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Potential New Cardiovascular Risk Factors

TO THE EDITOR: Harjai's excellent review (1) of potential cardiovascular risk factors is striking for its inattention to depression, one of the most prevalent (6% to 10% of primary care patients and 16% to 45% of cardiac patients) and inexpensively assessed factors associated with cardiovascular morbidity. Many reports published in the past decade have linked elevated levels of depressive symptoms and major depression to both the development and progression of cardiovascular disease, as well as mortality from it. Comprehensive summaries of the epidemiologic and pathophysiologic evidence have been published in the psychiatric literature (2). However, Harjai may have overlooked this evidence because of his focus on select physical and biochemical measures. Patients with depression experience at least as much physical and social dysfunction from this disorder as those with other cardiovascular risk factors, such as hypertension and diabetes (3). Furthermore, depression can have adverse effects on functional status, health-related quality of life, and comorbid medical illness that may affect patients' ability to make necessary behavioral changes and modify other cardiovascular risk factors (4). Although it is unclear whether treating depression will reduce cardiovascular morbidity for persons who have or are at risk for cardiovascular disease, efficacious treatments for depression that have low cardiovascular toxicity are widely available and in use. A large National Institutes of Health-funded clinical trial is currently examining whether treating depression after myocardial infarction can reduce subsequent cardiovascular morbidity (5). Still, more research in this area is needed. Future consensus panels, including those sponsored by the National Institutes of Health and the American Heart Association, should examine the evidence linking depression to cardiovascular disease. If this link is confirmed, depression should formally be added to the list of risk factors clearly associated with cardiovascular disease that is widely disseminated to health care professionals and the public through various government, professional, and lay media channels.