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Depressive Symptoms, Health Behaviors, and Risk of Cardiovascular Events in Patients With Coronary Heart Disease
Mary A. Whooley, MD;
Peter de Jonge, PhD;
Eric Vittinghoff, PhD;
Christian Otte, MD;
Rudolf Moos, PhD;
Robert M. Carney, PhD;
Sadia Ali, MD, MPH;
Sunaina Dowray, MPH;
Beeya Na, MPH;
Mitchell D. Feldman, MD, MPhil;
Nelson B. Schiller, MD;
Warren S. Browner, MD, MPH
JAMA. 2008;300(20):2379-2388.
Context Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown.
Objective To determine why depressive symptoms are associated with an increased risk of cardiovascular events.
Design and Participants The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years.
Setting Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008.
Main Outcome Measures Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators.
Results A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score  10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16-1.95; P = .002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00-1.71; P = .04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94-1.63; P = .12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79-1.40; P = .75).
Conclusion In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.
Author Affiliations: VA Medical Center, San Francisco, California (Drs Whooley, Ali, and Schiller and Mss Dowray and Na); University of California, San Francisco (Drs Whooley, Vittinghoff, Feldman, Schiller, and Browner); University of Groningen and Tilburg University, the Netherlands (Dr de Jonge); University Hospital Hamburg-Eppendorf, Hamburg, Germany (Dr Otte); Palo Alto VA Health Care System and Stanford University, California (Dr Moos); Washington University, St Louis, Missouri (Dr Carney); and California Pacific Medical Center, San Francisco, California (Dr Browner).
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