Depression linked with increased risk of peripheral arterial disease

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Depression was linked with an increased risk of peripheral arterial disease (PAD) in a study of more than 1,000 men and women with heart disease conducted by researchers at the San Francisco VA Medical Center and the University of California, San Francisco, USA. Results of a sub-analysis from The Heart and Soul study were recently published on the Journal of the American Heart Association (online version).

Marlene Grenon, lead author of the study and colleagues, used data from the Heart and Soul study, a prospective cohort that included 1024 participants (men and women) with coronary artery disease, recruited between 2000 and 2002 and followed for an average of seven years.

“We discovered that there was an association between depression and peripheral arterial disease at baseline, and also found that the patients who were depressed at the beginning of the study had a higher likelihood of developing PAD during follow-up at seven years,” said Grenon, vascular surgeon at San Francisco VA Medical Center and assistant professor of Surgery at University of California, San Francisco, USA.


Grenon and colleagues assessed depressive symptoms with the validated 9-item Patient Health Questionnaire. Prevalent peripheral arterial disease at baseline was determined by self-report and prospective PAD events were adjudicated on the basis of review of medical records. The investigators used logistic regression and Cox proportional-hazards models to estimate independent associations of depressive symptoms with prevalent PAD and subsequent PAD events.


The results show that 19% of patients had depressive symptoms and prevalent peripheral arterial disease was reported by 12% of patients with depression and 7% of those without depression. During follow-up, peripheral arterial disease events occurred in 7% of patients with depression and 5% of those without depression. Factors explaining >5% of the association between depression and incident PAD events included race/ethnicity, diabetes, congestive heart failure, high-density lipoprotein, triglyceride levels, serum creatinine, inflammation, smoking, and levels of physical activity.


“These findings add to the growing body of research showing the importance of depression in both the development and progression of PAD,” said senior author Beth Cohen, physician at San Francisco VA Medical Center and an assistant professor of Medicine at University of California, San Francisco. “This also emphasizes the need for medical providers to be attentive to the mental health of their patients who have developed, or who are at risk for, PAD.”


“We still do not know which comes first,” said Grenon. “Is it that patients with PAD become depressed because their mobility is impaired, or that people who are depressed engage in unhealthy behaviors such as smoking and lack of exercise, and are thus more at risk of developing PAD? Or might it be a vicious cycle, where one leads to the other?.” 
Further research is needed to tease out cause and effect, she said.


The study authors suggest that whatever the initial cause, lifestyle modifications such as being more physically active, eating better, quitting smoking and managing stress more effectively might reduce the risk for the association, as well as potentially address symptoms of both PAD and depression.


“These lifestyle changes would be considered healthy for anyone, and would also help overall cardiovascular health,” said Grenon.


“As providers, we can help patients recognise the connections between mental and physical health,” added Cohen. “This may help reduce the stigma of mental health diagnosis and encourage patients to seek treatment for problems such as depression.”


Co-authors of the study are Jade Hiramoto, University of California, San Francisco; Kim J Smolderen, Saint Luke’s Mid America Heart Institute, Kansas City, and Tilburg University, The Netherlands; Eric Vittinghof, University of California, San Francisco; and Mary A Whooley, San Francisco VA Medical Center and University of California, San Francisco and principal investigator of the Heart and Soul Study.

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