The following resources may
• Depression is a risk factor for future coronary heart disease, and is also
common in patients with clinical coronary disease and congestive
• Depressive symptoms following acute coronary events are associated with
increased cardiovascular morbidity, impairment in quality of life, and greater
versions of our Factfiles fromour website
• Depressed mood can be assessed using short questionnaires in patients who
have been discharged from hospital following acute cardiac events or cardiac Our research
surgery, and in individuals suffering from heart failure. Positive scores should
be followed up with further evaluation.
• Discuss issues of adherence to medication and lifestyle advice with patients
who are identified as depressed. If patients have been prescribed drugs for secondary prevention, ensure that these are being taken reliably.
• Consider treatment with selective serotonin uptake inhibitors in patients
Depression is a common problem in patients following acute cardiac events
such as myocardial infarction. Up to 20% of individuals have a major depressive
episode within a few weeks, and a further 25% experience minor depression
or elevated levels of depressive symptoms.
Depressive symptoms are present in around one quarter of patients withcongestive heart failure as well. It used to be thought that depressed mood was a normal part of coming to terms with the cardiac event and had no lastingimpact on health, but this is not the case.
Depression and cardiovascular health
Research over the last 15 years has demonstrated that patients who are
depressed in the weeks following an acute coronary syndrome have a poorer
cardiac outcome.1 Most studies have found at least a twofold increase in
death and recurrent cardiac events over the first 12 months after discharge
from hospital. Depression is also linked with greater use of health services,
poor quality of life and less successful rehabilitation.
Outcome is worst for the seriously depressed, but even patients with moderatelydepressed mood tend to have less good cardiovascular health over the next fiveyears. The same pattern is present in patients with congestive heart failure, withan increased risk of early mortality in depressed individuals.2 Depressed patientsalso show smaller gains in physical functioning following coronary arterybypass surgery.
Why is depression bad for cardiovascular health?
We do not completely understand the mechanisms through which
H. Depression as an aetiologic and prognostic factor in coronary heart
depression affects cardiovascular health. However, it is linked with several
biological processes that influence vascular pathology, including dysfunction
events among 146 538 participants in 54 observational studies. Eur Heart
of the vascular endothelium and activation of platelets.
2. Rutledge T, Reis VA, Linke SE, Greenberg
Depressed individuals have reduced heart rate variability that is indicative
BH, Mills PJ. Depression in heart failure
of disturbances in cardiac autonomic control, and alterations in the secretion
a meta-analytic review of prevalence, intervention effects, and associations
of the stress hormone cortisol.3 Additionally, depressed people are less likely
than other patients to adhere to treatment advice and take medication
reliably, and tend to be more sedentary. Thus biological and behavioural
factors may both contribute to the link between depression and poor
et al. Psychophysiological biomarkers explaining the association between
depression and prognosis in coronary artery patients: A critical review of the literature. Neurosci Biobehav Rev
Depression is known to be a risk factor for coronary disease, an association
4. Lichtman JH, Bigger JT, Jr., Blumenthal
that is independent of standard risk factors such as smoking, hypertension
JA, et al. Depression and coronary heartdisease: recommendations for
and high cholesterol levels.1 This means that some patients suffering with
acute coronary disease will have experienced depression before their
a science advisory from the American Heart Association Prevention
cardiac event, while in others the depressed mood will be a new experience.
Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on
There is some evidence that new onset depression is more cardiotoxic,
but findings have not been completely consistent. Depressive problems
Interdisciplinary Council on Qualityof Care and Outcomes Research:
can be reliably assessed by clinical interviews and simple questionnaires
such as the Hospital Anxiety and Depression scale or the Patient Health
Questionnaire administered following discharge from hospital.4 High scoreson these measures will identify the majority of individuals who are
5. Thombs BD, de Jonge P, Coyne JC, et al.
depressed. However, care is needed in the interpretation of somatic
symptoms of depression such as fatigue, since these may also be signs
a systematic review. JAMA 2008;300:2161-71.
M, et al. Safety and efficacy of Sertraline
Management of depression
for depression in patients with heart failure results of the SADHART-CHF
The management of depression in cardiac patients is a field of intense clinical
investigation at the moment. The only randomised clinical trial published
Heart Disease in Chronic Heart Failure) Trial. J Am Coll Cardiol 2010;56:692-699.
to date that was statistically powered to assess cardiac outcomes was a comparison of cognitive-behaviour therapy with usual care. This showed
7. Pizzi C, Rutjes AW, Costa GM, Fontana F,
modest effects on depression, but no differences in event free survival.5
Cardiac rehabilitation programmes that incorporate stress management
in patients with depression andcoronary heart disease. Am J Cardiol
methods such as The Heart Manual developed by the BHF Care and
Education Research Group lead to decreases in depressive symptomlevels, though whether they reduce future cardiac morbidity is not known.
Factfile is an information resource producedby the British Heart Foundation for GPs based
Selective serotonin uptake inhibitors (SSRIs) have proved quite effective
on up to date clinical evidence and expert
in the treatment of the depressive symptoms of patients with coronary heart
opinion. As a digest of many data sources, it is necessarily the culmination of assessments
disease, but have less effect on patients with heart failure.5,6 But there is
made by the BHF’s medical professionals andshould not be taken as a definitive statement
no robust evidence to date that treatment with SSRIs is beneficial in terms
of correct clinical practice in any given situation. Consequently, the BHF is notable
of cardiac morbidity and mortality.7 Other medications, in particular tricyclic
to give any warranties in relation to particular
anti-depressants, may have cardiac side effects and should be avoided.
clinical decisions taken or courses of treatment or action pursued based upon the information contained in the Factfiles.
British Heart Foundation
Greater London House
180 Hampstead Road
London NW1 7AW
Telephone 020 7554 0000
British Heart Foundation 2011,registered charity in England and Wales(225971) and in Scotland (SC039426).
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