New research presented at the American Heart Association's 2023 Scientific Sessions highlights the link between mental health and cardiovascular disease. The findings show that anxiety and depression accelerate the development of cardiovascular risk factors, and cumulative stress scores are significantly linked to heart disease, suggesting that mental health has a significant impact on heart health.
Two studies presented at the American Heart Association's 2023 Scientific Sessions link mental health to heart health, showing that depression and anxiety accelerate cardiovascular risk factors and critical events.
Depression and anxiety may accelerate the onset of heart attack and stroke risk factors, according to a Boston study. People with a higher genetic susceptibility to stress develop cardiovascular risk factors at a younger age than those without the genetic marker.
Another study conducted in Dallas found that accumulated stress can lead to health behaviors such as smoking that can negatively impact cardiovascular health and potentially increase plaque buildup in arteries and other known cardiovascular disease risk factors.
The heart and brain are closely linked, and depression, anxiety and chronic stress all increase the risk of heart and brain health complications, according to two preliminary studies presented at the American Heart Association's 2023 Scientific Sessions. The conference is the world's top exchange event for the latest scientific advances, research and evidence-based clinical practice updates in the field of cardiovascular science.
Mental health conditions including depression, anxiety and stress increase the risk of poor heart health, according to the American Heart Association, and in two new studies, researchers measured the extent to which a person's mental state affects heart health.
"There is a clear link between mental health and cardiovascular disease risk," said Glenn N. Levine, M.D., FAHA, chair of the writing committee for the American Heart Association's 2021 Scientific Statement on Mental Health, Well-Being, and the Mind-Body Connection. "These studies add to the growing body of data we have about how negative mental health increases the risk of heart and brain disease."
Depression and anxiety accelerate the increase in cardiovascular risk factors: mechanisms contributing to increased risk of cardiac events (MDP274)
The first study examines the mechanisms by which mental state affects heart health. Researchers have found that anxiety and depression accelerate the development of new cardiovascular disease risk factors.
"While depression and anxiety are known to increase the risk of cardiovascular diseases such as heart attack and stroke, the mechanisms behind this are not fully understood," said study lead author Giovanni Civieri, MD, a researcher at the Center for Cardiovascular Imaging Research at Massachusetts General Hospital and Harvard Medical School in Boston. "In our study, we identified a mechanism that appears to largely explain the link between these psychological factors and cardiovascular disease."
Civieri and colleagues looked at data from adults who had not had a previous cardiac event enrolled in the Mass General Brigham Biobank at Massachusetts General Hospital in Boston. Over the course of up to 10 years of follow-up, the time required for the development of new cardiovascular risk factors was measured.
Researchers found:
Thirty-eight percent of participants developed new cardiovascular risk factors during follow-up, such as high blood pressure, high cholesterol, or type 2 diabetes.
Participants who had been diagnosed with anxiety or depression developed new risk factors an average of six months earlier than those without depression or anxiety.
Depression and anxiety increase the risk of major cardiovascular events, such as heart attack or stroke, by about 35%.
Approximately 40% of the link between depression and/or anxiety and major heart disease and stroke events is due to accelerated development of cardiovascular disease risk factors.
People with a higher genetic predisposition to stress developed their first cardiovascular risk factors at a younger age (on average 1.5 years earlier than people without the genetic marker).
"Over an average of 5 years, it is normal for cardiovascular risk factors to develop more than 6 months earlier. The fact that the genetic analysis supports the clinical findings is intriguing and provides further confidence in our findings," Civieri said.
Researchers believe that depression and anxiety may induce changes in the brain that trigger downstream effects in the body, such as increased inflammation and fat deposition.
The findings highlight the importance of screening for cardiovascular risk factors in patients with depression and anxiety.
"This study suggests that health care workers should be aware that negative mental health conditions -- such as depression or anxiety -- can not only affect a patient's mental state, but also their physical health and risk for heart disease. So these are not benign conditions," said Levine, an attending physician and professor of medicine at Baylor College of Medicine and chief of cardiology at the Michael E. Deback VA Medical Center, both in Houston. "These are things we want to actively refer people to mental health professionals."
Civieri also encourages people with depression or anxiety to get screened more frequently for cardiovascular risk factors, such as high blood pressure, high cholesterol and type 2 diabetes. "While we have not investigated this, there is reason to believe that treating depression and anxiety may reduce the accelerated development of cardiovascular risk factors," he said.
