonlinear association between them [effective degrees of freedom: 4.803, χ2: 876.7, P < 0.001], with an inflection point at a METS-VF of 8.09 (P < 0.001 for log-likelihood ratio test). Below this inflection point, METS-VF exhibited a significant positive association with CAS risk (OR: 1.874, 95% CI: 1.796-1.954; P < 0.001). Conversely, no significant association was observed when METS-VF ≥ 8.09 (OR: 0.998, 95% CI: 0.786-1.268; P = 0.989).

CONCLUSIONS

METS-VF and CAS demonstrated a positive non-linear correlation, with the curve indicating a saturation effect at METS-VF = 8.09.

Associations between emotional support and cardiovascular risk factors and subclinical atherosclerosis in middle-age

OBJECTIVE

To test the hypothesis of low emotional support being associated with lifestyle and biomedical cardiovascular disease (CVD) risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults.

METHODS AND MEASURES

Cross-sectional data were obtained from participants aged 40-60 years who had one or more conventional CVD risk factor. They underwent assessment based on questionnaires, clinical examination, blood sampling, and carotid ultrasound of plaque formation and carotid intima-media wall thickness (cIMT). Based on the Interview Schedule for Social Interaction, the participants were categorised as either low in emotional support (n = 884) or as a referent (n = 2570). Logistic regression analyses were conducted to study the associations.

RESULTS

Logistic regression analyses showed that low emotional support was significantly associated with smoking, alcohol consumption and physical inactivity (OR = 1.53 - 1.94), estimated risk of CVD morbidity and mortality (OR = 1.56 - 1.68), and plaque formation (OR = 1.39). No significant associations were found regarding biomedical CVD risk factors or cIMT.

CONCLUSION

The findings suggest that low social support is associated with lifestyle CVD risk factors, estimated risk of CVD morbidity and mortality, and subclinical atherosclerosis in middle-aged healthy adults, encouraging causal evaluation with longitudinal data investigating an impact of emotional support on mechanisms underlying CVD.

[The application of the BL-38 subjective complaints scale in an epidemiological cohort study (Study of Health in Pomerania)]

The application of the BL-38 subjective complaints scale in an epidemiological cohort study (Study of Health in Pomerania) Objective: We provide an overview of the application of the BL-38 complaints scale in the epidemiological Study of Health in Pomerania. We examine the influence of socio-demographic variables on complaint burden and the stability of complaint burden over time. Methods: 16 studies that used the BL-38 in analyses of SHIP-data were examined in terms of how the BL-38 was operationalised and the statistically significant results yielded. We conduct linear regression analyses to assess effects of sociodemographic variables on complaint burden in four SHIP populations and assess test-retest-reliability over a 17-year period. Results: The BL-38 is predominantly used flexibly to depict specific complaints in analyses covering a heterogeneous range of disciplines and study questions. Total, somatic and mental complaint burden have different determinant, predictive and confounding effects. Test-retest-reliability was moderate. Conclusions: The BL-38 allows consideration of (specified) health complaint patterns across many research disciplines. Cross-sectional and longitudinal reproducibility of significant results underlines its validity. The results underscore the importance of subjective health complaints in epidemiological and psychosomatic research.

Gender Differences in Associations Between Stress and Cardiovascular Risk Factors and Outcomes

Psychological stress, a subjective perception of an adverse environmental change, is a hallmark of modern society. Although psychological stress has previously been established as a risk factor for cardiovascular disease (CVD), it is unclear whether stress influences cardiovascular risk differently in men versus women. Gender disparities exist in the prevalence of stress as well as in the prevalence and prognosis of CVD; therefore, associations between stress and CVD risk and mortality may vary by sex. The purpose of this review was to summarize the evidence from recent and landmark studies on gender differences in the associations of stress with CVD risk factors and end points and to highlight clinical and public health implications as well as future research directions in this field. Taken together, research to date indicates that while stress is associated with poorer cardiovascular health metrics in both men and women, the influence of stress on measures of glucose regulation and dyslipidemia and on overall CVD risk may be stronger among women. However, men may be more susceptible to the influence of stress on body adiposity, blood pressure, and CVD mortality. In terms of behavioral risk factors for CVD, associations between stress and diet quantity and quality appear to be stronger among women, but the influence of stress on sedentary behaviors and sleep may be stronger among men. Given that gender disparities exist in the prevalence of overall and different types of stress (eg, financial stress, caregiving stress, and occupational stress), future studies should decipher the potential differential associations between types of stress and cardiovascular risk among men and women to identify vulnerable populations and develop targeted interventions.

