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Depression, anxiety, and platelet reactivity in patients with coronary heart disease

Ilan S. Wittstein
DOI: http://dx.doi.org/10.1093/eurheartj/ehq097 1548-1550 First published online: 22 April 2010

This editorial refers to ‘Anxiety is a better predictor of platelet reactivity in coronary artery disease patients than depression’, by M.U. Zafar et al., on page 1573

There is considerable epidemiological evidence supporting the association between chronic emotional stress and coronary heart disease (CHD). Emotional factors that have been linked to atherosclerosis and adverse cardiac events include primarily negative affective disorders such as depression, anxiety, anger, and hostility.1,2 It is now well established that depression is related not only to the incidence of CHD but also to the prognosis of patients with established disease. In a meta-analysis concerned with the role of depression in the development of coronary artery disease, Rugulies found that individuals with clinical depression have >2.5 times the risk of a myocardial infarction or coronary death as the general population.3 In patients with established coronary disease, not only is major depression a significant predictor of mortality following acute myocardial infarction, but the level of depressive symptoms has a dose–response relationship with cardiac mortality over several years of follow-up.4

The importance of other affective disorders in the development and progression of CHD is less well established. Large-scale prospective studies have demonstrated a significant link between anxiety and sudden cardiac death,5 but studies documenting an association between anxiety and the development of coronary artery disease have been inconclusive. In patients with known CHD, Suls and Bunde found a relatively weak association between anxiety and hard cardiac events.6 More recent studies, however, have demonstrated that anxiety is an independent predictor of major cardiac events in patients with stable coronary disease.7,8 Hostility and anger are felt to represent the potentially harmful aspects of Type A behaviour, and their relationships to CHD have therefore received considerable attention. While some studies have reported …