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Mental distress may increase risk for death in patients with stable CAD
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Patients with stable CAD who had persistent moderate to severe psychological distress had an increased risk for CV and all-cause mortality, according to a study published in Heart.
Ralph A. H. Stewart, MBChB (Otago), FRACP, FCSANZ, MD , honorary professor of medicine at the University of Auckland in New Zealand, and colleagues analyzed data from 950 patients from the LIPID trial. Patients were aged 31 to 74 years with a history of acute MI or hospitalization for unstable angina pectoris 3 to 36 months before randomization to pravastatin or placebo. Follow-up persisted for a median of 12.1 years (interquartile range, 8.6-12.5).
Mental distress assessment
Patients completed a 30-question General Health Questionnaire at baseline, which assessed mental distress including anxiety and depression. Each patient completed at least four questionnaires periodically up to 4 years. Severity of distress was measured on a Likert scale. Levels of distress were defined as never distressed, sometimes distressed (score > 5), persistent mild distress (score > 5 on three or more occasions) and persistent moderate distress (score > 10 on three or more occasions).
The outcomes of interest were CV death and all-cause mortality between 48 months and the end of follow-up.
Sixty-two percent of patients (n = 587) did not report distress at any follow-up visit, 27% (n = 255) had mild or greater distress on one or two visits, 7.7% (n = 73) reported mild distress on at least three visits and 3.7% (n = 35) had moderate distress on at least three visits.
Effects of distress of mortality
At follow-up, 199 CV deaths and 398 deaths occurred.
Patients with moderate distress had a higher risk for all-cause mortality (adjusted HR = 2.85; 95% CI, 1.74-4.66) and CV death (adjusted HR = 3.94; 95% CI, 2.05-7.56) vs. those with no distress. Those who reported distress on one or two visits or mild distress on three or more visits did not have an increased risk for all-cause or CV mortality.
The association was similar after adjustment for other mortality predictors.
“The study findings are relevant to possible interventions for managing anxiety and depression in patients with stable CHD,” Stewart and colleagues wrote. “Screening and treating anxiety and depression early after [MI] is currently recommended, but randomized clinical trials of interventions to reduce depression and anxiety have reported no reduction in major CV events or had low-statistical power. An alternative strategy would be to focus efforts on identifying patients who have persistent distress for multimodal or stepped-care interventions. Because repeated interactions are likely to be needed, these may be more effectively undertaken by the patient’s primary care or usual health care providers.”
“[A] hypothesis posits that persistent or recurrent psychological distress leads to permanent alterations in the stress-regulatory systems perpetuating increased cardiometabolic risk even in the absence of stressor itself,” Gjin Ndrepepa, MD, of the department of adult cardiology at Deutsches Herzzentrum München, Technical University, Munich, wrote in a related editorial. “Repeat episodes of depression have a more robust impact on C-reactive protein than isolated ones. In the same vein, persistent psychological distress during the life course was associated with a worse cardiometabolic profile compared with distress occurring in childhood or adulthood alone.” – by Darlene Dobkowski
Disclosures: The LIPID trial was funded by Bristol-Myers Squibb. The researchers and Ndrepepa report no relevant financial disclosures.
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