Research background and details:
The analysis used data from 71,262 adults (mean age 49, 45% male), collected between December 2010 and December 2020.
Sixteen percent of the study group were taking medications to treat depression or anxiety; however, Civieri explained that statistically adjusting for such medications did not have a significant impact on the results.
Subjects who provided genetic data were assessed for a genetic marker of stress sensitivity (the Neuroticism Polygenic Risk Score).
The observational study design and possible misclassification of depression and anxiety diagnostic codes are limitations of this study.
Associations of cumulative perceived stress with cardiovascular risk factors and outcomes: findings from the Dallas Heart Study (MDP100)
In a second, unrelated study, researchers explored the impact of cumulative stress on heart and brain health by studying responses to questionnaires from adults without cardiovascular disease in the Dallas Heart Study.
"This unique study explores the relationship between our new cumulative stress score and its sub-items and cardiovascular risk factors in an attempt to further understand this relationship," said lead author Ijeoma Eleazu, MD, a cardiology fellow at the University of Texas Southwestern Medical Center in Dallas. "To our knowledge, this is the first study to perform a multidimensional analysis of the relationship between perceived stress and cardiovascular disease."
Over a one-month period, the researchers combined general daily stress, psychosocial stress (stress that poses a threat to psychological or social functioning), economic stress and perceived neighborhood stress into a score called a "cumulative stress score." Eleazu explained that the new score was strongly associated with the development of cardiovascular disease after adjusting for known cardiovascular disease risk factors such as high blood pressure, type 2 diabetes, smoking and high cholesterol, as well as income and education.
Even after adjusting for risk factors such as high blood pressure, high cholesterol, smoking and type 2 diabetes, as well as income and education, the researchers found that the greater the cumulative stress, the higher the risk of cardiovascular disease:
Linked to a 22% increased risk of atherosclerosis, which causes plaque buildup and reduces adequate blood flow;
20% increased risk of overall cardiovascular disease, including coronary heart disease and heart failure;
Women, those ages 18-45, those with lower income and education levels, and those who self-identify as black or Hispanic adults are at higher risk for cardiovascular disease.
Additionally, cumulative stress scores were higher among those who reported racial/ethnic discrimination and lacked health insurance; stress scores were also higher among those who had high blood pressure, were overweight, were inactive, and smoked.
"There are individual-level factors of perceived stress that make up our psychosocial score, there are demographic factors that are reflected in the economic stress score, and there are even environmental factors that are reflected in the neighborhood stress score," Eleazu said. "These individual factors are, by themselves, more associated with cardiovascular disease than the multidimensional cumulative stress score." The correlations appear to be less strong. These findings suggest that if we focus on just one factor, or make a broad and/or subjective assessment of stress, we may not be able to adequately capture the impact of stress. This is particularly important for diverse or minority populations who may experience various types and multiple stressors at the same time."
The analysis also shows that ongoing stress increases the risk of poor heart and brain health in two ways: by directly affecting physical health, and by increasing negative lifestyle behaviors such as smoking and being sedentary, which in turn can lead to reduced cardiovascular health.
Previous research has shown that chronic stress can lead to elevated levels of stress hormones such as cortisol, which can affect blood sugar levels, inflammation and other biological cascades that affect the heart, Eleazu said.
"There is a real connection between the heart and the mind. Taking care of your mind affects your physical health as well," she said. "It would be a very good thing if more patients discussed their stress levels with their doctors and more doctors screened patients for high stress burden. That way, together we could combat adverse outcomes."
Levine added, "This new concept of adding up a person's cumulative stress and assessing it is great because in some areas of our lives we may not have a lot of stress, but in other areas of our lives, like finances or health, we may have a lot of stress. This study found that it's better to look at a person's overall cumulative stress -- rather than just asking them about one aspect of their life or lives that may be influencing stress."
Research background and details:
Data evaluated were from 2,685 adults without cardiovascular disease who participated in the Dallas Heart Study Phase 2 (2007-2009), a multiethnic group based in Dallas.
The average age of participants was 48 years; 55% were female; 49% were Black adults; 15% were Hispanic/Latinx adults.
Participants were followed for an average of 12.4 years, with cardiovascular events and death judged by a panel of cardiovascular experts.
Eleazu explained that limitations of the study include that there may be some unknown conflicting factors that were not taken into account, and that cumulative scores are a new technology that has not yet been fully validated.