Study reveals association between depression and coronary spasm

A study published in the current issue of Psychotherapy and Psychosomatics explores the relationship between depression and coronary artery spasm.

Prinzmetal and colleagues described a syndrome characterized by angina at rest associated with coronary spasm, i.e. temporarily increased vascular tonus. Considering that coronary spasm has a potential psychological background and a lesser structural basis for its symptoms, the Authors of this paper hypothesized that depression, known as having an important effect on cardiovascular health even at a sub-threshold level, may contribute substantially to the occurrence of coronary spasm. The aim of this study was to evaluate associations of depression with coronary spasm and coronary atherosclerosis and the strength of these associations. The sample included patients with chest pain who were referred for coronary angiography (CAG) and later diagnosed with either coronary spasm or coronary atherosclerosis, from a well-established cohort. Study participants were 335 patients with chest pain or chest discomfort consecutively admitted for CAG to the Cardiac Center at the Kangnam St. Mary's Hospital between July 2004 and May 2005. Twenty-six subjects dropped out due to either unexpected discharge before assessment (n = 17), or they required emergent/intensive care (n = 9). 292 subjects (83.2%) were included in the final analysis. CAG was conducted for confirmative and differential diagnosis of coronary artery disease. Coronary atherosclerosis was  diagnosed by the presence of atherosclerotic stenosis that was 50% larger than the luminal reference diameter in one or more coronary arteries. Coronary spasm was diagnosed by induced coronary artery spasm showing > 90% narrowing of a coronary artery from the baseline diameter (i.e. chest symptoms and ST-segment elevation after intracoronary injection of acetylcholine). Control subjects were defined as having neither of these conditions, but having recurrent chest pain. In order to yield a psychiatric diagnosis, semi-structured interviews were held by a psychiatrist who was completely unaware of the medical history or status of the study subjects. These interviews were conducted within a 24-hour period after CAG, utilizing DSM-IV criteria. Depressive symptoms were measured using the 17-item Hamilton Depression Rating Scale (HDRS). The investigators used univariate and multivariate multinomial logistic regression models to investigate the relation between depression and coronary artery disease as determined by CAG. Multinomial logistic regression modeling with outcome measures of normal coronary angiographic findings, coronary spasm and coronary atherosclerosis were used. Out of 292 participants who were included in the final analysis, 63 were diagnosed as suffering from coronary spasm (21.6%), as were 117 from the coronary atherosclerosis group (40.1%, stable/unstable angina or myocardial infarction). 112 subjects with normal angiographic findings served as a control group (38.4%). 32 (11.0%) of the participants had clinical depression. The means (ranges) of HDRS scores for each coronary spasm, coronary atherosclerosis, and control group were 6.76 (0-26), 5.51 (0-20) and 4.33 (0-19), respectively. A univariate multinomial logistic regression model indicated that the prevalence of coronary spasm was higher in patients who were men (OR = 2.06, 95% CI = 1.10-3.86, p = 0.02) and had a history of smoking (OR = 2.43, 95% CI = 1.17-5.50, p = 0.02). There was a negative association between the presence of hypertension (OR = 0.40, 95% CI = 0.20-0.80, p = 0.01) and the diagnosis of coronary spasm. Adjusting for established risk factors in the multivariate multinomial logistic regression model, depression was associated with the diagnosis of coronary spasm (OR = 4.17, 95% CI = 1.51-11.54, p = 0.006), but not with coronary atherosclerosis (OR = 1.13, 95% CI = 0.40-3.21, p = 0.81) relative to a reference diagnosis of normal coronary angiographic findings. When tested with subgroups according to depressive symptom severity, there was a dose-response relationship between depression and coronary spasm, but not between depression and coronary atherosclerosis (p values for trend = 0.001 and 0.31, respectively). The current study replicated well-known dose-response associations between known risk factors and coronary atherosclerosis. The investigators did not find any interaction effects between depression and the risk factors for the occurrence of specific types of coronary artery disease (all p values for interaction > 0.20). The current study is the first report showing a strong association between depression and coronary spasm. This dose-response association was independent of known risk factors for coronary atherosclerosis. Furthermore, these coronary atherosclerosis risk factors do not seem to contribute to the development of coronary spasm.