The Troubled Heart: How Depression and Anxiety Impact Heart Disease

By Beth Israel Deaconess Medical Center

Everyone feels sad or anxious occasionally. But for some, depression and/or anxiety can be more extreme, affecting both psychological and physical health. Each year in the U.S., 6.7 percent of adults experience major depression and 18 percent of adults have an anxiety disorder, according to the National Institute of Mental Health.

Unfortunately, people with heart disease are more likely to suffer from depression and anxiety — which increases the risk of future heart attacks, strokes and even death. Some researchers also feel that depression may raise the risk of heart disease in otherwise healthy individuals.

"It's a cycle of both cause and consequence," says Meghan York, MD, a clinical cardiologist at Beth Israel Deaconess Hospital-Needham and the CardioVascular Institute at Beth Israel Deaconess Medical Center. "Anxiety and depression can place you at greater risk for heart disease. And patients who have experienced heart-related events may experience depression or anxiety, which raises the risk for future issues to occur."

What are the Chances and Risks?

Growing knowledge about depression as a risk factor for cardiac disease prompted the American Heart Association to recommend that all cardiac patients be screened for depression. Studies have found that 9.3 percent of patients with heart disease experience major depression, compared with 4.8 percent for those without heart disease. The numbers are even higher for patients who have endured surgery or medical events related to heart disease.

"Stroke and heart attack survivors are more likely to be depressed than the general population," says York. "For example, after a heart attack, about 20 percent of patients are diagnosed with depression. This mix of heart disease and depression has ramifications that extend beyond the symptoms of the two disorders."

Recent research reflects the seriousness of this risk. People with heart disease who suffer from anxiety disorders have twice the risk of dying from any cause, according to a study published earlier this year. The study also found that the combination of anxiety and depression is even more lethal for heart disease patients, causing a three times greater risk of mortality.

While increased risk for heart disease patients with depression has been well established for years, research also points to an elevated risk for future heart disease among those who suffer from depression.

One study found that men with major depression are twice as likely to develop heart disease. Conducted by Washington University School of Medicine and the Veterans Administration, the study involved more than 1,200 male twins who served in the military and found that, even among twins with similar genetic profiles, only the men with a history of depression had a higher cardiovascular risk.

What is the Connection to Heart Risk?

"Anxiety and depression each influence cardiovascular risk in different ways," says York. "Continued anxiety increases nervous system activity, which can result in higher blood pressure and inflammation. In fact, some studies show that an emotional upset can even trigger a heart attack, raising risk by 10 percent.

"The assumption is that anxiety-prone patients have higher levels of adrenal-based hormones, like cortisol," she adds. "Cortisol activated by chronic stress or anxiety can cause elevated blood pressure, lower immunity, and inflammation."

Physicians know that the impact of depression on health often involves lifestyle choices associated with the ailment, including lack of exercise, poor diet, or excessive alcohol.

"Depression may also result in people becoming less compliant with medication and regular doctor visits," says York.

But there's also evidence that depression may cause physical changes in the body that can damage the cardiovascular system. Research presented to the American Heart Association in 2011 found that depression may cause a higher risk of narrowed arteries in the legs and pelvis, a condition called peripheral artery disease (PAD).

Symptoms for Concern

How do you know that your depression or anxiety needs treatment?
For depression, symptoms may vary in severity, frequency, and duration, but a major depressive disorder prevents normal functioning and interferes with a person's day-to-day life. Symptoms may include continual sadness; feeling hopeless, helpless or worthless; fatigue; loss of interest in activities; insomnia; an inability to concentrate; or thoughts of suicide.

People with an anxiety disorder may have persistent fears or worries and difficulty relaxing or concentrating. Physical symptoms can include headaches, muscle or tension aches, fatigue, irritability, trembling, sweating, or feeling out of breath. In some cases, an anxiety attack may be so severe that the person visits the emergency room, thinking that they are having a heart attack.

Treating the Conditions

"Patients should be open about discussing feelings and fears with their physicians," says York. "Many people, particularly women, tend to shrug off symptoms of anxiety, for example. It's important to pay attention to events that bring you a surge of anxiety. And if you have pain or discomfort, you should tell your primary care physician right away."

Treating anxiety and depression can involve counseling or medication, and sometimes a combination of the two. But lifestyle can also play a major role in easing or preventing the two disorders.

"Patients can also learn relaxation techniques, such as breathing exercises or meditation," says York. "And eating healthy foods, keeping fit, quitting smoking if needed, and drinking little or no alcohol can make a difference for both mental stability and heart health."

For heart disease and heart attack patients, cardiologists conduct screenings for depression and are alert for symptoms. Studies have not shown that treating depression can alter long-term outcomes for heart disease patients, but it most certainly affects long-term quality of life.

"If you've had a heart attack or a diagnosis of heart-disease," says York, "it's important to know that depression or anxiety is very common for those with these conditions. Reaching out to your physician is the first step to getting your feelings back under control and improving your ability to relax and enjoy life again."

Above content provided by the CardioVascular Institute at Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.

Posted January 2014