title: Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease.
abstract: BACKGROUND
  Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown.
  
  
  OBJECTIVE
  To determine why depressive symptoms are associated with an increased risk of cardiovascular events.
  
  
  METHODS
  The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years.
  
  
  METHODS
  Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008.
  
  
  METHODS
  Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators.
  
  
  RESULTS
  A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score > or = 10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16-1.95; P = .002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00-1.71; P = .04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94-1.63; P = .12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79-1.40; P = .75).
  
  
  CONCLUSIONS
  In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.
authors.affiliation: VA Medical Center, San Francisco, California, USA. mary.whooley@ucsf.edu
authors.forename: Mary A
authors.initials: MA
authors.lastname: Whooley
authors.forename: Peter
authors.initials: P
authors.lastname: de Jonge
authors.forename: Eric
authors.initials: E
authors.lastname: Vittinghoff
authors.forename: Christian
authors.initials: C
authors.lastname: Otte
authors.forename: Rudolf
authors.initials: R
authors.lastname: Moos
authors.forename: Robert M
authors.initials: RM
authors.lastname: Carney
authors.forename: Sadia
authors.initials: S
authors.lastname: Ali
authors.forename: Sunaina
authors.initials: S
authors.lastname: Dowray
authors.forename: Beeya
authors.initials: B
authors.lastname: Na
authors.forename: Mitchell D
authors.initials: MD
authors.lastname: Feldman
authors.forename: Nelson B
authors.initials: NB
authors.lastname: Schiller
authors.forename: Warren S
authors.initials: WS
authors.lastname: Browner
mesh_terms: D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use; D015897:Comorbidity; D003327:Coronary Disease / Q000453:epidemiology* / Q000401:mortality / Q000523:psychology* / Q000534:rehabilitation; D003863:Depression / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D003865:Major Depressive Disorder / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D015444:Exercise; D005260:Female; D015438:Health Behavior; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index
chemical_list: D000928:Antidepressive Agents