Depression and anxiety in the practice of cardiology

Copyright © Polskie Towarzystwo Kardiologiczne INTRODUCTION Depression raises significant public health concerns. According to the National Comorbidity Survey Replication Study, the lifetime prevalence of major depressive disorder (MDD) in the U.S. population is 16.6% [1]. While not included in the MDD’s diagnostic criteria, anxiety is among the three most frequent signs (along with the symptoms of personality disorders and substance abuse) presented by depressive patients [2]. Although easy to overlook in general medical settings, depression and anxiety impose a significant burden on patients with various somatic diseases, and cardiac patients are no exception to the rule. Epidemiological data suggests that MDD affects approximately 17–20% of those with coronary heart disease (CHD), 16–28% of myocardial infarction (MI) survivors [3] (with even higher ratios of subclinical depressive syndromes [4]), and 30% of patients with heart failure (HF) [5]. The negative impact of MDD on the risk of developing CHD and on the disease’s subsequent course has become widely acknowledged. It has also been confirmed that depression is a major contributor to increased mortality, morbidity, rehospitalisation rates, reduced health status and functional impairment in patients with congestive heart failure (CHF) [6]. Notably, MDD has been found to be independent risk factor for early-onset cardiovascular diseases (CVD) and CHD-related mortality in a sample of patients below 40 years of age [7]. The following four pathophysiological mechanisms have been posited to account for the link between CVD and MDD: alterations in platelet activity, increased activity of inflammatory cytokines, decreased heart rate variability (HRV), and hyperactivity of the hypothalamic-pituitary-adrenal axis (implying activation of the sympathetic nervous system) [8]. It should not be forgotten that the CVD-MDD relationship is a mutual one. While discussing the common ground between depression and HF, Nair et al. [9] noticed that depressed patients are less active, often cling to an inadequate diet, have worse compliance with medication, and are more prone to abusing tobacco and alcohol. Thus, such behavioural disturbances may exert deleterious effects on both the course of HF and the patient’s self-image, possibly leading to the exacerbation of depression. Also, as heavy smoking has been found to be an independent risk factor for MDD [10], it is worth mentioning that nicotine dependence seems to be a pathogenetic common ground for both depression and CVD. Given these facts, the aim of this review was to highlight the importance of the accurate diagnosis and treatment of anxiety and depression in patients attending cardiologic facilities.