A Trifecta of Broken Hearts

Sad recent news  on the topic of depression and hearts.

1) The first big news is that depression is signficantly associated with an increased incidence of heart failure after a heart attack. The study showed, first, that depression after heart attacks is very common (10%), and that it is a marker, at least, for much higher incidence of heart failure – specifically “the incidence of HF [heart failure] was 3.6 per 100 for those without a post-CAD [coronary artery disease] diagnosis of depression and 16.4 per 100 for those with a post-CAD diagnosis of depression. A depression diagnosis was associated with a 2-fold increased risk in the incidence of heart failure (HR 2.0; multivariate HR, 1.5; P < .0001).” The study also noted that treated the depression with anti-depressant medication made no difference in the incidence of heart failure whatsoever. The whole question of depression after heart attacks and heart failure incidence leaves unanswered the-chicken-and-the-egg problem – is the depression a marker from something the body is doing that manifests heart failure later, or is depression somehow “causing” heart failure? No one knows the answer to that one…

2) So once the heart failure is established, does the depression go away? And is depression in heart failure patients serious? The Archives of Internal Medicine last November published a study showing that depression is common, profound, and increases mortality in heart failure patients by 33%. Even though the heavily-industry-supported study makes statements about treatment of depression that may not be (in the end) unbiased, the raw numbers from the study about depression, heart failure and death are chilling. Specifically:

• 30% of the total study cohort met study criteria for depression; 24.5% of these patients with depression were receiving antidepressants, as were 12.5% of nondepressed individuals.
• The average duration of follow-up was 972 days, with a median follow-up of 801 days. During this period, a total of 429 participants (42.7%) died, including 53.3% of the depressed cohort and 38.1% of the non-depressed group. Both depression and worsened heart failure were associated with a higher risk for mortality.

3) On the slightly brighter news side, shortly after that previous study was published, JAMA published results from the evocatively-named Heart and Soul Study. The authors state that, prior to the development of heart disease/heart attacks/heart failure, the bulk of the link between depression and an increased risk of heart disease can all be accounted for by lack of exercise. Not all, but most of it.

The lead author stated, “‘Surprisingly, we found that the fancy physiological mediators really were not explaining the association [between depression and heart disease mortality] and that it seemed to be all about health behaviors.’ According to Whooley, depressed patients were less likely to take their medications as prescribed, less likely to exercise, and more likely to smoke. ‘And after you accounted for those health behaviors, the association between depression and CVD went away. So we concluded that link between depression and heart disease is largely explained by these health behaviors.'”

Other studies have shown that lack of exercise is definitely linked to increase rates of depression (depression is also recently linked to increased time watching TV – coincidence? I think not…).

In a succinct summary of a complex problem, Dr. Whooley goes on to state in the interview, “It doesn’t matter whether patients first grew depressed due to lack of physical exercise or stopped exercising when they became depressed. ‘Very likely it’s a vicious cycle and the association is bidirectional,’ she said. ‘In our opinion, it doesn’t really matter whether it’s the chicken or the egg because the bottom line is the same—if you increase exercise in these patients, you’re going to reduce their risk of heart disease. But the thing to remember about depressed patients is that they are that much less motivated to do things, so it takes extra effort to get them to exercise, take their medications, and stop smoking.'”

Bottom line: The stakes are high, every step of the way – before heart disease, before heart failure, after heart failure. Your heart is begging you to move. Spring is calling! Take a stroll and make your heart proud.

Check in Wednesday for some recent bright news about what DOES work with heart patients and depression!