For centuries, the mind–body relationship has been postulated. These findings suggest that depression and anxiety are not simply “in the mind.” They are real illnesses, like any other physical illnesses, and can negatively impact the entire body, including the cardiovascular system.
Despite the abundance of investigation and demonstration of a clear relationship between mental health and cardiovascular diseases, patients with coronary disease, myocardial infarction, heart failure, and arrhythmias are rarely assessed for psychological distress or mental illness as a contributor to or resulting from the cardiovascular disorder. Psychological distress and mental distress are terms used to describe a range of symptoms and experiences of a person's internal life that are commonly held to be troubling, confusing, or out of the ordinary. Mental distress has a wider scope than the related term, “mental illness.” Whereas mental illness refers to a specific set of medically defined conditions, a person in mental distress may exhibit some of the symptoms described in psychiatry, such as anxiety, confused emotions, hallucination, anger, and depression without actually being “ill” in a medical sense. A wide range of life situations, including bereavement, stress, loss of a job, sleep deprivation, alcohol or drug use, assault, abuse or accidents, can induce mental distress. This may resolve without further medical intervention, yet may be a trigger for cardiovascular events.
The overlap of symptoms of cardiovascular disease such as palpitations, chest tightness, and shortness of breath that occur in healthy persons, including those due to stress, makes it very difficult for physicians and their patients to assign a causal or related role to mental health. Primary care physicians and cardiologists focus on treating symptoms and risk factors, which leaves little time to address feelings and emotions. Further, because of the social stigma that has traditionally existed around mental illness, patients and families may be hesitant to discuss mental health. The purpose of this commentary is to underscore the importance of mental health and its associations with cardiovascular disease.
Depression and Cardiovascular Disease
The prevalence of depression in patients with cardiovascular disease is threefold higher than that in the general population. Depression is underdiagnosed in the medical setting.
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The American Heart Association recommends that depression be recognized as a major risk factor for coronary heart disease, similar to hyperlipidemia, diabetes, hypertension, and smoking. There is about an 80% increase in the risk of developing new or worsening cardiovascular disease (ie, more complications or hospitalizations), as well as death from cardiovascular diseases in adults with depression with or without prior cardiovascular disease.3
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Depression is also common in patients who have angina and can increase the risk of developing myocardial infarction,5
stroke, sudden death, and atrial fibrillation.4
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The relationship between depression and anxiety and cardiovascular disease is bidirectional.3
In other words, depression and anxiety can increase the risk of developing cardiovascular disease; cardiovascular disease can increase the risk of developing depression and anxiety, and each may lead to a worse outcome.3
How Depression Can Promote Cardiovascular Disease
The American Heart Association has concluded that depression can accelerate atherosclerosis
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as well as promote the onset and severity of the coronary risk factors of diabetes, hypertension, and high levels of low-density lipoprotein (Table).3
The most important reason depression increases the risk for, or worsens outcomes in, cardiovascular disease, is its effects on lifestyle and compliance with recommended treatments. Depression has been shown to increase the risk of an unhealthy lifestyle, including smoking; diet higher in calories, salt, and saturated fat; and decrease in exercise and medication compliance.3
Each of these increases the risk of cardiovascular disease and worsens the outcome.3
The value of a healthy lifestyle and compliance with treatments can't be underestimated. The risk of myocardial infarction and strokes increases 10-fold in patients who do not follow their physicians' recommendations, compared with those who do.TablePotential Mechanisms of How Depression and Anxiety Impact the Heart and Interventions to Reverse These Effects
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SNRI = serotonin and norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor.
In addition to its effects on compliance, physiologically, depression is associated with an increase in the stress hormone cortisone. High levels of cortisone
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can lead to increased blood glucose, weight gain, low high-density lipoprotein, and increased blood pressure. It can also increase other hormones (adrenaline), which can increase resting heart rate, blood pressure, and heart rate response to exertion, each of which may increase the risk of myocardial infarction, arrhythmias, and heart failure.3
Inflammation from poor dental hygiene, pneumonia, surgical procedures, and arthritis increases the risk for heart attacks. Depression may increase inflammation as well. Depression may also lead to increased platelets activity,3
increasing risk of coronary artery occlusion.Anxiety, Psychological Distress, and Cardiovascular Disease
While the evidence is not as strong, anxiety, anger, and stress may increase the risk of cardiovascular disease, similar to depression (Table).
