The connection between cardiovascular health and mental health is well-established, with a range of research findings indicating a bidirectional association in which cardiovascular health may influence psychological functioning and vice versa. A statement released by the American Heart Association (AHA) in 2021 focused on this link and emphasized the importance of provider awareness and appropriate screening measures to identify the potential need for psychological support.1
“Mental health has an important impact on cardiovascular health, with negative factors portending higher cardiovascular risk and positive factors demonstrating an association with improved cardiovascular outcomes,” Eugene C. DePasquale, MD, assistant professor of clinical medicine and medical director of the Heart Failure, Heart Transplantation and Mechanical Circulatory Support Program at Keck Medicien of USC in Los Angeles, told us in an interview.
In addition to these general associations, recent findings highlight the potential influence of psychological health on outcomes following myocardial infarction (MI). A 2021 study2 examined rates of major adverse cardiovascular events (MACE) in the 5 years post-MI among 283 young adult and middle-aged survivors (mean age, 51; 64% Black; 50% women). The incidence of MACE during the follow-up period was 47% in patients with high scores on a measure of psychological distress, compared to 22% in those with scores indicating mild distress (hazard ratio [HR], 2.7; 95% CI, 1.5-4.9).
In a study published in February 2022 in Scientific Reports, Sreenivasan et al investigated associations between the presence of specific mental health disorders and the risk for all-cause hospital readmission within 30 days of discharge following MI.3 Using a database capturing all-payer inpatient stays in acute care hospitals in the United States from 2016 to 2017, the authors analyzed hospitalizations of adults with acute MI and co-occurring major depressive disorder (MDD), anxiety disorders, bipolar disorder, and schizophrenia or another psychotic disorder based on ICD-10-CM diagnostic codes.
Among the 1,045,752 admissions (mean age, 66.6±12.9 years; 37.6% women) for MI that met inclusion criteria, the prevalence of any mental health disorder was 15%. Rates of each subtype of mental health disorder were 5.2% for MDD, 0.8% for bipolar disorder, 8.8% for anxiety disorders, and 0.7% for schizophrenia and other psychotic disorders.
The average rate of 30-day, all-cause rehospitalization after MI was 10.4% for the entire cohort. After adjusting for demographics, medical and cardiac comorbidities, and coronary revascularization, the diagnosis of a comorbid mental health disorder was independently associated with a higher 30-day readmission risk compared with patients with no co-occurring mental health disorder as follows: major depression (HR, 1.11; 95% CI, 1.07-1.15), bipolar disorder (HR, 1.32; 95% CI, 1.19-1.45), anxiety disorders (HR, 1.09; 95% CI, 1.05-1.13) and schizophrenia and other psychotic disorders (HR, 1.56; 95% CI, 1.43-1.69).
The results also demonstrated that patients with mental health disorders were less likely to receive coronary revascularization (MDD, 52.8%; bipolar disorder, 56.7%; anxiety disorder, 56.7%; and schizophrenia/other psychotic disorders, 41.7%) than patients without co-morbid a mental health disorder (61.6%; P <.001 for all).
These findings warrant close attention due to the elevated mortality and morbidity associated with hospital readmissions following acute MI.3
“Multidisciplinary efforts are likely key to improving outcomes in this population,” Dr DePasquale said. “These efforts include not only increasing access to coronary revascularization for these patients, but also providing medical and behavioral interventions to mitigate the disparities and reduce adverse outcomes.” He notes the need for additional studies to increase understanding and guide improvements in each of these areas.
To further discuss these observations and related clinical implications, we checked in with Erin D. Michos, MD, MHS, FACC, FAHA, associate professor of medicine and epidemiology and associate director of preventive cardiology at Johns Hopkins School of Medicine in Baltimore, Maryland. Dr Michos co-authored both the 2022 study and the AHA statement described above.3,1
Regarding your findings, what are the possible reasons for the increased risk of 30-day readmission after MI in patients with mental health disorders?