Self-perceived stress is associated with adiposity and atherosclerosis. The GEA Study

Background

A growing body of evidence suggests that psychological stress is an independent cardiovascular risk factor. Obesity prevalence shows accelerating trends worldwide, and is known to be associated with a range of comorbidities and survival. The aim of this study was to assess the relationship between self-perceived psychological stress with parameters of adiposity, metabolic syndrome, and subclinical atherosclerosis in Mexican participants.

Methods

Metabolic Syndrome was defined using the Adult Treatment Panel III criteria, obesity was defined as BMI >30, subclinical atherosclerosis disease was determined by computed tomography, and carotid intima media thickness was determined by ultrasonography. Self-perceived psychological stress was assessed using a single-item questionnaire.

Results

A total of 1243 control subjects were included in the sample, mean age 54.2 ± 9 years old; the prevalence of chronic self-perceived psychological stress (>5 years) was 10.13 %, female gender (62.7 %), obesity prevalence (48.4 %), and self-reporting sedentary lifestyle (56.3 %). The chronic stressed cohort presented higher subcutaneous abdominal fat content (285 vs 319 cm²), and carotid intima media thickness (0.63 vs 0.66 mm; p < 0.01 for both). However, after adjustment for lifestyle/social covariates (Model 1) and biological mediators (Model 2), chronic self-perceived stress was independently associated with obesity in men (OR 2.85, 95 % CI 1.51 – 5.40) and carotid atherosclerosis in women (OR 2.262, 95 % CI 1.47 – 4.67; p < 0.01 for both).

Conclusion

Our study suggests that self-reported chronic stress is an independent risk factor for obesity in men. In addition, carotid atherosclerosis was also found to be an independent risk factor in women in a Mexican population sample.

Corticotropin-Releasing Hormone (CRH) Promotes Macrophage Foam Cell Formation via Reduced Expression of ATP Binding Cassette Transporter-1 (ABCA1)

Atherosclerosis, the major pathology of cardiovascular disease, is caused by multiple factors involving psychological stress. Corticotropin-releasing hormone (CRH), which is released by neurosecretory cells in the hypothalamus, peripheral nerve terminals and epithelial cells, regulates various stress-related responses. Our current study aimed to verify the role of CRH in macrophage foam cell formation, the initial critical stage of atherosclerosis. Our quantitative real-time reverse transcriptase PCR (qRT-PCR), semi-quantitative reverse transcriptase PCR, and Western blot results indicate that CRH down-regulates ATP-binding cassette transporter-1 (ABCA1) and liver X receptor (LXR)-α, a transcription factor for ABCA1, in murine peritoneal macrophages and human monocyte-derived macrophages. Oil-red O (ORO) staining and intracellular cholesterol measurement of macrophages treated with or without oxidized LDL (oxLDL) and with or without CRH (10 nM) in the presence of apolipoprotein A1 (apoA1) revealed that CRH treatment promotes macrophage foam cell formation. The boron-dipyrromethene (BODIPY)-conjugated cholesterol efflux assay showed that CRH treatment reduces macrophage cholesterol efflux. Western blot analysis showed that CRH-induced down-regulation of ABCA1 is dependent on phosphorylation of Akt (Ser473) induced by interaction between CRH and CRH receptor 1(CRHR1). We conclude that activation of this pathway by CRH accelerates macrophage foam cell formation and may promote stress-related atherosclerosis.

