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Abstract & commentary
Source: Ariyo A, et al. Depressive symptoms and risks of coronary heart disease and mortality in elderly americans. Circulation 2000;102:1773-1779.
Depression occurs in 19-30% of all elderly patients and only 1% of those so effected receive the necessary treatment for this serious illness.1,2 Many published studies have suggested that abnormally high depression scores may predispose an individual to an increased risk of developing coronary heart disease (CHD) especially in middle-aged populations, but data regarding the relationship between depression and CHD in the elderly have been sparse.3,4
Ariyo and colleagues in the Cardiovascular Health Study Collaborative Research Group have now published the results of a multicenter study that started in 1989 evaluating cardiovascular risk factors in 5888 Americans aged 65 and older. No evidence of CHD was present at baseline in the 4493 participants who subsequently provided annual information regarding their depressive tendencies, which were assessed by using the Depression Scale of the Center for Epidemiological Studies. These subjects were followed for six years and, in each case, the cumulative mean depression score was assessed and correlated with all cardiovascular events and/or CHD deaths. Among participants with the highest cumulative mean depression scores, the risk of CAD increased by 40% and risk of death by 60% compared with those individuals who had the lowest mean depression scores.
Comment by Harold L. Karpman, MD, FACC, FACP
Many previously published studies have demonstrated that depressive symptoms constitute a risk factor for CHD3-7 and CHD mortality.4,6-8 However, the data presented by Ariyo et al differ from previously reported studies because they focused exclusively on the elderly. There now seems to be little question that depressive symptoms constitute an independent risk factor for the development of CHD and total mortality in the elderly and, in addition, this risk appears to increase for those individuals who score higher on the Depression Scale.
The results of the reported study could have been influenced by depression produced by other events such as life-threatening illnesses, which are obviously more common in the elderly. Equally important, it should be noted that participants with prior cardiac disease were excluded at the onset so there appeared to be an independent relationship between the depressive symptoms and subsequent cardiovascular events. The prospective nature of this study, the large sample size, the duration of follow-up, and the blinded ascertainment of cardiac events all tend to make the final results even more impressive. As an aside, it should be noted that the results were similar in men and women even though women had higher depression scores at the beginning of the study.
Multiple theories have been advanced as to why depression would be associated with CHD risk. For example, it has been speculated that depressed individuals frequently exercise less, smoke more, and have a higher likelihood of indulging in anxiety-provoking behavior patterns, all of which may increase cardiovascular risk. It has also been speculated that depression produces anxiety, which may result in an increase in autonomic sympathetic activation.9,10 Many published papers have suggested that there is an inter-relationship between depression and abnormal lipid/glucose metabolism,11,12 which may encourage the earlier development of CHD. Finally, sudden deaths associated with depressive states have been attributed to an imbalance between the autonomic parasympathetic and sympathetic nervous systems resulting in increased sympathetic activity and induction of lethal ventricular arrhythmias.13
The importance of the data presented by Ariyo et al is obvious in that 31 million Americans are 65 or older and, in this group, 5 million are afflicted with depressive symptoms. Between 7-12% of men and 20-25% of women will develop a major depressive episode during their lifetime. The strong relationship between depression and CHD demonstrated in this study makes it mandatory for all primary care physicians to familiarize themselves with the relationship and to vigorously treat depression with drugs and/or psychotherapy early after the onset of depression, much before cardiovascular symptoms and/or sudden cardiac death occur. It would appear that treating this very important risk factor may be equally important as is treating an abnormal lipid panel, or as is advising patients to discontinue cigarette smoking, to bring their weight down to ideal levels, and/or to initiate a regular exercise program. In other words, treating depressive symptoms in the elderly should not be overlooked since such therapy is obviously incredibly important in preventing the onset of symptomatic CHD or even sudden cardiac death in the elderly. (Dr. Karpman is Clinical Professor of Medicine, UCLA School of Medicine, Los Angeles, Calif.)
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