CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 30 AFRICA The non-negligible association between SYNTAX score and anxiety–depressive disorders Levent Cerit, Zeynep Cerit, Hamza Duygu Abstract Objective: Anxiety–depressive disorders are more common in patients with coronary artery disease (CAD) and are strongly associated with higher morbidity and mortality rates. The Hospital Anxiety and Depression Scale (HADS) is a wellvalidated diagnostic tool for screening of anxiety–depression disorders. The SYNTAX score (SS) is the angiographic scoring system and is commonly used to evaluate the severity and complexity of CAD. The aim of this study was to evaluate the association between the HADS and SS. Methods: The HADS questionnaire was filled in by subjects before the coronary angiography procedure. Biochemical, clinical and echocardiographic parameters, and SS were evaluated in all patients. Patients were assessed using the HADS. The patients were divided into two groups according to the SS [≥ 23: high SYNTAX score group (HSSG), < 23 low]. Results: The HADS scale was significantly higher in HSSG (24.8 ± 10.7 vs 11.3 ± 6.4 p < 0.001). There was no significant difference between the groups regarding laboratory parameters. On multivariate analysis, diabetes mellitus, hyperlipidaemia and the HADS were independent predictors of high SYNTAX score. Conclusion: In our study, we found that diabetes mellitus, hyperlipidaemia and the HADS were independent predictors of a higher SS. Keywords: anxiety–depressive disorders, coronary artery disease, diabetes mellitus, hyperlipidaemia Submitted 8/1/19; accepted 10/5/22 Published online 18/8/22 Cardiovasc J Afr 2023; 34: 30–34 www.cvja.co.za DOI: 10.5830/CVJA-2022-022 Anxiety–depressive disorders are common in patients with coronary artery disease (CAD), with an estimated prevalence of about 20–45%. Patients with CAD had a three-fold higher prevalence of major depressive disorder (MDD) than in the general population. Anxiety disorders are strongly associated with a lower quality of life, poorer somatic outcomes, higher medical costs, increased risk for all-cause mortality and major adverse cardiac events, independent of disease severity. Depression is associated with a 2.7-fold risk of impaired cardiovascular outcome and prognosis, independent of other risk factors in the post-myocardial infarction period.1 The prevalence of minor or major depression is approximately 30–40% among patients undergoing coronary artery bypass graft surgery (CABG), and 15% of patients meet the full MDD criteria. The female gender, living alone, younger age, lower educational status and pre-CABG depressive symptoms are strongly associated with post-CABG depression. Depression has been associated with longer hospitalisation, poorer functional outcomes, more peri-operative complications, worse health-related quality of life, progression of atherosclerotic disease, higher rates of rehospitalisation and mortality in patients undergoing CABG.2 The American Heart Association has recommended routine screening for depression in CAD patients due to the unfavourable short- and long-term effects of depression on cardiovascular outcomes.3 The link between depression and CAD is most likely multifactorial. Some mechanisms have been proposed about the potential link between depression and CAD, including platelet hyper-reactivity (elevated plasma platelet factor 4 and β-thromboglobulin), endothelial dysfunction, inflammatory activation (increased C-reactive protein, interleukin-6, intercellular adhesion molecule-1 and fibrinogen levels), increased sympathetic activity and/or reduced vagal activity (reduced heart rate variability) and hypothalamic–pituitary– adrenal axis dysfunction.4 Additionally, behavioural and social characteristics of depressed patients, including unhealthy diet, sedentary lifestyle, insufficient medication adherence, tobacco use and chronic life stress might also contribute to the development and progression of CAD.5 The Hospital Anxiety and Depression Scale (HADS) has well-established psychometric features for the screening of depressive disorders and evaluation of the severity of depressive symptoms at different stages of CAD.6 Recently, Frasure-Smith et al.4 demonstrated that the HADS had acceptable sensitivity and specificity for screening of generalised anxiety disorder in stable CAD patients. The SYNTAX score (SS) is an angiographic grading tool to evaluate the complexity and extensity of CAD. It is widely used for determining the optimal revascularisation strategy. It is also a powerful stratification mechanism allowing uniform, standardised assessment of CAD complexity and extensity.7 There is inconsistent data about the association between CAD and anxiety–depressive disorders in the literature. There are scarce data about the association between the HADS and SS. In the light of this, we assessed the relationship between the HADS and SS in this study population. Methods This prospective study involved 997 patients who had coronary angiography to investigate stable angina pectoris. We enrolled Near East University Hospital, Nicosia, Cyprus Levent Cerit, MD, drcerit@hotmail.com Near East University, Nicosia, Cyperus Zeynep Cerit, MD Hamza Duygu, MD
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