CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 33 Heart rate variability (HRV) is a well-known risk factor for adverse cardiovascular outcomes. Depressed patients have linearly reduced HRV associated with the severity of depression. Furthermore, patients with both CAD and depression have greater decreases in HRV.20 In addition to the abovementioned mechanisms, brain-derived neurotrophic factor (BDNF) may also play an important role in the association between depression and adverse cardiovascular events. Depression has been strongly and consistently linked to low levels of BDNF, which were linked to increased cardiomyocyte death and impaired systolic function in experimentally induced myocardial infarction.21 Medication non-adherence and lower level of physical fitness are associated with an increased risk of cardiovascular events in patients with MDD. Depressed patients fail to succeed in healthpromoting behaviours, including maintenance of a healthy diet, regular exercise, adherence to medications, stress reduction and lowering of cholesterol level.5 There are inconsistent results about the association between anxiety–depression and CAD in the literature. Low et al.22 found an inverse association between coronary artery occlusion and anxiety symptoms. Assari et al.23 found an inverse association may exist between the extent of coronary stenosis (single-, two-, threevessel disease) and the severity of anxiety symptoms in patients who undergo coronary angiography. On the other hand, Tennant and et al.24 found no association between angiographic findings and psychological status, including anxiety levels. Additionally, Vural et al.25 found that the depression score was strongly correlated to CAD after controlling for gender and other variables. They reported that every five-point increase in depression score was associated with a 25–30% increase in the risk of abnormal coronary angiography findings or definitive CAD. In the literature, different severity modalities were used to evaluate the extensity/severity of CAD.24,25 In our study, the SS system was used with high diagnostic value to evaluate the extensity and severity of CAD, and a higher anxiety–depressive scale was found to be an independent predictor of high SS. Although adverse cardiovascular outcomes of anxiety– depressive disorders are well known, healthcare providers often fail to identify obvious symptoms of anxiety in patients with CAD. Considering the close association between MDD and adverse cardiovascular outcomes, every patient should be evaluated with regard to anxiety–depressive disorders, according to the American Heart Association recommendation.3 Our study has some limitations. First is the small sample size of this study. Second, by nature of the cross-sectional study, we cannot claim a definitive causal relationship between CAD and anxiety–depression disorder. Third, we evaluated symptoms of anxiety–depression instead of the clinical diagnosis of any anxiety–depression disorder. Fourth, our results cannot be applied to patients with acute coronary syndromes because only stable CAD patients were involved in our study. Conclusion In our study, we found that DM, HL and HADS were independent predictors of a higher SS. Physicians should pay attention to the importance of anxiety–depressive disorder assessment, which is likely to be overlooked due to intensive daily routine programmes. Further studies with a larger number of patients are required for evaluation of the association between the severity of anxiety–depression and CAD. References 1. Shanmugasegaram S, Russell KL, Kovacs AH, Stewart DE, Grace SL. 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