Depression and Anxiety in Cardiac Disease
Depression and Anxiety in Cardiac Disease
Depression and anxiety disorders are common and persistent—and they have a lasting impact on quality of life, functioning, and cardiac health. In this article, we review the associations between negative psychological states and cardiovascular health, the physiologic and health behavior mechanisms that may mediate these relationships, ways to diagnose depression and anxiety disorders, and safe and effective treatments for these disorders.
Among patients with heart disease, such as coronary artery disease or heart failure, depression and anxiety disorders are extremely common. In these populations, 20% to 40% have elevated depressive symptoms, and 15% to 20% suffer from MDD.1-3 Anxiety may be even more common than depression. A recent meta-analysis suggests that over 50% of patients with heart failure have elevated rates of anxiety, and 13% meet criteria for an anxiety disorder.4 These prevalence rates are significantly higher than those in the general population and highlight the high-risk status of cardiac patients for these disorders.
In contrast to being a transient response to cardiac symptoms or a cardiac event, depression and anxiety may persist in many cases. After a myocardial infarction, depression tends to persist over the next year.5 Similarly, among individuals who have significantly elevated anxiety following an episode of acute coronary syndrome, only 50% have a resolution of their anxiety in the year after the event, which suggests that for many patients anxiety can remain a chronic problem.6
Associations between psychiatric illness and cardiac health
Depression, anxiety, and anxiety disorders may play a significant role in heart health and have been implicated in the development and progression of both coronary artery disease and heart failure. Of these, depression has been studied most extensively. In patients without heart disease, depression is prospectively associated with the development of atherosclerosis and heart failure.7,8 Similarly, in patients with established heart disease, depression is associated with poor outcomes. Depression confers a 2-fold increased risk of mortality and adverse cardiac events after myocardial infarction or heart failure and has been linked to poor outcomes after cardiac surgery.2,9,10 The evidence for depression’s links to cardiac health is so strong that the American Heart Association (AHA) labeled depression a risk factor for poor medical outcomes following acute coronary syndrome.11
Anxiety also appears to be associated with cardiac health, although less strongly than depression. In patients with coronary artery disease, anxiety is associated with an increased risk of adverse cardiac events; however, when adjusted for potential confounding variables, this relationship is significantly weakened, which suggests that other factors may be driving this relationship.12 In patients with heart failure, anxiety has been associated with poor outcomes in some analyses but not others, and this relationship typically disappears when controlling for covariates.13
The links between anxiety disorders and cardiac health are significantly stronger. Anxiety disorders, such as generalized anxiety disorder (GAD), panic disorder, and PTSD, have been associated with an increased risk of coronary artery disease or heart failure.8,14 Among patients with established cardiovascular disease, anxiety disorders also are associated with poor cardiac outcomes. For example, following myocardial infarction, GAD has been prospectively linked to increased rates of subsequent mortality.15
Mediators of the relationship between depression/anxiety and cardiac health
The links between depression, anxiety, and cardiovascular disease are complex and involve psychological, biological, and behavioral mechanisms.3 Depression, arrhythmias, and coronary artery disease frequently co-occur because they share common behavioral and pathophysiological drivers—unhealthy lifestyle, autonomic dysregulation, hypothalamic-pituitary-adrenal (HPA) axis dysregulation, endothelial dysfunction, and inflammation—that are intricately related to one another.3,16