Anxiety and depression in patients three months after myocardial infarction: Association with markers of coagulation and the relevance of age
Introduction
An association of psychological factors, in particular anxiety and depression, with the development and progression of coronary artery disease (CAD) has been confirmed by recent research [1], [2], [3], [4], [5], [6], [7]. One of several possible mediators between anxiety/depression and heart function is an activation of coagulation and/or impairment of fibrinolysis via psychological distress [8], [9], [10], [11], [12]. Elevated plasma levels of fibrinogen, von Willebrand factor (vWF), tissue plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1), and D-dimer, as well as increased plasma activities of factors VII (FVII:C) and factor VIII (FVIII:C) and elevated levels of homocysteine are associated with incidence of CAD, risk of cardiac events, and cardiac mortality [13], [14], [15], [16], [17]. A correlation between psychological distress and a hypercoagulable state, characterized by an activation of coagulation and impairment of fibrinolysis, has been well confirmed in healthy individuals [8], [18]. There have also been findings of elevated homocysteine levels in patients with anxiety or depression [19], [20], [21]. In patients with CAD, associations between psychological factors and haemostasis have been studied much less frequently, with the evidence being inconsistent. Several studies [22], [23] found anxiety and depression affecting platelet functioning in CAD patients. Von Känel et al. [24] reported an enhanced reaction of the coagulation system to acute psychological stress in patients with CAD. In a sample of 11 CAD patients, Hevey and McGee [25] found an impairment of fibrinolysis under experimental stress. Lahlou-Laforet [26] showed an association of depression with PAI-1 in 231 male CAD patients. However, no correlation of depression with markers of coagulation and fibrinolysis was found in 303 patients (with or without CAD) before elective angiography in a study from Schroeder [27].
Within 18 months after an acute myocardial infarction, 20–40% of all patients experience moderate to severe anxiety and depression [28], [29]. In this vulnerable phase, the impact of anxiety and depression on coagulation is of special interest. To our knowledge, this is the first study to examine the association between anxiety and depression and the coagulation system in the first months after an acute myocardial infarction. Taking the current literature into consideration, our hypothesis was that anxiety and depression would be associated to activated coagulation and impaired fibrinolysis, and therefore would be positively correlated with fibrinogen, FVII:C, FVIII:C, vWF, F1 + 2, D-dimer, t-PA, and PAI-1 levels.
Section snippets
Subjects and study design
The study was approved by the local ethics committee in conformity with the provisions of the Declaration of Helsinki (revised 2004). Inclusion criteria were; patients aged 18 to 85 years who had been hospitalized for an acute MI with a body mass index between 18 and 50 kg/m2 and had no history of cancer or current acute infection. Exclusion criteria were: patients on anticoagulant medication, low German language proficiency, a psychiatric diagnosis except anxiety or depression, and refusal of
Anxiety and depression symptom distribution in the sample
In the week after acute myocardial infarction (T0) the HADS-sum score was 12.36 (SD = 7.36), HADS-anxiety 7.23 (SD = 3.99), and HADS-depression 5.13 (SD = 4.06). Three months after the event (T1) the HADS-sum score was 10.54 (SD = 7.88), HADS-anxiety 5.89 (SD = 4.43), and HADS-depression 4.65 (SD = 4.06).
There were significant differences between the HADS measurements from T0 to T1. Values decreased on all scales (HADS-sum score: t = 3.74, df = 147, p < 0.001; HADS-anxiety: t = 4.68, df = 147, p < 0.001;
Discussion
Studies which have found an association between anxiety and depression and coagulation factors were mostly performed in samples of people without CAD. The clinical importance of such an association however, is highest in a population at risk, such as patients after a myocardial infarction. Furthermore, post-MI-patients are prone to a higher prevalence of anxiety and depression.
We investigated levels of anxiety, depression, coagulation factors, and fibrinolysis factors in a sample of 148
Conclusions
Research results concerning the association of anxiety and depression with coagulation markers in CAD patients are inconsistent. In our study, no such association was found in patients three months after myocardial infarction. The impact of ageing on anxiety and coagulation and on the relationship between both factors should be highlighted in further research.
Source of funding
This study was conducted with the support of a research grant from the Deutsche Stiftung für Herzforschung (grant number F/03/11).
Competing interests
The authors declare that they have no competing interests.
References (55)
Acute mental stress and hemostasis: when physiology becomes vascular harm
Thromb. Res.
(2015)Psychological distress and cardiovascular risk: what are the links?
J. Am. Coll. Cardiol.
(2008)- et al.
Fibrinolytic activity, clotting factors, and long-term incidence of ischaemic heart disease in the Northwick Park Heart Study
Lancet (London, England)
(1993) - et al.
Effect of acute psychological stress on the hypercoagulable state in subjects (spousal caregivers of patients with Alzheimer's disease) with coronary or cerebrovascular disease and/or systemic hypertension
Am. J. Cardiol.
(2001) - et al.
Relation of depressive mood to plasminogen activator inhibitor, tissue plasminogen activator, and fibrinogen levels in patients with versus without coronary heart disease
Am. J. Cardiol.
(2006) - et al.
Clopidogrel does not induce fibrinolysis in healthy subjects
Thromb. Res.
(2004) - et al.
The validity of the Hospital Anxiety and Depression Scale. An updated literature review
J. Psychosom. Res.
(2002) - et al.
Latent structure of the Hospital Anxiety And Depression Scale: a 10-year systematic review
J. Psychosom. Res.
(2012) - et al.
No further research needed: abandoning the Hospital and Anxiety Depression Scale (HADS)
J. Psychosom. Res.
(2012) - et al.
Why the HADS is still important: reply to Coyne & van Sonderen
J. Psychosom. Res.
(2012)
The Hospital Anxiety and Depression Scale: a meta confirmatory factor analysis
J. Psychosom. Res.
Effects of depressive symptoms and anxiety on hemostatic responses to acute mental stress and recovery in the elderly
Psychiatry Res.
Association between anxiety and mortality in patients with coronary artery disease: a meta-analysis
Am. Heart J.
The prevalence of anxiety in older adults: methodological issues and a review of the literature
J. Affect. Disord.
Aging-related diagnostic variations: need for diagnostic criteria appropriate for elderly psychiatric patients
Biol. Psychiatry
Hemostasis factors and aging
Exp. Gerontol.
Panic disorder and incident coronary heart disease: a systematic review and meta-regression in 1131612 persons and 58111 cardiac events
Psychol. Med.
Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis
Psychosom. Med.
Job strain predicts recurrent events after a first acute myocardial infarction: the Stockholm Heart Epidemiology Program
J. Intern. Med.
Psychological and social factors in coronary heart disease
Ann. Med.
Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease
Arch. Gen. Psychiatry
Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies
Eur. Heart J.
Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis
Psychosom. Med.
Exaggerated platelet and hemodynamic reactivity to mental stress in men with coronary artery disease
Psychosom. Med.
Effects of psychological stress and psychiatric disorders on blood coagulation and fibrinolysis: a biobehavioral pathway to coronary artery disease?
Psychosom. Med.
Association between anxiety and factors of coagulation and fibrinolysis
Psychother. Psychosom.
Hemostatic factors and the risk of myocardial infarction or sudden death in patients with angina pectoris. European Concerted Action on Thrombosis and Disabilities Angina Pectoris Study Group
N. Engl. J. Med.
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