March 9, 2009 — Depression, anger, and hostility may be red flags of heightened heart disease risk, even if you don’t have heart disease right now.

That news comes from two studies published in the March 17 edition of the Journal of the American College of Cardiology.

Highlights from the studies include:

• 
  Depression and heart disease: Sudden cardiac death may be more than twice as common among women with symptoms of major depression than women who aren’t depressed. This finding comes from a study of more than 63,000 U.S. female nurses followed from 1992 to 2004. The nurses had no history of heart disease when the study started. The study also linked sudden cardiac death to antidepressant use, but it’s not clear if that’s related to the drugs or the depression.
• Anger/hostility and heart disease: Chronically angry or hostile adults with no history of heart disease may be 19% more likely than their peers to develop heart disease. And angry or hostile heart disease patients may be 24% more likely than other heart disease patients to have a poor prognosis. These findings came from reviewers who pooled data from 44 studies conducted in America, Europe, Asia, and Australia between 1983 and 2006.

The reports don’t prove that depression, anger, or hostility caused heart disease. But the findings held regardless of other heart disease risk factors, suggesting a stubborn link among those traits.

It’s a connection that doctors and patients need to take seriously and talk about, heart experts tell WebMD.

Heart Disease, Depression, Anger

“There is clearly a link between depression, anger, anxiety, stress, and outcomes in heart disease,” says Philip Binkley, Wilson professor of medicine at The Ohio State University’s division of cardiovascular medicine.

The new reports underscore that link, notes Redford Williams, MD, director of the Behavioral Medicine Research Center at Duke University.

“What these papers tell us is what we have all known and anybody would accept — that being hostile and angry a lot of the time is bad for your health, being depressed is bad for your health,” Williams says.

Williams tells WebMD that he “absolutely” considers chronic anger, hostility, or depression to be risk factors for heart disease, just like high blood pressure (hypertension), smoking, or high cholesterol.

Based on the new reports and previous research, “I think you pretty well have to conclude that yes indeed, these are risk factors,” Williams says.

Binkley agrees.

“The biggest message that we try to get out to people is this is a risk factor and a health problem,” Binkley says. “This is something we have to talk about. The worst thing is to ignore it.”

Cardiologist Pamela Douglas, MD, Geller Professor of Medicine at Duke University, also sees a strong link between depression and heart disease — but she stops short of calling depression a risk factor for heart disease. She says it’s not clear which comes first, depression or heart disease. “It’s sort of a chicken-or-the-egg issue,” Douglas says.

All three experts agree that other heart disease risk factors often accompany depression — and it never hurts to screen for heart hazards. And if you already know you have heart disease, you should be screened for depression, according to guidelines set in September 2008 by the American Heart Association.

What About Antidepressants?

As noted earlier, the new report on depression and heart disease showed a possible link between antidepressant use and the risk of sudden cardiac death.

Those findings raise more questions than they answer.

“The question is, is that just because the antidepressants were a sign of a more severe depression or was it a result of something about the antidepressants themselves?” Williams asks.

Williams notes that some antidepressants, called tricyclic antidepressants, are known to have possible effects on cardiac arrhythmias. But the new report doesn’t show what kind of antidepressants the patients were taking or other details about their antidepressant use.

“It could be that the drug itself was contributing to the risk of sudden cardiac death in patients who were depressed … but my guess would be that it’s probably, if anything, a function of the severity of the depression,” Williams says.

Binkley says that people taking antidepressants shouldn’t jump to conclusions. “We need to collect much more information. This is one study,” says Binkley.

Douglas agrees that the antidepressant findings aren’t totally clear. But she says, “Don’t take ’em if you don’t need ’em.”

Does Treatment Help?

Douglas and Binkley say studies haven’t proven that treating depression (or hostility and anger) eases heart disease.

“We don’t have much information on that,” Douglas says.

“That’s still something we need to learn much more about,” Binkley says.

But Williams says a program he and his wife, Virginia Williams, PhD, have developed has been shown to lower blood pressure, depression, hostility, and anger.

Williams says the strategy, which is the basis of a company called Williams LifeSkills Inc. that he and Virginia formed and have a financial interest in, boils down to this:

When you’re in a situation that triggers anger, sadness, or anxiety, ask yourself these four questions: Is this important? Am I having an appropriate reaction? Is this situation modifiable (can I do anything about it)? Is it worth it to me to do something about it?

“A ‘no’ to any of those four questions means … change your reaction [to the situation],” says Williams. He suggests self-talk, breathing exercises, prayer, or whatever else it takes to shift your reaction.

But if you answer “yes” to all four questions, then it’s time to be appropriately assertive, which Williams says means describing the problematic behavior, explaining how you feel, requesting change, and, if all that fails, setting reasonable consequences.

Williams also recommends focusing on damage prevention by improving communication and relationships.

That includes speaking clearly, listening well (not interrupting, acting interested in what the speaker is saying, recapping their main points when they’re done, and being prepared to be changed by what you hear), showing empathy, and looking for opportunities to make your interactions with other people more positive (such as by paying compliments and being a good listener.)