Depression and poor outcome after an acute coronary event: Clarification of risk periods and mechanisms

Voluntary wheel running as a promising strategy to promote autonomic resilience to social stress in females: Vagal tone lies at the heart of the matter

Social stress is a major risk factor for comorbid conditions including cardiovascular disease and depression. While women exhibit 2-3× the risk for these stress-related disorders compared to men, the mechanisms underlying heightened stress susceptibility among females remain largely unknown. Due to a lack in understanding of the pathophysiology underlying stress-induced comorbidities among women, there has been a significant challenge in developing effective therapeutics. Recently, a causal role for inflammation has been established in the onset and progression of comorbid cardiovascular disease/depression, with women exhibiting increased sensitivity to stress-induced immune signaling. Importantly, reduced vagal tone is also implicated in stress susceptibility, through a reduction in the vagus nerve's well-recognized anti-inflammatory properties. Thus, examining therapeutic strategies that stabilize vagal tone during stress may shed light on novel targets for promoting stress resilience among women. Recently, accumulating evidence has demonstrated that physical activity exerts cardio- and neuro-protective effects by enhancing vagal tone. Based on this evidence, this mini review provides an overview of comorbid cardiovascular and behavioral dysfunction in females, the role of inflammation in these disorders, how stress may impart its negative effects on the vagus nerve, and how exercise may act as a preventative. Further, we highlight a critical gap in the literature with regard to the study of females in this field. This review also presents novel data that are the first to demonstrate a protective role for voluntary wheel running over vagal tone and biomarkers of cardiac dysfunction in the face of social stress exposure in female rats.

Estimating the prevalence of depression in people with acute coronary syndromes: A systematic review and meta-analysis

BACKGROUND

The epidemic of acute coronary syndromes (ACS) poses a great challenge to depression. However, the prevalence of depression among ACS patients has not been fully determined. This meta-analysis aimed to provide an estimation of the global prevalence of depression among ACS patients (ACS depression).

METHODS

Online databases including PubMed, Cochrane Library, Web of Science, and Scopus were searched for all relevant studies that reported the prevalence of ACS depression through March 2023. Pooled prevalence of ACS depression with 95% confidence interval (CI) was estimated by the random-effect model. All statistical analyses were performed using comprehensive meta-analysis software. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier CRD42023409338).

RESULTS

A total of 28 studies (17 cohort studies, 9 cross-sectional studies, and 2 case-control studies) were included. The overall pooled prevalence of depression in ACS, derived from 28 studies, was 28.5% (95% CI: 0.28-0.29, P = .000, I2 = 99%). 21 included studies showed a prevalence of 20.3% (95% CI: 0.20-0.21, P = .000, I2 = 96%) in men, and the prevalence in women was 13.6% (95% CI: 0.13-0.14, P = .000, I2 = 95%). Subgroup analysis showed the lowest prevalence in Europe (20.7%, 95% CI: 0.20-0.22, P = .000, I2 = 98%); On different diagnostic criteria, the diagnostic and statistical manual of mental disorders (DSM-IV) (36.8%, 95% CI: 0.35-0.38, P = .000, I2 = 96%) has the highest prevalence. In terms of end year of data collection, the prevalence of ACS depression was lower for studies that ended data collection after 2012 (25.7%, 95% CI: 0.25-0.27, P = .000, I2 = 99%) than in studies before 2012 (30%, 95% CI: 0.29-0.31, P = .000, I2 = 98%).

CONCLUSION SUBSECTIONS

This systematic review and meta-analysis suggest high global prevalence of depression among ACS patients, underlining the necessity of more preventive interventions among ACS patients especially in Asian and North American regions.

Psychopathology, Personality and Depression after Acute Coronary Syndrome: A Network Analysis in an Italian Population

Several biopsychosocial factors are associated with the onset of a Major Depressive Episode (MDE) after cardiovascular events. However, little is known of the interaction between trait- and state-like symptoms and characteristics and their role in predisposing cardiac patients to MDEs. Three hundred and four subjects were selected among patients admitted for the first time at a Coronary Intensive Care Unit. Assessment comprised personality features, psychiatric symptoms and general psychological distress; the occurrences of MDEs and Major Adverse Cardiovascular Events (MACE) were recorded during a two-year follow-up period. Network analyses of state-like symptoms and trait-like features were compared between patients with and without MDEs and MACE during follow-up. Individuals with and without MDEs differed in sociodemographic characteristics and baseline depressive symptoms. Network comparison revealed significant differences in personality features, not state-like symptoms: the group with MDEs displayed greater Type D personality traits and alexithymia as well as stronger associations between alexithymia and negative affectivity (edge differences between negative affectivity and difficulty identifying feelings was 0.303, and difficulty describing feelings was 0.439). The vulnerability to depression in cardiac patients is associated with personality features but not with state-like symptoms. Personality evaluation at the first cardiac event may help identify individuals more vulnerable to development of an MDE, and they could be referred to specialist care in order to reduce their risk.