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General anxiety about daily tasks, even if criteria for an official diagnosis of generalized anxiety disorder are not met, and psychological distress, including anger and stress, have been shown to promote and precipitate cardiovascular diseases. The effect may also be progressive, meaning more episodes of anxiety, anger, and stress may be associated with a higher risk of cardiovascular diseases as well as symptoms or signs overlapping with cardiovascular diseases including chest pain, despite normal coronary arteries and palpitations or heart pounding even in the absence of structural or functional heart diseases.3
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While the definition of anxiety disorders infers chronicity, anxiety and negative emotions like anger, fear, grief, and severe emotional stress can result in the release of the hormone adrenaline, which temporarily increases blood pressure
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and results in constriction of arteries that can result in myocardial infarction (classic myocardial infarction or the “broken heart syndrome”) and induce cardiac irregularities in persons with and without structural heart disease, including atrial fibrillation, atrial flutter and tachycardia, premature ventricular contractions, and even sudden death. Repeated temporary increases in blood pressure may lead to plaque disruption, resulting in myocardial infarction or strokes, and in patients with a weakened aorta, such as those with aortic aneurysm or survivors of an aortic dissection, may lead to aortic dissection or rupture.6
Recommendations
Mental distress and mental illnesses are real and can be associated with severe cardiovascular consequences. Thus, it is important for patients to discuss their mental health with their doctor frequently, and for clinicians to assess the mental health of their patients, especially because mental illness often times goes undiagnosed. Depression and anxiety and an exaggerated stress response have effective treatments. Treatment improves long-term cardiovascular health and also dramatically and effectively increases quality of life.
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Medications, as well as nonmedication interventions, such as cognitive-behavioral therapy, mindfulness meditation, yoga, transcendental meditation, slow breathing exercises, and exercise, are excellent treatment options. These can reverse many of the cardiovascular changes from mental distress and mental illness. Moderate-intensity aerobic exercise for at least 30 minutes, on 5 or more days of the week, reduces the risk of myocardial infarction and death from cardiovascular disease.3
While beyond the scope of this commentary, there is evidence of benefit from the regular practice of meditation (Table). The goal of cultivating mindfulness is to become more aware of the present moment without judgment, often focusing on immediate physical sensations in the body, including the breath. This anchor for the attention is available to return to when the mind gets caught up in a story, a plan, a train of thought, or intense emotions. At any moment the individual can return their attention to this anchor, without judging themselves or their wandering minds and without holding on to whatever drew their attention away, but just letting it go, letting it be. Improvement can be seen in a few weeks, and when practiced long term, particularly facilitated by an expert, mindful meditation is very helpful for reducing stress and for a reduced emotional response, smoking cessation, lowering blood pressure, and enhancing quality of life by contributing to a more coherent and healthy sense of self and identity.
References
- Association between depression and development of coronary artery disease: pathophysiologic and diagnostic implications.Vasc Health Risk Manag. 2011; 7: 159-164
- Depression and heart failure.Hellenic J Cardiol. 2009; 50: 410-417
- Psychiatry and Heart Disease: The Mind, Brain, and Heart.Wiley-Blackwell, Hoboken, NJ2011
- Depression and vascular disease: what is the relationship?.J Affect Disord. 2004; 79: 81-95
- The influence of happiness, anger, and anxiety on the blood pressure of borderline hypertensives.Psychosom Med. 1986; 48: 461-470
- Role of exertion or emotion as inciting events for acute aortic dissection.Am J Cardiol. 2007; 100: 1470-1472
- Depression in heart failure: a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes.J Am Coll Cardiol. 2006; 48: 1527-1537
- Diagnostic and Statistical Manual of Mental Disorders.4th ed. American Psychiatric Association, Washington, DC1994
Article info
Publication history
Published online: June 08, 2016
Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: All authors participated in writing the manuscript.
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Published by Elsevier Inc.
