Patients with coronary heart disease who have both depression and stress are at increased risk of myocardial infarction and death, according to findings from a large, prospective, cohort study.

Of 4,487 adults with CHD who were part of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, 1,337 experienced MI or death during a median of nearly 6 years of follow-up. Those with both high depressive symptoms and high stress at baseline – about 6% of the study population – were at significantly increased risk of such events (adjusted hazard ratio, 1.48) during the first 2.5 years of follow-up, compared with those with low stress and low depressive symptoms. However, the association was not significant beyond the initial 2.5 years (HR, 0.89), Carmela Alcántara, Ph.D., of Columbia University, New York, and her colleagues reported.

Those with low stress and high depressive symptoms, and those with high stress and low depressive symptoms, were not at increased risk (HR, 0.92 and 0.86, respectively) at any point during follow-up (Circ. Cardiovasc. Qual. Outcomes 2015 March 10 [doi:10.1161/IRCOUTCOMES.114.001180]).

The findings provide initial empirical evidence to support a “psychosocial perfect storm conceptual model” based on the idea that it takes an underlying chronic psychosocial vulnerability such as depression along with a more transient state such as psychological stress to precipitate a clinical event. The confluence of these factors may be particularly destructive in the short term, the investigators concluded, noting that the findings could have implications for the development of preventive treatments that focus on depression and stress during this vulnerable period in CHD patients.

The National Institute of Neurological Disorders and Stroke and the National Heart, Lung, and Blood Institute supported the study. Dr. Alcantara reported having no disclosures, but two other authors received salary support from Amgen for research, and one served as a consultant for DiaDexus.