Sleep problems associated with long-term mortality in acute coronary syndrome: Effects of depression comorbidity and treatment

OBJECTIVES

The effects of sleep disturbance and its treatment on the prognosis of patients with acute coronary syndrome (ACS) are not well understood. This study investigated the impact of sleep disturbance on long-term all-cause mortality, according to depression comorbidity and treatment, in patients with ACS.

METHODS

A cross-sectional baseline study and a nested 24-week double-blind escitalopram-placebo controlled trial were carried out from May 2007 to March 2013; 5-12-year follow-up for all-cause mortality was conducted. A total of 1152 patients with ACS were stratified by baseline depression comorbidity and treatment allocation into four groups: no depression (N = 706), depression on escitalopram (N = 149), depression on placebo (N = 151), and depression on medical care as usual (CAU; N = 146). Sleep disturbance was evaluated by the Leeds Sleep Evaluation Questionnaire. During the 5-12-year follow-up, Kaplan-Meyer event rates for all-cause mortality were calculated; hazard ratios (HRs) using Cox regression models were estimated after adjustment for a range of covariates.

RESULTS

Worse sleep states at baseline increased long-term all-cause mortality in all patients (HRs 1.08-1.59). The associations between worse sleep states and long-term all-cause mortality were significant in patients without depression and in patients with depression who received CAU, but not in patients with depression who participated in the 24-week trial.

CONCLUSIONS

Routine evaluations of sleep disturbance in ACS and further treatment allocation may contribute to reducing long-term mortality associated with the disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier for the 24 week drug trial, NCT00419471.

Acute coronary syndrome-associated depression: Getting to the heart of the data

OBJECTIVES

We sought to identify and consider methodological issues that may have limited or confounded investigations into links between depression and acute coronary syndrome (ACS) events.

METHODS

We reviewed salient research studies to identify such issues.

RESULTS

Against previous conclusions, we found that lifetime depression is unlikely to have any primary ACS impact, while we clarify that 'incident depression' (depression commencing at variable periods around the time of the ACS event) appears to confer a greater risk than non-incident depression. As the time periods of incident depressions are likely to have quite differing causes, evaluating any consolidated risk period appears unwise. It remains unclear whether it is 'depression' that provides the risk for ACS events or a higher order factor. Variable use of depression measures and failure to evaluate depressive sub-types have further limited clarification. The response by ACS patients to antidepressant medication appears limited, and it remains to be determined whether exposure to an antidepressant might be a contributing factor. Finally, studies may have focused on an excessively refined association, and neglected to recognise that depression is associated with a wide range of vascular events, suggesting that a broader conceptual model may be required.

LIMITATIONS

The authors have considered only a limited set of studies in preparing this review, with the critique relying at times on subjective interpretation.

CONCLUSIONS

After decades of research pursuing links between depression and ACS events explanatory links remain obscure, presumably reflecting a range of methodological issues that we have discussed in this paper .

Temperament and Depression After a First Acute Coronary Syndrome

Few studies assess the role of personality styles in predicting the onset of depression among cardiac patients. This study evaluates whether temperament and character can represent a risk factor for the development of incident first-ever depressive episodes in patients at their first acute coronary syndrome (ACS). Two hundred sixty-seven (72.1%) subjects (male) completed the Temperament and Character Inventory (TCI) a few days after the cardiac event. At baseline and after 1, 2, 4, 6, 9, 12, and 24 months of follow-up, the participants completed the Primary Care Evaluation of Mental Disorder (PRIME-MD) and the Hospital Anxiety and Depression Scale to establish the presence of a depressive episode and its severity. During the follow-up, 61 (22.8%) participants developed a depressive episode. Temperamental risk factors for incident depression were scored high on novelty seeking and harm avoidance at the TCI. Given the detrimental effect of depression on cardiac prognosis, clinicians should take temperament variables into account when determining the treatment plans of their patients with ACS.

Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events

Women are at increased risk for developing depression and cardiovascular disease (CVD) across the lifespan and their comorbidity is associated with adverse outcomes that contribute significantly to rates of morbidity and mortality in women worldwide. Immune-system activity has been implicated in the etiology of both depression and CVD, but it is unclear how inflammation contributes to sex differences in this comorbidity. This narrative review provides an updated synthesis of research examining the association of inflammation with depression and CVD, and their comorbidity in women. Recent research provides evidence of pro-inflammatory states and sex differences associated with alterations in the hypothalamic-pituitary-adrenal axis, the renin-angiotensin-aldosterone system and the serotonin/kynurenine pathway, that likely contribute to the development of depression and CVD. Changes to inflammatory cytokines in relation to reproductive periods of hormonal fluctuation (i.e. the menstrual cycle, perinatal period and menopause) are highlighted and provide a greater understanding of the unique vulnerability women experience in developing both depressed mood and adverse cardiovascular events. Inflammatory biomarkers hold substantial promise when combined with a patient's reproductive and mental health history to aid in the prediction, identification and treatment of the women most at risk for CVD and depression. However, more research is needed to improve our understanding of the mechanisms underlying inflammation in relation to their comorbidity, and how these findings can be translated to improve women's health.