Posttraumatic stress disorder, combat exposure, and carotid intima-media thickness in male twins

Posttraumatic stress disorder (PTSD) is associated with an increased risk of ischemic heart disease, though the pathophysiologic mechanisms remain unclear. Carotid artery intima-media thickness (CIMT) is a measure of subclinical atherosclerosis. We examined whether PTSD and combat exposure were associated with CIMT in Vietnam War-era twins after controlling for shared genetic and childhood factors. Between 2002 and 2010, we studied 465 middle-aged twins from the Vietnam Era Twin Registry who were free from cardiovascular disease. PTSD was diagnosed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and CIMT was measured by ultrasound. Mixed-effects regression models were used to examine individual, between-pair, and within-pair associations. Approximately 13% of participants met the criteria for PTSD, and 45% served in the Vietnam Theater. PTSD was associated with 32.7 μm higher CIMT (95% confidence interval (CI): 0.9, 64.5) after adjustment for confounders. The average CIMT for the pair increased by 59.7 μm for each additional twin with PTSD (95% CI: 15.9, 104.2). We found no significant within-pair differences in CIMT when comparing PTSD-discordant co-twins. Results for combat exposure were similar, but its association with CIMT weakened after adjustment for PTSD (95% CI: 7.0, 45.3). Among Vietnam War-era veterans, combat exposure and PTSD are associated with CIMT, though the associations are largely mediated by shared childhood factors.

Acute Psychological Stress Accelerates Reverse Cholesterol Transport via Corticosterone-Dependent Inhibition of Intestinal Cholesterol Absorption

Rationale:

Psychological stress is associated with an increased risk of cardiovascular diseases. However, the connecting mechanisms of the stress-inducing activation of the hypothalamic-pituitary-adrenal axis with atherosclerosis are not well-understood.

Objective:

To study the effect of acute psychological stress on reverse cholesterol transport (RCT), which transfers peripheral cholesterol to the liver for its ultimate fecal excretion.

Methods and Results:

C57Bl/6J mice were exposed to restraint stress for 3 hours to induce acute psychological stress. RCT in vivo was quantified by measuring the transfer of [ 3 H]cholesterol from intraperitoneally injected mouse macrophages to the lumen of the small intestine within the stress period. Surprisingly, stress markedly increased the contents of macrophage-derived [ 3 H]cholesterol in the intestinal lumen. In the stressed mice, intestinal absorption of [ 14 C]cholesterol was significantly impaired, the intestinal mRNA expression level of peroxisome proliferator–activated receptor-α increased, and that of the sterol influx transporter Niemann-Pick C1–like 1 decreased. The stress-dependent effects on RCT rate and peroxisome proliferator–activated receptor-α gene expression were fully mimicked by administration of the stress hormone corticosterone (CORT) to nonstressed mice, and they were blocked by the inhibition of CORT synthesis in stressed mice. Moreover, the intestinal expression of Niemann-Pick C1–like 1 protein decreased when circulating levels of CORT increased. Of note, when either peroxisome proliferator-activated receptor α or liver X receptor α knockout mice were exposed to stress, the RCT rate remained unchanged, although plasma CORT increased. This indicates that activities of both transcription factors were required for the RCT-accelerating effect of stress.

Conclusions:

Acute psychological stress accelerated RCT by compromising intestinal cholesterol absorption. The present results uncover a novel functional connection between the hypothalamic-pituitary-adrenal axis and RCT that can be triggered by a stress-induced increase in circulating CORT.

Genetic variation in the PNPLA3 gene is associated with alcoholic liver injury in caucasians

