Impaired endothelial function may underlie increased risk of cardiovascular events for patients with coronary heart disease and depression

Impaired endothelial function may explain why individuals with coronary heart disease and elevated symptoms of depression have an increased risk of cardiovascular events, according to an article in the August 16 issue of the Journal of the American College of Cardiology.

“Our study reiterates the association of depression with poor vascular health. The findings suggest that clinicians should evaluate patients with coronary disease for depressive symptoms ? and give tentative support for referring those patients for therapy,” said Alan Hinderliter, MD, a coauthor of the study.

The researchers, including lead author Andrew Sherwood, PhD, studied 143 patients with documented coronary heart disease to assess endothelial function and symptoms of depression. In the patients (mean age, 63 years), endothelial function was assessed through flow-mediated dilation. The depression assessment was conducted by obtaining and scoring patients’ responses to the 21-item Beck Depression Inventory (BDI).

Participants, two thirds of whom were male, all indicated that they were sedentary at the time of enrollment, and all had briefly discontinued anti-ischemic medications prior to flow-mediated dilation assessment.

Although depression is relatively common in patients with cardiovascular disease and coronary heart disease and is associated with adverse outcomes, how depressive symptoms contribute to elevated risk is unknown. The study found impaired endothelial function in patients with high Depression scores compared with those with relatively lower Depression Inventory scores. “Our results suggest that the increased incidence of cardiovascular events in depressed patients is mediated, in part, by endothelial function,” Hinderliter said.

Other studies have found a link between depression and impaired endothelial function in otherwise healthy individuals, but this study is the first to document the association in a population with coronary heart disease, the authors noted.

The researchers found that flow-mediated dilation was significantly impaired in the 47 participants (33%) whose Depression Inventory scores were greater than 10 (considered an indication of clinically significant depressive symptoms), compared with those who were not deemed depressed (0.75% vs. 7.46, p = 0.001). The mean Inventory score was 16 in the depressed group and 4 in the non-depressed patients.

Interestingly, flow-mediated dilation was improved in patients who were taking antidepressant medication, which may suggest that such medications lower cardiovascular risk by favorably altering vascular endothelial function. To date, however, there is no evidence that successful treatment of depression actually reduces cardiovascular risk associated with depression, Hinderliter noted.

In a commentary, Robert Carney, PhD, professor of psychiatry at Washington University School of Medicine in St. Louis, who was not connected with the study, said that despite the lack of highly definitive findings, the study has important implications.

“The study adds another piece to the puzzle of how depression may increase the risk for cardiac events, including death. The results of this and similar studies suggest that this risk may be reduced if depression is recognized and treated,” Carney said. “Thus, treating clinicians need to do a better job of recognizing depression in patients [with coronary heart disease], and either offer treatment or refer to a specialist.”

The researchers acknowledged the study’s limitations, primarily that it was an observational study involving a relatively small sample, and that the Beck Depression Inventory scoring is not a clinical measure of, nor a basis for, diagnosis of clinical depression.

“Our study demonstrated a relationship between depressive symptoms and endothelial dysfunction in patients with coronary heart disease. It does not, however, establish a ‘cause-and-effect’ relationship between depression and endothelial dysfunction,” Hinderliter said.

“The study was well conducted, but it will be important to replicate it and to further investigate the finding in a larger sample of patients,” Carney said.







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