I
n this cover story, CardioSource
WorldNews addresses each of these
elephants in the waiting room –
depression, diabetes, and obesity—
looking at what’s new and why they
should not be ignored.
Surprise: Your Patient Is
Depressed
Depression is an independent risk
factor for cardiovascular disease (CVD)
but, importantly, it also complicates
treatment and prognosis. We have
new data (and some old data that bear
repeating) to encourage more engagement with an issue many clinicians are
reluctant or feel unprepared to address.
The prospective cohort Heart and
Soul Study originally showed in 1,024
patients with stable coronary heart
disease (CHD) that depressive symptoms were associated with a higher
rate of CV events. One problem: the
association was largely explained by
poor health behaviors.1 However, only
now have the Heart and Soul investigators parsed the association between
depression and lifestyle behaviors.2 In
an analysis just published online ahead
of print, Nancy L. Sin, PhD, at the
Center for Healthy Aging, The Pennsylvania State University, University Park,
PA, and colleagues indicated that the
directionality of the data was stronger
for depressive symptoms as a predictor
of subsequent health behavior change.
She and her colleagues wrote,
“Given the importance of psychosocial
factors for determining CVD risk and
mortality, these findings suggest that
depressive symptoms may serve as critical targets in efforts to improve health
behaviors among patients with CHD.”
The benefits of screening all adults
for depression were emphasized in
a new U.S. Preventive Services Task
Force (USPSTF) recommendation
statement supporting screening
(in primary care) of all adults 18
years or older.3 One caveat: “Screening (should) be implemented with
adequate systems in place,” meaning
either having the systems and clinical
staff in place to conduct the screening
and then treat or a system of referral
for treatment as needed. While this
critical step should be handled at the
primary care level, it remains overlooked more often than not, probably
for the lack of those “systems.”
ACC.org/CSWN
There is a rationale for ignoring
this particular elephant in your office:
it’s really not your job. Yet studies
abound in the cardiovascular literature
linking psychological symptoms such
as anxiety and depression to cardiovascular risk. About 20% of patients
hospitalized for acute coronary syndrome (ACS) meet diagnostic criteria
for major depression, with even more
showing subclinical levels of depression. Numerous reports show a robust
association between depression and
increased CV morbidity and mortality. Moreover, adherence to therapy is
hard enough under ideal circumstances; throw in depression and you can
expect far from ideal results.
Granted, the heterogeneous nature
of the studies has made it difficult
to formally elevate depression to the
status of a risk factor for adverse
medical outcomes in ACS patients.
Nevertheless, a recent scientific
statement from the American Heart
Association4 concluded that “the
preponderance of evidence supports
the conclusion that depression after
ACS is a risk factor for all-cause and
cardiac mortality, as well as for composite outcomes including mortality
or nonfatal cardiac events. As such,
depression should be elevated to the
level of a risk factor for poor prognosis after ACS by the AHA and other
health organizations.”
The Dance of Depression and
Inflammation
It may not be news that inflammation
is linked to diabetes and obesity, but
did you know it’s also connected to
depression? So does that mean we
can lower cardiovascular risk by treating depression? Since it is unknown
which came first, there are major
efforts underway targeting inflammation in the CIRT and CANTOS
trials (see the sidebar “Inflammation:
The Uniting Force”) It’s encouraging
because there is some good evidence
that treating inflammation may
indee