A recent genome-wide study revealed an association between variation in the PNPLA3 gene and liver fat content. In addition, the PNPLA3 single-nucleotide polymorphism rs738409 (M148I) was reported to be associated with advanced alcoholic liver disease in alcohol-dependent individuals of Mestizo descent. We therefore evaluated the impact of rs738409 on the manifestation of alcoholic liver disease in two independent German cohorts. Genotype and allele frequencies of rs738409 (M148I) were determined in 1,043 alcoholic patients with or without alcoholic liver injury and in 376 at-risk drinkers from a population-based cohort. Relative to alcoholic patients without liver damage (n = 439), rs738409 genotype GG was strongly overrepresented in patients with alcoholic liver cirrhosis (n = 210; OR 2.79; P(genotype) = 1.2 × 10(-5) ; P(allelic) = 1.6 × 10(-6) ) and in alcoholic patients without cirrhosis but with elevated alanine aminotransferase levels (n = 219; OR 2.33; P(genotype) = 0.0085; P(allelic) = 0.0042). The latter, biochemically defined association was confirmed in an independent population-based cohort of at-risk drinkers with a median alcohol intake of 300 g/week (OR 4.75; P(genotype) = 0.040; P(allelic) = 0.022), and for aspartate aminotransferase (AST) levels. Frequencies of allele PNPLA3 rs738409(G) in individuals with steatosis and normal alanine aminotransferase (ALT) and AST levels were lower than in alcoholics without steatosis and normal ALT/AST (P(combined) = 0.03). The population attributable risk of cirrhosis in alcoholic carriers of allele PNPLA3 rs738409(G) was estimated at 26.6%.

CONCLUSION

Genotype PNPLA3 rs738409(GG) is associated with alcoholic liver cirrhosis and elevated aminotransferase levels in alcoholic Caucasians.

Psychological factors and subclinical atherosclerosis in postmenopausal Chinese women in Hong Kong

BACKGROUND

Substantial evidence shows that psychological factors are associated with cardiovascular diseases. However, data on the association between psychological factors and subclinical atherosclerosis is lacking in postmenopausal Chinese women.

OBJECTIVES

To examine the associations of perceived stress and trait anxiety with subclinical atherosclerosis in postmenopausal Chinese women in Hong Kong. Their relationships with biological and behavioral risk factors were also examined.

METHODS

Between 2002 and 2004, we recruited 518 postmenopausal women aged 50-64 years. Perceived stress and trait anxiety were evaluated by the perceived stress scale and the state-trait anxiety inventory, respectively. Subclinical atherosclerosis was determined by measuring carotid intima-media thickness (IMT) and plaque using B-mode ultrasonography.

RESULTS

Perceived stress and trait anxiety showed no significant association with IMT or plaque. Multivariate analyses showed high perceived stress scores were associated with an increased risk of elevated total cholesterol (OR=2.10; 95% CI=1.17-3.77) and elevated low-density lipoprotein cholesterol (LDL-C) (OR=2.39; 95% CI=1.36-4.21). High trait anxiety scores were associated with a 2.7-fold risk of elevated LDL-C (OR=2.74; 95% CI=1.56-4.80). Women with high perceived stress or trait anxiety scores were more likely to be physically inactive.

CONCLUSIONS

Perceived stress and trait anxiety were associated with atherogenic lipid levels, but not subclinical atherosclerosis. Maintaining high physical activity may help alleviate psychological stress and anxiety.

Self-perceived psychological stress and ischemic stroke: a case-control study

BACKGROUND

A growing body of evidence suggests that psychological stress contributes to coronary artery disease. However, associations between stress and stroke are less clear. In this study, we investigated the possible association between ischemic stroke and self-perceived psychological stress, as measured by a single-item questionnaire, previously reported to be associated with myocardial infarction.

METHODS

In the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS), 600 consecutive patients with acute ischemic stroke (aged 18 to 69 years) and 600 age-matched and sex-matched population controls were recruited. Ischemic stroke subtype was determined according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Self-perceived psychological stress preceding stroke was assessed retrospectively using a single-item questionnaire.

RESULTS

Permanent self-perceived psychological stress during the last year or longer was independently associated with overall ischemic stroke (multivariate adjusted odds ratio (OR) 3.49, 95% confidence interval (CI) 2.06 to 5.93). Analyses by stroke subtype showed that this association was present for large vessel disease (OR 3.91, 95% CI 1.58 to 9.67), small vessel disease (OR 3.20, 95% CI 1.64 to 6.24), and cryptogenic stroke (OR 4.03, 95% CI 2.34 to 6.95), but not for cardioembolic stroke (OR 1.48, 95% CI 0.64 to 3.39).

