Depression and coronary heart disease: 2018 position paper of the ESC working group on coronary pathophysiology and microcirculation

Major depression is a highly prevalent condition, affecting approximately 10% of the population. It is also a growing global problem, and has been consistently associated with increased risk of coronary heart disease (CHD). It is therefore not surprising that depression is highly comorbid with CHD, being two to three times more common among patients with CHD than in the general population. The prevalence of depression is 15–30% in patients with CHD, and is approximately twice as high in women than men, especially affecting young women in the aftermath of acute myocardial infarction (MI). Depression as a risk factor for CHD has been characterized from mild depressive symptoms to a clinical diagnosis of major depression. As defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), clinical depression, or major depression, is characterized by depressed mood or anhedonia (loss of interest or pleasure) for at least 2 weeks accompanied by significant functional impairment and additional somatic or cognitive symptoms. Most epidemiological studies of depression and incidence of CHD have used depressive symptom scales, and have frequently demonstrated a dose–response pattern, with higher levels of depressive symptoms being associated with higher risk. The exact mechanisms linking depression to increased CHD risk are complex and multifactorial, and still incompletely understood. Although adverse lifestyle behaviours and traditional CHD risk factors, such as smoking and sedentary lifestyle, largely contribute to the risk, they do not explain it entirely. In CHD patients, depression is also associated with severity of functional impairment, lower adherence to therapy and lower participation in cardiac rehabilitation. Whether and to what extent these factors explain the relationship between depression and CHD deserves future study. The present paper summarizes key aspects in our current knowledge linking depression and CHD within the intersecting fields of neuroscience, cardiovascular physiology, and behavioural medicine, with the objective of bringing attention to this area and stimulating interdisciplinary research, clinical awareness, and improved care.