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CLINICAL RESEARCH: PSYCHOLOGICAL FACTORS AND CAD

Depression and Risk of Sudden Cardiac Death and Coronary Heart Disease in Women

Results From the Nurses' Health Study

William Whang, MD, MS^_*,_*, Laura D. Kubzansky, PhD, MPH^¶, Ichiro Kawachi, MD, PhD^¶, Kathryn M. Rexrode, MD, MPH, Candyce H. Kroenke, ScD, MPH, Robert J. Glynn, ScD^||, Hasan Garan, MD, MS^_* and Christine M. Albert, MD, MPH^,

^_* Division of Cardiology, Columbia University Medical Center, New York, New York
University of California, Berkeley, California
Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
^|| Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
^¶ Department of Society, Human Development, and Health, Harvard School of Public Health, Boston, Massachusetts

Manuscript received June 16, 2008; revised manuscript received September 24, 2008, accepted October 26, 2008.

^_* Reprint requests and correspondence: Dr. William Whang, Harkness 366, 180 Fort Washington Avenue, New York, New York 10032 (Email: ww42{at}columbia.edu).

Objectives: We assessed the association between depression and sudden cardiac death (SCD) and cardiac events among individuals without baseline coronary heart disease (CHD).

Background: Depression is a risk factor for cardiac events and mortality among those with CHD, possibly from arrhythmia.

Methods: We studied depressive symptoms and a proxy variable for clinical depression consisting of severe symptoms and/or antidepressant medication use and their relationship to cardiac events in the Nurses' Health Study. Questionnaires in 1992, 1996, and 2000 assessed symptoms with the Mental Health Index (MHI-5), and antidepressant use was assessed in 1996 and 2000. Primary end points included SCD, fatal CHD, and nonfatal myocardial infarction.

Results: Among 63,469 women without prior CHD/stroke in 1992, 7.9% had MHI-5 scores <53, previously found to predict clinical depression. Depressive symptoms were associated with CHD events, and the relationship was strongest for fatal CHD, where the association remained significant even after controlling for CHD risk factors (hazard ratio [HR]: 1.49; 95% confidence interval [CI]: 1.11 to 2.00 for MHI-5 score <53). In models from 1996 onward, our proxy variable for clinical depression was most associated with SCD in multivariable models (HR: 2.33, 95% CI: 1.47 to 3.70), and this risk was primarily due to a specific relationship between antidepressant use and SCD (HR: 3.34, 95% CI: 2.03 to 5.50).

Conclusions: In this cohort of women without baseline CHD, depressive symptoms were associated with fatal CHD, and a measure of clinical depression including antidepressant use was specifically associated with SCD. Although antidepressant use might be a marker of worse depression, its specific association with SCD merits further study.

Key Words: coronary disease • epidemiology • sudden cardiac death • women

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CHD = coronary heart disease   CI = confidence interval   HR = hazard ratio   MHI = Mental Health Index   MI = myocardial infarction   SCD = sudden cardiac death   SSRI = selective serotonin reuptake inhibitor

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