CONCLUSION

In this case-control study, we found an independent association between self-perceived psychological stress and ischemic stroke. A novel finding was that this association differed by ischemic stroke subtype. Our results emphasize the need for further prospective studies addressing the potential role for psychological stress as a risk factor for ischemic stroke. In such studies ischemic stroke subtypes should be taken into consideration.

Panic disorder and risk of new onset coronary heart disease, acute myocardial infarction, and cardiac mortality: cohort study using the general practice research database

AIMS

To determine the risk of coronary heart disease (CHD), acute myocardial infarction (MI), and CHD-related mortality in patients with panic attacks/disorder.

METHODS AND RESULTS

We conducted a cohort study using 650 practices in the 'General Practice Research Database'. We selected all 57 615 adults diagnosed with panic attacks/disorder and a random sample of 347 039 unexposed, frequency matched for sex/age, and measured incidence of CHD, MI, and CHD-related mortality rate. There was a significantly higher incidence of MI following new onset panic in people under 50 years of age, but not in older age groups. There was a higher incidence of CHD for all ages, more marked in those under 50 years, but no significant differences in CHD mortality. Fully adjusted models showed panic attacks/disorder were associated with a significantly increased hazard of MI in those under 50 years (HR 1.38, 95% CI 1.06-1.79) and CHD at all ages (<50 years, HR 1.44, 95% CI 1.25-1.65; > or =50 years, HR 1.11, 95% CI 1.03-1.20), but no increased hazard of MI over 50 years (HR 0.92, 95% CI 0.82-1.03), and a slightly reduced CHD-mortality at all ages (HR 0.76, 95% CI 0.66-0.88).

CONCLUSION

New onset panic attacks/disorder were associated with increased hazard of subsequent CHD/MI diagnosis in younger people, but with less effect in people over 50, and a slightly reduced hazard of CHD-related mortality. This may be due to initial misdiagnosis of CHD as panic attacks or an underlying increased risk of CHD with panic attacks/disorder in younger people.

Is there an association between depression and cardiovascular mortality or sudden death?

The results of many studies and recent meta-analyses strongly suggest that depression is a risk factor for total and cardiovascular mortality, both in the general population and in patients with known heart disease. By contrast, the association between depression and sudden death or cardiac arrest has received little attention. This issue has been investigated in three recent studies; two were carried out in the general population and showed depression to be a independent risk factor for sudden death. The other study was carried out in patients with acute myocardial infarction (AMI); the adjusted relative risk (RR) of sudden death was significantly increased in depressed patients but, after adjustment for dyspnea/fatigue (a common symptom for heart disease and depression), the RR was no longer statistically significant. However, when the cognitive-affective depressive symptoms were examined separately from the somatic ones (dyspnea/fatigue, etc.), there was a clear trend for an association between cognitive-affective symptoms and sudden death. Because a risk factor can be defined as 'independent' only in a multivariate analysis in which variables are dichotomized, the presence of common symptoms between heart disease and depression represents a very difficult problem. However, taken together, the results of studies carried out in the general population and in patients with AMI strongly suggest that depression is a significant risk factor for sudden death.

The relation of exposure to shift work with atherosclerosis and myocardial infarction in a general population

OBJECTIVES

We tested the hypothesis that working shifts is related to atherosclerosis and myocardial infarction.

BACKGROUND

The number of shift workers is continuously increasing. Shift work is discussed to be related with cardiovascular heart disease.

METHODS

A total of 2510 subjects recruited for the population-based Study of Health in Pomerania were tested, 698 of whom were former shift workers. A general population sample was examined to reach generalizibility and to produce results independent from the effects of the personal shift schedule and from the specific working conditions. Carotid ultrasound was performed to evaluate carotid intima-media thickness. We used multivariable analyses to estimate the coronary heart disease risk, adjusted for age, sex and atherosclerotic risk factors, stratified by exposure to shift work and its duration.

RESULTS

Atherosclerotic risk factors differed in part between shift workers and non-shift workers. Shift work was associated with atherosclerosis and myocardial infarction, depending on the duration of the exposure and the age of the participants. Multivariable Cox regression analysis identified shift work as a risk factor for myocardial infarction to be manifest at younger ages (adjusted hazard ratio 1.53, 95% CI 1.06-2.22).

