It is well known that an ailing mind leads to an ailing body. But can an ailing mind affect the sexes differently when it comes to cardiovascular (CV) disease? In a study published in the Journal of the American Heart Association, Smolderen et al. showed that a higher rate of lifetime history of depression and depressive symptoms at the time of an acute myocardial infarction (AMI) was observed among young women compared with men. Additionally, depressive symptoms affected those with more vulnerable socioeconomic and clinical profiles. The analysis was part of the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study that enrolled 3,572 patients with AMI, 67% of whom were women. The recruitment occurred between 2008 and 2012 in this multinational study and spanned 3 continents, including the United States, Spain, and Australia. The aim of the study was to examine the risk factors and outcomes for young patients (ages 18-55 years) recovering from an AMI. Unique to this study was a 9-item Patient Health Questionnaire (PHQ-9) that was used to ascertain the frequency and severity of depressive symptoms over a 2-week period. The questionnaire was based on the Diagnostic and Statistical Manual of Mental Disorders. In addition to this, perceived stress data (14-item Perceived Stress Scale) and health status data (Seattle Angina Questionnaire and European Quality of Life-5 Dimensions) were also obtained.

A total of 1,175 men and 2,397 women (mean age 48 years and range of 44-52) was included. More women than men reported previous diagnosis of depression (48% vs. 24%; p < 0.0001). Similarly, at the time of AMI, more women than men had significant depression with PHQ-9 scores ≥10 (39% vs. 22%; p < 0.0001). Among those with a previous history of depression, women had a higher overall PHQ-9 score (p < 0.0001) compared with men and were more likely to present with PHQ-9 scores ≥10 (26% vs. 10%, p < 0.0001). This pattern was seen across all study countries. Unmarried status, lack of employment, and lower educational level were associated with higher PHQ-9 scores for depression, as was poor access to preventive health care. A greater number of CV risk factors were associated with higher PHQ-9 scores (>10) in both sexes. After adjusting for several important clinical, demographic, socioeconomic, and CV risk factors, young women with AMI were 60% more likely than their male counterparts to have significant depression.

This study is among many recently published studies that highlighted gender disparities in an AMI population. However, this study has focused on the depressive symptoms in a large AMI population in significant detail. It brings forth an important finding of higher prevalence of depression, of all severity, in young women with AMI compared with men. It also finds that a history of depression is more common in women than men presenting with AMI.

Depression screening is rarely used as a part of the work-up for CV risk assessment. It has been previously shown that depression is associated with worse CV outcomes¹ and is potentially reversible with both pharmacological and non-pharmacological strategies, including cognitive and behavioral therapies, and stress-reduction techniques. These strategies can be incorporated in the post-discharge rehabilitation program in at-risk patients with AMI. One may argue that the diagnosis of AMI and subsequent hospitalization can lead to short episodes of depression in these patients due to medical illnesses. However, in this study, almost half of the women with AMI reported a lifetime history of depression. Therefore, because depression alone can lead to unhealthy habits and other CV risk factors, preventative screening for depression in vulnerable patients of lower socioeconomic status may be useful to reduce their lifetime risk of CV events.

The authors suggested that a higher prevalence of depression in young women at the time of AMI may be at least a contributory factor to worse CV outcomes in these patients.² What may be more relevant in this study is whether depression is a manifestation of a genetic, inflammatory, or psychosocial milieu predisposing these young women to CV disease because depression was far more common in young women than men of similar ages. What is even more perplexing is that a large number of young women remain untreated or even undiagnosed with depression even though it may be of disabling severity.

Major depression is associated with worse prognosis in patients with AMI, and several studies have looked at the association of the severity of depression and CV events, sometimes in a dose-response relationship, even after adjustment for major CV risk factors.³ However, data to show the effect that treatment of depression has on clinical outcomes in AMI is currently limited, with only a few studies showing positive effects.^4,5 This may stem from the fact that the treatment strategies, either pharmacotherapy or cognitive, may have vastly different effects in these patients. Again, the majority of these studies were not randomized, and the duration and timing of intervention for depression could have had a bearing on benefit. In the future, controlled prospective studies to determine the effect of treatment of depression on CV outcomes may be useful. Until then, increased awareness among cardiologists regarding the prevalence of depression in this population may help early identification and treatment.⁶

In conclusion, the findings of this study add further evidence that CV disease in women, especially young women, is more complicated than in men. Though the majority of studies suggests that CV risk factors for women may be the same as those for men but more severe,⁵ the triggers or manifestations of those risk factors may be different. Whether depression is one piece of this puzzle is yet to be proven. Meanwhile, better screening and treatment protocols for clinical depression should be put in place for young women presenting with AMI.

References

1. Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014;129:1350-69.
2. Smolderen KG, Strait KM, Dreyer RP, et al. Depressive symptoms in younger women and men with acute myocardial infarction: insights from the VIRGO study. J Am Heart Assoc 2015;4:pii: e001424.
3. Friedman M, Thoresen CE, Gill JJ, et al. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project. Am Heart J 1986;112:653-65.
4. Glassman AH, O'Connor CM, Califf RM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002;288:701-9.
5. Gupta A, Wang Y, Spertus JA, et al. Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010. J Am Coll Cardiol 2014;64:337-45.
6. Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation 2008;118:1768-75.

Keywords: American Heart Association, Clinical Protocols, Cognition, Depression, Depressive Disorder, Major, Diagnostic and Statistical Manual of Mental Disorders, Habits, Health Status, Hospitalization, Myocardial Infarction, Prevalence, Prognosis, Prospective Studies, Quality of Life, Risk Assessment, Risk Factors, Social Class, Acute Coronary Syndrome

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