ABC | Volume 111, Nº5, November 2018

Original Article Serpytis et al Anxiety and depression after myocardial infarction Arq Bras Cardiol. 2018; 111(5):676-683 city, Lithuania), found the prevalence of mental disorders to be higher than in other comparable studies, although lower than that observed in our study. 16 Another noteworthy explanation for the high prevalencemight be the fact that mental health problems in Lithuania are particularly widespread, as demonstrated by the suicide rates that are amongst the highest worldwide. 17 It is particularly important to note that the HADS-D score was especially higher in women. Although we did not assess the impact of depression on patient outcomes, it is nonetheless necessary to stress the predictive influence of depressive symptoms in acute coronary syndrome [ACS]. A meta-analysis including 22 studies, carried out by Van Melle et al., 18 concluded that depression is associated with a two-fold increase in mortality following MI. Furthermore, depression is associated with worse long-term outcomes after MI. For example, it was determined that moderate or high stress at the time of the MI is associated with an increased two-year mortality and an increased risk of angina in the first year. 19 Bush et al . 20 prospectively studied patients with MI who survived to discharge and determined that the highest mortality rates were observed in patients with the most severe depressive symptoms. Moreover, the ENRICHD study 21 also concluded that depression increases the risk of all-cause mortality for 30 months, even after adjusting for confounders. After the extensive review of 53 studies and four meta-analyses, the American Heart Association [AHA] stated that depression is an individual risk factor for adverse medical outcomes in patients with acute coronary syndrome. 21 Depression is an important risk factor that should be taken into consideration, not only after ACS but prior to CAD as well. Results of an 11-cohort study meta-analysis by Rugulies et al. 11 support this statement, since they concluded that clinical depression was a strong predictor of the development of coronary heart disease in an initially healthy population. Furthermore, another study demonstrated that depression was a stronger CHD predictor, especially for women (p = 0.002). 22 Our study revealed that women had a markedly elevated risk of having anxiety disorder. It should be highlighted that the prognostic significance of anxiety raises discussions, since some studies suggest that post-MI anxiety symptoms were not an independent prognostic risk factor for new cardiovascular events or death. 23 Moreover, according to Hosseini et al., 24 post-MI anxiety does not predict long-term quality of life in MI survivors. Nonetheless, we believe that post-MI anxiety should be taken into consideration in clinical practice, since it has been shown that not only depression but also pre-myocardial anxiety in the preceding 2 hours increase 10-year mortality rates in those aged > 65 years. 25 Moreover, Paine et al. 26 recently published an article stating that women with anxiety and no CAD history had higher rates of ischemia than women without anxiety. Since women are more prone to anxiety, it is important to mention that many CAD symptoms (for example, fatigue, chest pain and shortness of breath) overlap with anxiety symptoms and might mask CAD. This is more evident in women than men and contributes to the referral to other specialists and, thus, diagnostic delays. 27 Although a recent publication by Feng et al. 1 determined that especially those women between 45 and 64 years of age had the greatest risk for anxiety when it comes to cardiovascular disease, our findings did not support this conclusion. First, our study showed that women had the highest probability to develop anxiety from 68 to 75 years of age. Second, the analysis showed that age did not have any influence on either anxiety or depression prevalence in women. On the other hand, there was a significant association between age in men and depressive symptomatology prevalence and it was shown that a relatively younger population, aged 55 to 62 years, had the highest risk of developing depression. Furthermore, male patients showed a significant weak positive correlation between age and depression severity and a weak negative correlation between age and anxiety severity. The cardiovascular risk factor analysis showed that a higher anxiety score was identified in male patients who smoked, whereas the HADS-A score did not differ between women who smoked and did not smoke. Similarly, a significantly higher HADS-D score was found in those patients who were hypodynamic. Also, an association between diabetes mellitus and the HADS-D score was evident and men who had diabetes mellitus also had a significantly higher depression score, whereas female patients did not show any significant association between diabetes mellitus and emotional disorders. Although our analysis did not demonstrate any association between hypertension and mental disorders, another study listed depression as being associated with several known prognostic factors, such as a history of treatment of hypertension, diabetes, advanced Killip Class and left ventricular ejection fraction of 35% or less. 28 We would also like to address the association found between elevated anxiety and depression levels and hypercholesterolemia in females. A quite recent experimental study by Engel et al. 29 aimed to investigate this pathophysiological association and concluded that depressive-like behavior in hypercholesterolemic mice is accompanied by alterations in the monoaminergic metabolism, providing new evidence about the association between hypercholesterolemia and depression. It is of paramount importance to mention the need for routine screening for depression since it is also associated with decreased adherence to medications 30 and a three-fold increase in the risk of noncompliance with medical treatment regimens. 31 Moreover, it leads to significantly reduced quality of life 32,33 and higher healthcare costs. 34 All patients should be screened within one month of MI. The AHA recommends using Patient Health Questionnaire-2, which consists of one question seeking to identify a depressive mood in the preceding two weeks and another for anhedonia in the preceding two weeks. 35 If the answer is positive to either question, then the patient should be referred for a more thorough clinical evaluation by a professional qualified in the diagnosis and management of depression or screened with the Patient Health Questionnaire-9, which has shown to be diagnostically superior in patients with CHD. 36 In contrast, there are no specific guidelines from the AHA for anxiety disorder screening in CHD. This can be partially due to the high prevalence of anxiety symptoms in angina and MI. Furthermore, it has been shown that anxiety rating scales have relatively high false positive scores that result in reduced cost-effectiveness of routine screening. 37 680