Successful psychological therapy for depression may reduce subsequent CVD risk

25th April 2023

Psychological therapy that improves a patient’s depression could also reduce their risk of developing cardiovascular diseases in the future, according to new research.

In the first-of-its-kind study, published in the European Heart Journal, researchers retrospectively examined a cohort of 636,955 individuals who had completed the Improving Access to Psychological Therapy (IAPT) primary care programme for depression.

Individuals were free of cardiovascular disease (CVD) before entry into the IAPT and over 45 years of age, with a mean age of 55. Some 58.6% showed an improvement in their depression. Regression models then estimated the association between improvement of depression and the risk of subsequent CVD events.

In fully adjusted models, those whose depression symptoms improved after psychological therapy were 12% less likely to experience a cardiovascular event than those who did not, over an average three-year follow up.

Indeed, improving depression symptoms gave rise to a significant lowering in the risk of any new onset of CVD (hazard ratio, HR = 0.88, 95% CI 0.86 – 0.89). This was true for coronary heart disease (HR = 0.89), stroke (HR = 0.88) and all-cause mortality (HR = 0.81).

This reduction in CVD risk and risk of death from all causes was higher in those aged under 60, with 15% and 22% decreased risk respectively. Those over 60 years of age had a 5% decreased risk of developing CVD and 14% decreased risk of death from all other causes.

The authors suggest that management of depression with psychological therapies might therefore reduce the risk of subsequent CVD, but more research is needed to understand the causality of these associations.

Long-term physical health benefits

Commenting on the study, lead author Celine El Baou, PhD candidate from UCL Psychology & Language Sciences, said: “The findings are important as they suggest that the benefits of psychological therapy may extend beyond mental health outcomes and to long-term physical health. They stress the importance of increasing access to psychological therapy to under-represented groups, for example minority ethnic groups who may be more at risk of experiencing cardiovascular disease.”

The authors also noted that previous studies have shown that people who experience depression are around 72% more likely to develop cardiovascular disease in their lifetime.

A study published earlier in 2023 also highlighted that depression and poor mental health among young adults is more likely to lead to premature CVD and suboptimal cardiovascular health. The researchers concluded that prioritising mental health might help to reduce CVD risk and improve cardiovascular health in young adults.

In 2021/22, 1.24 million referrals accessed the Improving Access to Psychological Therapies (IAPT) programme (now renamed NHS Talking Therapies for anxiety and depression) compared to 1.02 million the previous year, according to latest NHS Digital statistics.

Pregnancy hypertensive disorders linked to higher future risk of cardiovascular disease

24th February 2023

Pregnancy hypertensive disorders increase the longer term risk of cardiovascular diseases according to a results of a Mendelian analysis

Women who experience pregnancy hypertensive disorders such as preeclampsia have a higher risk of developing cardiovascular disorders in the future according to the findings of a Mendelian randomisation analysis by UK and Dutch researchers.

Hypertensive disorders during pregnancy affect 8% to 10% of all pregnant women and can lead to serious complications including mortality. In fact, one systematic analysis revealed how 14% of maternal deaths were due to hypertensive disorders. Moreover, observational evidence suggests that having a pregnancy-related hypertensive disorder increases the risk of cardiovascular events in later life. Nevertheless, observational data cannot be used to determine a causal relationship due to potential confounding. However, a better study design that can determine whether such a relationship is causal is the use of Mendelian randomisation (MR). This approach uses the genetic risk of disease as a proxy for the disease itself and can be used to mitigate the effect of confounding, as the MR estimate can be used to interpret the effect of the exposure, in this case pregnancy-related hypertensive diseases, on the outcome of interest (cardiovascular disease).

In the current study, researchers used estimates of genetic association obtained from genome-wide association data, to examine the association between gestational hypertension and preeclampsia and the risk of subsequently developing coronary artery disease, ischaemic stroke, heart failure and atrial fibrillation. The team also employed mediation analysis based on multivariable MR, to consider the impact of potential mediators e.g., body mass index, systolic blood pressure etc, on any identified associations.

Pregnancy hypertensive disorders and future cardiovascular risk

For any genetically predicted hypertensive disorder, there was an elevated risk of developing coronary artery disease (Odds ratio, OR = 1.24, 95% CI 1.08 – 1.43, p = 0.02). The risk was also elevated when considering gestational hypertension (OR = 1.08, p = 0.04), preeclampsia or eclampsia (OR = 1.06, p = 0.03) and ischaemic stroke (OR = 1.27, P < 0.001). However, the risks were non-significant for both gestational hypertension and preeclampsia and there were also non-significant for both heart failure and atrial fibrillation.

In the mediation analysis, there was a partial attenuation of the overall risk for CAD after adjusting for systolic blood pressure (adjusted OR = 1.10 vs 1.24) and the presence of type 2 diabetes (adjusted OR = 1.16 vs 1.24).

The authors concluded that given their findings, the presence of pregnancy-related hypertensive disorders should be considered as risk factors for cardiovascular disease.

Citation
Rayes B et al. Association of Hypertensive Disorders of Pregnancy With Future Cardiovascular Disease. JAMA Netw Open. 2023

Depression and poor mental health linked to higher incidence of CVD in young adults

3rd February 2023

Both depression and poor mental health days in young adults are associated with a higher risk of premature cardiovascular disease

Depression and poor mental health among young adults is more likely to lead to premature cardiovascular disease (CVD) and suboptimal cardiovascular health according to the findings of a large study of US adults by US and UK researchers.