CONCLUSIONS

Exposure to shift work is a risk factor for atherosclerosis and myocardial infarction. Special prevention programs for shift workers should be provided.

Association between depression and subclinical carotid atherosclerosis in patients with Type 1 diabetes

AIMS

Recent studies have suggested an association between depression and subclinical atherosclerosis as measured by presence of carotid atherosclerotic plaque and increased intima-media thickening in non-clinical populations. Given the high prevalence of depression in patients with Type 1 diabetes and the diabetes-related risk factors for atherosclerosis, we hypothesized that this relation might also be of special relevance in Type 1 diabetic patients.

METHODS

Intima-media thickness (IMT) and the presence of plaques in the carotid arteries were quantitatively assessed by high-resolution ultrasound in 175 adults (89 men, 86 women) with an established diagnosis of Type 1 diabetes. Having been treated for depression or current Beck Depression Inventory scores > 10 were considered to indicate depression.

RESULTS

In men, the risk of plaque was higher in depressed subjects relative to non-depressed participants after adjustment for age, smoking status, systolic blood pressure, dyslipidaemia and body mass index [odds ratio (OR) 5.19; 95% confidence interval (CI) 1.29, 20.81]. Depressed women did not have an increased risk of plaque compared with non-depressed women (OR 0.97; 95% 95% CI 0.22, 4.34). We did not observe an association between depression and IMT, in men or in women.

CONCLUSIONS

In line with previous research, our findings suggest a link between depression and subclinical atherosclerosis in Type 1 diabetic men, but not in women.

The role of tumor necrosis factor-alpha in stress-induced worsening of cerebral ischemia in rats

Whereas stress is known to be one of the risk factors of stroke, few experimental studies have examined the possible mechanisms by which stress may affect stroke outcome. Most of the knowledge on the effects of stress on cerebrovascular disease in humans is restricted to catecholamines and glucocorticoids effects on blood pressure and/or development of atherosclerosis. By using an experimental paradigm consisting of the exposure of Fischer rats to repeated immobilization sessions (1 h daily during seven consecutive days) prior to permanent middle cerebral artery occlusion (MCAO), we have found that stress worsens behavioral outcome and increases infarct size after MCAO. These changes occur concomitantly to an increase in inducible nitric oxide synthase (iNOS) expression and to the accumulation of lipid peroxidation markers in brain tissue. The possible regulatory role of TNFalpha was studied by looking at the mechanisms of release of this cytokine as well as to the expression of its receptors (TNFR1 and 2). The results of the present study suggest an increase in TNFalpha expression and release after stress, as well as an increase in the expression of TNFR1. Pharmacological blockade of TNFalpha with anti-TNFalpha led to a decrease in the infarct size as well as in the oxidative/nitrosative biochemical parameters seen after ischemia. In summary, our results indicate that TNFalpha accounts, at least partly, for the worsening of MCAO consequences in brain of rats exposed to stress. Furthermore, the data presented here provide evidence that stress can increase brain ischemic damage and support a possible protective effect of treatment of stressful situations before and during the development of the brain ischemia.

The adrenal gland is a source of stress-induced circulating IL-18

The present study compared plasma IL-18 levels between sham-operated and adrenalectomized mice following stress to investigate whether the adrenal gland contributes to the elevation of circulating IL-18 during stress. Two hours of stress provoked a robust, stressor-dependent, elevation of IL-18 mRNA and peptide in the adrenal gland in sham-operated mice. Consistently, levels of circulating mature IL-18 increased during stress and remained elevated for up to 6 h after stress. The stress-induced increase in circulating IL-18 was abolished by adrenalectomy. These findings demonstrate that the adrenal gland is required to achieve elevation of circulating IL-18 during stress.

Depression, stress, and coronary heart disease: the need for more complex models

Depression has been related both to the development of coronary heart disease and to prognosis in patients following acute myocardial infarction, but the clinical significance of these associations remains uncertain.