Persistent comorbid symptoms of depression and anxiety predict mortality in heart disease

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Abstract

Background

Incident anxiety and depression are associated separately with cardiac events and mortality in patients after acute coronary syndromes, but the influence of persistent comorbid depression and anxiety on mortality remains unknown. The purpose of this study was to determine the prevalence of comorbid persistent depressive and anxious symptoms in individuals with ischemic heart disease and to evaluate effects on mortality.

Methods

Prospective, longitudinal cohort design in the context of a randomized trial to decrease patient delay in seeking treatment for ischemic heart symptoms (PROMOTION trial) was used, with twelve-month follow-up of 2325 individuals with stable ischemic heart disease. Participants were assessed on enrollment and at 3 months using the Multiple Adjective Affect Checklist and the Brief Symptom Inventory for depressive and anxious symptoms, respectively.

Results

At 3 months, 608 individuals (61.7%) reported persistent symptoms of depression, anxiety, or both. Three hundred seventy-nine (42.5%) and 1056 (45.4%) had persistent anxious and depressive symptoms, respectively. Those with persistent, comorbid symptoms had higher mortality compared to others (p = .029). The combined presence of anxious and depressive symptoms contributed significantly to mortality when compared to symptom-free participants (OR 2.35, 95% CI 1.23–4.47, p = .010). The presence of persistent depressive symptoms only and persistent anxious symptoms only were not associated with death, when other demographic and clinical variables were considered.

Conclusions

Persistent symptoms of anxiety and depression increased substantially the risk of death in patients with ischemic heart disease. Future research into shared and unique pathways and treatments is needed.

Introduction

Depression and anxiety are common in patients with chronic ischemic heart disease (IHD). For depression and anxiety, prevalence rates of 32% and 26%, respectively, have been reported in post-myocardial infarction patients and in stable populations of IHD patients [1], [2], [3], [4], [5]. These emotional states are known to persist after a cardiac event, and rates of both have been reported to increase during the first year after a myocardial infarction (MI) [3]. In IHD patients, depression has been associated independently with increased mortality and morbidity, including increased cardiac and all-cause mortality and increased non-fatal cardiac events [6], [7], [8], [9], [10]. While anxiety is also associated with increased morbidity in IHD, its association with mortality is less certain [11], [12].

Despite the known deleterious effects of both incident depression and anxiety on cardiac outcomes, the impact of persistent mood disorders has received relatively little attention. Persistent depression has been associated with poor adherence to treatment regimens after MI, but few studies have looked at the effect of persistent depression on cardiac events or mortality. A recent report regarding persistent depression in men with Type 2 diabetes found that persistent depression was associated with lower mortality risk. Evidence regarding the effect of persistent anxiety on cardiac prognosis is also scarce [12]. Both persistent anxiety and depression have been shown to have negative effects on subsequent health-related quality of life [13].

Anxiety and depression are highly comorbid, both in psychiatric populations and in individuals with chronic medical conditions, including heart disease [14], [15], [16]. Although the effect of depression on future cardiac events has been well established, previous reports have not considered the mediating or confounding effect of co-existing anxiety on mortality and morbidity. Anxiety and depression may act synergistically to increase the risk of death or other cardiac events. To date, this possibility has not been systematically investigated. Only a single study has reported that anxiety is more closely related to cardiac events than depression, when both are present in patients with IHD [17]. No investigators have reported the influence of comorbid persistent anxiety and persistent depression on subsequent cardiac events. The purpose of the current study was to determine the prevalence of comorbid persistent depression and anxiety in community dwelling individuals with documented IHD and to evaluate the effect of comorbid persistent depression and anxiety on mortality.

Section snippets

Design

As part of a large multicenter clinical trial to reduce prehospital delay in IHD patients experiencing symptoms of acute coronary syndrome (the PROMOTION trial), 3523 patients from seven sites in three countries (United States, Australia, New Zealand) were randomized to receive either usual care or a brief teaching intervention delivered by expert nurses and aimed at increasing knowledge of acute coronary event symptoms, along with when and how to seek treatment [18]. This report constitutes an

Results

Patients were primarily male (n = 1717, 73.8%) and elderly (67.2 ± 10.7 years). Persistent symptoms of both anxiety and depression were common in the sample. Overall, 1435 individuals (61.7%) reported persistent symptoms of anxiety, depression or both (Fig. 1). Considering symptoms of each dysphoria individually, 987 (42.5%) participants had persistent symptoms of anxiety, while 1056 (45.4%) had persistent depressive symptoms. Demographic and clinical characteristics of patients with and without

Discussion

Our findings emphasize the ubiquitousness of symptoms of anxiety and depression in community-dwelling adults with IHD. The majority of individuals in our study (61.2%) suffered from significant symptoms of depression, anxiety or both. This is consistent with the reports of other investigators, who confirm that persons with IHD are more likely to experience both anxiety and depression than those without IHD [22], [23], [24]. In fact, among individuals with IHD, the odds of developing anxiety and

Acknowledgements

Funded by National Institutes of Health, National Institute of Nursing Research (R01 NR05323). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [50].

Lynn V. Doering takes responsibility for the integrity of

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