A worrying trend over the past 20 years is the observed increase in the prevalence of recognised cardiovascular disease risk factors e.g., obesity, physical inactivity and a poor diet, among younger individuals in developed countries. Moreover, though not considered as a traditional CVD risk factor, the American Heart Association accepts that depression should be considered as a risk factor for adverse outcomes in patients with acute coronary syndrome. But to what extent does the presence of depression or even poor mental health, affect the risk of CVD among younger adults was the subject of the current study.

Researchers used data from the behavioural risk factor surveillance system which includes a nationally representative sample of non-institutionalised adults. The system assesses health-related risk behaviours and chronic health conditions, based on an annual telephone survey. The research team collected data on self-reported depression and poor mental health days (PMHDs), as well as CVD and suboptimal cardiovascular (CV) health, based on recognised risk factors, e.g., smoking, physical inactivity. In addition, self-reported PMHDs were categorised as 0, 1 – 13 or 14 to 30.

Depression and risk of premature cardiovascular disease
In total, data were collected from 593,616 with a mean age of 34.7 years (50.3% male).

The prevalence of depression was 19.6% and 2.5% for CVD. The researchers calculated that those with depression had a much higher odds of CVD compared to those without the condition (odds ratio, OR = 2.32, 95% CI 2.13 – 2.51). There was also a graded increased risk of CVD, depending on the number of reported PMHDs rising from an odds ratio of 1.48 (1 to 13 days) to 2.29 (14 to 30 days). These estimates were unaffected by gender or individual’s status (rural or urban). Suboptimal cardiovascular health was also higher among those with depression (OR = 1.79) and a similar graded relationship observed based on the number of PMHDs.

The authors concluded that based on their findings, prioritising mental health might help to reduce CVD risk and improve cardiovascular health in young adults.

Citation
Kwapong YA et al. Association of Depression and Poor Mental Health With Cardiovascular Disease and Suboptimal Cardiovascular Health Among Young Adults in the United States. J Am Heart Assoc 2023

Morning physical activity linked to lowest risk of cardiovascular disease

8th December 2022

Morning physical activity is associated with the greatest risk reduction for cardiovascular disease and stroke compared to a midday pattern

Individuals with higher levels of morning physical activity have the lowest risk of incident cardiovascular disease and stroke compared to those who have a midday peak pattern according to an analysis by Dutch researchers.

Cardiovascular diseases (CVD) are the leading cause of global mortality with an estimated 17.9 million lives lost each year. One modifiable factor linked to CVD is physical activity (PA) and data suggests that PA is not only associated with lower risk for of CVD but that the greatest benefit is seen for those who engage in higher levels of activity. However, emerging evidence suggests that the timing of PA may also be an important and influential factor. For example, in a study of more than 7,000 women, researchers found that women who are less active during morning hours may be at higher risk of obesity. In addition, an exercise-based trial which considered the impact of exercise timing on weight loss, showed that morning physical activity led to a significantly higher weight loss compared to evening activity. But mornings might not always be best as a study in men with type 2 diabetes observed that those who undertook high intensity interval training (HIIT) in an afternoon compared to morning session, had better glucose control.

In trying to better understand the impact of the timing of physical activity on the risk of incident CVD, the Dutch researchers collected physical activity data from participants in the UK-Biobank through triaxial accelerometer over a 7-day period which collected 24-hour mean activity levels. The team then used this data to create four different clusters of physical activity: cluster 1 represented the average pattern among the total biobank population which peaked around midday; cluster 2 were those with an early morning peak; cluster 3 a late morning peak and cluster 4, those with an evening peak. Regression analysis was used based on two models, the first (model 1) was adjusted for age and gender, and the second (model 2) additionally adjusted for body mass index and smoking status.

Morning physical activity and cardiovascular outcomes

A total of 86,657 individuals with a mean age of 61.6 years (58% female) were included and followed for 6 years during which time there were 2,911 cases of incident CVD and 796 strokes.

In an analysis based on model 1, participants who had higher levels of morning or later morning (clusters 2 and 3) physical activity, had a 11% (hazard ratio, HR = 0.89, 95% CI 0.80 – 0.99) and 16% (HR = 0.84, 95% CI 0.77 – 0.92) respectively, lower incidence of incident CVD compared to those in cluster 1. However, only those in cluster 3 (late morning physical activity) had a significantly reduced risk of stroke (HR = 0.83, 95% CI 0.70 – 0.98) and ischaemic stroke (HR = 0.79, 95% CI 0.64 – 0.97). Interestingly, when the researchers used model 2, the benefits were no longer statistically significant apart from a reduced risk of ischaemic stroke for those in cluster 3 (HR = 0.73, 95% CI 0.57 – 0.94).

In subgroup analysis based on gender and using model 2, there were statistically significant reductions in the risk of incident CVD but only among women who were either early and later morning exercisers. In addition, the risk of ischaemic stroke was only significantly lower among women in cluster 3 (HR = 0.56, 95% CI 0.38 – 0.83). When stratifying by participant levels of activity (i.e., either less or more active) and using model 2, although there were reductions in the risk of both CVD and stroke, among those who were more active, these reductions were non-significant.

The authors concluded that morning physical activity was associated with lower risks of incident cardiovascular diseases and that these findings highlighted the potential importance of chrono-activity in CVD prevention.

Citation
Albalak G et al. Setting your clock: associations between timing of objective physical activity and cardiovascular disease risk in the general population. Eur J Prev Cardiol 2022