Clinical Investigation
Acute Ischemic Heart Disease
Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans Administration patients

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Background

Depression is a risk factor for incident myocardial infarction (MI), but little is known about the independent or additive risk from anxiety disorders.

Methods

In a 7-year retrospective cohort design, we identified a cohort free of cardiovascular disease in fiscal years 1999 and 2000 that contained 96,612 patients between 25 and 80 years of age who had an International Classification of Diseases, Ninth Revision, Clinical Modification code indicating a diagnosis of depression in 2000 (baseline) and 259,387 patients without depression. Cox proportional hazards models stratified by depression were computed to test for a main effect of anxiety disorder unspecified, generalized anxiety disorder, panic disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder (PTSD) on risk of incident MI. The models were adjusted for multiple MI risk factors and sociodemographics.

Results

Depressed as compared to nondepressed Veterans Administration patients were at increased risk for incident MI (HR 1.39; 95% CI 1.34-1.45). In nondepressed patients those with anxiety disorder unspecified (HR 1.34; 95% CI 1.21-1.47), panic disorder (HR 1.43; 95% CI 1.11-1.83), and PTSD (HR 1.25; 95% CI 1.16-1.36) were at increased risk for incident MI. The independent risk associated with anxiety disorders was reduced in patients comorbid for depression.

Conclusions

In Veterans Administration patients free of heart disease in 1999 and 2000, those with depression, anxiety disorder unspecified, panic disorder, and PTSD were at increased risk of incident MI. Anxiety disorders are independent risk factors for MI. Depression partially accounts for the effect of anxiety disorders on risk of MI in patients with both conditions.

Section snippets

Background

Numerous epidemiological studies have established that depression is a risk factor for cardiovascular disease.1 Most studies have demonstrated that a history of depression increases the likelihood of incident heart disease, including myocardial infarction (MI), by approximately 2-fold.2, 3, 4, 5, 6 This effect remains after adjusting for common vulnerabilities including smoking, diabetes, and hypertension. Though less well studied, a growing literature has demonstrated that anxiety is a risk

Methods

We used a retrospective cohort design. Data were obtained from inpatient and outpatient International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses, Current Procedural Terminology codes, Pharmacy Benefits Management records and sociodemographic information maintained by the Veterans Health Administration (VHA) national medical care data sets beginning in Fiscal Year (FY) 1999, the first year that national data is considered complete. These data are

Patients with and without depression

The distributions of the covariates in the depressed and nondepressed groups are shown in Table I. Patients with depression were significantly younger at baseline as compared to nondepressed patients (51.6 vs 57.2 years, P < .0001). About 90% of the cohort were male but females were disproportionally over-represented among depressed patients (P < .0001). Depressed patients were more likely (P < .0001) to be white, not married, and to have only VA insurance coverage.

Compared to nondepressed

Discussion

In a cohort of patients receiving care in the VA medical system who were free of cardiovascular disease at baseline, we observed an increased risk for incident MI among patients with depression, anxiety disorder unspecified, GAD, panic disorder, and PTSD. In time-dependent adjusted analyses, anxiety disorder unspecified, panic disorder, and PTSD were significant predictors of MI in non-depressed; however, the effect of these anxiety disorders on risk of MI was attenuated among depressed

Acknowledgements

Dr Carney received an honorarium from Forest Laboratories, Inc, for participating in a symposium and completing a review of the literature concerning depression and heart disease. Dr Scherrer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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