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Matters of the heart and mind
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The importance of treating mental health conditions such as depression and anxiety has become increasingly recognized throughout the medical community. The use of medications such as selective serotonin reuptake inhibitors has increased tremendously in the past few decades, and the relevance of such mental conditions on other chronic disease states such as CVDs has become more widely appreciated.
This appears to be particularly true in women, who tend to have a higher proportion of mental health conditions compared with men. Women tend to also appear more susceptible to acute stressors, as evidenced by the condition referred to as takotsubo cardiomyopathy, or “broken heart syndrome,” in which an acute mental or physical stress situation leads to the sudden onset of left ventricular dysfunction. This condition is believed to be due to an excess of catecholamines, which is found predominantly in women.
The importance of mental health has been assessed in women in studies such as the Women’s Health Initiative (WHI) and the Nurses’ Health Study, which have demonstrated an increased risk for ischemic heart disease and associated mortality in women with depression, particularly in women younger than 55 years compared with men of similar age. In the WISE study, even in women without obstructive coronary disease — but with signs and symptoms of ischemia — symptoms of depression in interaction with anxiety were predictive of CV events.
Common mechanistic pathways
Although it was once thought that such mental health conditions mediated an increase in CV risk through an associated increase in traditional risk factors such as tobacco abuse and poor diet, it has become increasingly apparent that there are common mechanistic pathways leading to neurologic and CV dysfunction.
Physical stress, such as strenuous exercise, is a known trigger for ischemia. However, studies have demonstrated the powerful effects of mental stress alone on the CV system. This condition, known as mental stress-induced myocardial ischemia, has been well documented, with ischemia noted by a variety of imaging modalities, and appears more predominant in women. Mental stress-induced myocardial ischemia has been associated with increased risk for mortality in patients with known CAD.
There is also overlap in the effects of psychotropic therapies used to treat mental health conditions. For example, neurohormonal transmitters, such as serotonin, are targeted for the treatment of depression. However, data suggest that serotonin also plays an important role in the regulation of endothelial function and platelet activity. These effects of serotonin on vascular function may be influenced by the presence of other hormones such as estrogen. Additionally, women are known to have an increased risk for coronary microvascular dysfunction. It may be possible that such neurotransmitters have a differential effect on the coronary microvasculature leading to angina and adverse CV events. Thus, mechanisms leading to mental health dysfunction and increased CV risk appear to overlap and exert a differential effect by sex.
Recent research
As the association between mental health conditions/psychosocial effects and CVD becomes more apparent, contemporary research has served to provide insight into some possible pathophysiologic mechanisms for these conditions. Two recently published studies highlight this interplay between neurologic and CV conditions.
In a recent study published in Circulation: Cardiovascular Quality and Outcomes, Paine and colleagues assessed symptoms of mood and anxiety with the presence of ischemia by single-photon emission CT among more than 2,000 participants. According to their findings, in patients without prior history of CVD, women with anxiety were more likely to have ischemia compared with women without anxiety. In contrast, Paine and colleagues reported that the same relationship did not hold true in men.
In patients with a history of CVD, another recent study by Vaccarino and colleagues, published in the Journal of the American Heart Association, demonstrated a nearly fourfold higher incidence of mental stress-induced myocardial ischemia assessed by myocardial perfusion imaging among women younger than 50 years compared with men of any age. Although there has a been a suggestion of particularly susceptibility to mental stress-induced myocardial ischemia in younger women, this study by Vaccarino and colleagues is the first to specifically assess this condition in a large group of young women. Although the mechanisms are not well understood, there is thought that mental stress-induced myocardial ischemia may be a particular manifestation of coronary microvascular dysfunction — which, as mentioned above, tends to be more prevalent in women.
Call for increased recognition
It has been increasingly recognized that women have nontraditional risk factors that increase their risk for long-term adverse CV events. Among these nontraditional risk factors, mental health conditions such as anxiety and depression are common but often not recognized for their association with CV risk. These notable recent studies described above demonstrate that the importance of recognizing mental health conditions in patients with and without CVD is particularly important in women as the associated long-term risks appear to vary by sex.
The American Heart Association and American Psychiatric Association both endorse routine screening for depression during CV prevention visits. Providers should be proactive in screening women for mental health conditions and providing appropriate referral/treatment where indicated.
- References:
- Paine NJ, et al. Circ Cardiovasc Qual Outcomes. 2016;doi:10.1161/CIRCOUTCOMES.115.002491.
- Rutledge TR, et al. Psychosom Med. 2009;doi:10.1097/PSY.0b013e3181bd6062.
- Vaccarino V, et al. J Am Heart Assoc. 2016;doi:10.1161/JAHA.116.003630.
- For more information:
- Ki Park, MD, MS, FSCAI, is an assistant professor in interventional cardiology at University of Florida and Malcom Randall VA Medical Center, Gainesville. She can be reached at ki.park@medicine.ufl.edu.
Disclosure: Park reports no relevant financial disclosures.