We were unable to determine the reasons for this result, but I can speculate: The suboptimal rates of coronary revascularizations could lead to recurrent ischemic events, and this may be 1 reason for readmission. Suboptimal initiation and adherence to guideline-recommended post-MI preventive therapies and referral to cardiac rehab may be other mechanisms.
Patients with mental health disorders may have insufficient social support and are potentially at risk for discrimination. Additionally, psychological distress can negatively impact the cardiovascular system. Persistent psychological distress is associated with detrimental biological processes such as increased stress hormone release, increased inflammation, impaired glucose control, hypercoagulability, and endothelial dysfunction. Chronic stress can also lead to activation of the sympathetic nervous system with increased heart rate and increased blood pressure, which can further worsen ischemia in patients with underlying cardiovascular disease.1
What are the possible reasons why patients with mental health disorders were less likely to receive coronary revascularization after MI?
Clinician biases, possible late presentations, and logistical challenges in providing optimal invasive care (such as if patients with severe depression or bipolar disorder decline an offered option of coronary revascularization) are possible reasons for a lower rate of the procedure among these subgroups.
What are recommendations for clinicians regarding the relationship between mental health and heart health?
It is imperative to make sure that all patients are treated according to evidence-based, guideline-directed medical care, implementing checklists and protocols to reduce treatment bias. Additionally, cardiovascular disease should not be addressed as an isolated entity, but rather as 1 part of an integrated system in which mind, heart, and body are interconnected. Negative psychological status appears to impact cardiovascular health and prognosis directly.
In addition to the current findings, we previously demonstrated an alarming increase in the prevalence of major depression and bipolar disorder among patients with acute MI over a 10-year period.4 These are worrisome trends. Taken together, these data emphasize that it is vitally important to provide comprehensive care for patients with mental health disorders, with a goal to achieve optimal revascularization rates, reduce the risk for readmission, and improve long-term outcomes.
Along with routine guideline-directed medical care following MI (such as antiplatelet agents, statins, ACEi/ARB, beta blockers, and so forth) and referral to cardiac rehab, there should also be attention to screening for mental health disorders and making sure that patients have adequate support and resources to address their mental health.
[Editor’s note: The AHA statement1 recommends the use of brief, well-validated screening tools such as the Patient Health Questionnaire-2 and the Generalized Anxiety Disorder Questionnaire-2 to assess for depression or anxiety, as well “brief questions about optimism, motivation, and positive affect and their impact on self-management.”]
For those not already connected, patients with significant psychological distress should be connected with a trained mental health professional. It’s about treating the whole person.
What further research is needed to improve outcomes in survivors of MI with a comorbid mental health disorder?
Focused mental health interventions are warranted to address the increasing burden of comorbid mental health disorders among patients with acute MI. Future research is needed to determine what are the best interventions to improve outcomes in patients with MI and a mental health disorder, but these would likely involve a team-based approach to care that includes social work and trained mental health professionals. There needs to be better screening for mental health disorders overall, and culturally sensitive care to treat the whole person without bias or discrimination.
- Levine GN, Cohen BE, Commodore-Mensah Y, et al. Psychological health, well-being, and the mind-heart-body connection: A scientific statement from the American Heart Association. Circulation. Published online January 25, 2021. doi:10.1161/CIR.0000000000000947
- Garcia M, Young A, Almuwaqqat Z, et al. Psychological distress and the risk of adverse cardiovascular outcomes in young and middle-aged survivors of myocardial infarction. Poster session presented at ACC.21. JACC. 2021;77(18).
- Sreenivasan J, Kaul R, Khan MS, Malik A, Usman MS, Michos ED. Mental health disorders and readmissions following acute myocardial infarction in the United States. Sci Rep. Published online February 28, 2022. doi:10.1038/s41598-022-07234-z
- Sreenivasan J, Khan MS, Khan SU, et al. Mental health disorders among patients with acute myocardial infarction in the United States. Am J Prev Cardiol. Published online December 8, 2020. doi:10.1016/j.ajpc.2020.100133