Carl J Lavie, M.D., Arthur R. Menezes, M.D., Richard V. Milani, M.D.                                                                            

We read with interest the recent study by Chamberlain and colleagues¹ from Olmsted county demonstrating the association of depression and anxiety with hospitalizations for cardiovascular diseases (CVD), as well as the association of depression with increased all-cause mortality.  We have previously published on the high prevalence of hostility and total psychosocial stress (PSS), as well as depression and anxiety, in patients with CVD.^2-9  We agree that greater  attention directed at depression, anxiety, and total PSS is needed in secondary, as well as primary, prevention of CVD.

Although the prevention and treatment of PSS may require multifactorial interventions, one tried and proven, yet underutilized, therapy is formal cardiac rehabilitation and exercise training (CRET) programs.^10-11  We have demonstrated that following formal CRET programs, patients with CVD have nearly 50% reductions in the prevalence of depression, anxiety, hostility, and total PSS, as well as improvements in other major coronary heart disease (CHD) risk factors. ^2-12 Moreover, we have demonstrated that only small improvements in cardiorespiratory fitness (CRF) are needed to reduce depression and depression-related increased mortality,⁸ including in patients with CHD-related heart failure.¹²  In fact, our data indicate that most of the mortality reduction following formal CRET is due to changing the patient with high PSS to low PSS.⁹

We agree with Chamberlain et al¹ that greater efforts directed at depression, anxiety, and total PSS is needed throughout the medical field and, particularly, in the prevention and treatment of CVD.  Additionally, greater efforts are needed to improve referrals and utilization of formal CRET programs in patients with established CVD and to improve levels of CRF with regular exercise training in CHD prevention.

References
1.    Chamberlain AM, Vickers KS, Colligan RC, Weston SA, Rummans TA, Roger VL.  Associations of preexisting depression and anxiety with hospitalization in patients with cardiovascular disease.  Mayo Clin Proc 2011;86(11):1056-1062.
2.    Lavie CJ, Milani RV.  Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training. Mayo Clin Proc 2005;80(3):335-342.
3.    Lavie CJ, Milani RV.  Effects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility.  Mayo Clin Proc 1999;74(10):959-966.
4.    Lavie CJ, Milani RV.  Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation. Arch Intern Med 2006;166(17):1878-1883.
5.    Lavie CJ, Milani RV.  Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training. Am J Cardiol 2004;93(3):336-339.
6.    Lavie CJ, Milani RV, O’Keefe JH, Lavie TJ.  Impact of exercise training on psychological risk factors.  Prog Cardiovasc Dis 2011(6);53464-470.
7.    Menezes AR, Lavie CJ, Milani RV, O’Keefe JO, Lavie TJ.  Psychological risk factors and cardiovascular disease:  is it all in your head?  Postgrad Med 2011;123(5):165-176.
8.    Milani RV, Lavie CJ.  Impact of cardiac rehabilitation on depression and its associated mortality. Am J Med 2007;120(9):799-806.
9.    Milani, RV, Lavie CJ.  Reducing psychosocial stress: a novel mechanism of improving survival from exercise training. Am J Med 2009;122(10):931-938.
10.    Lavie CJ, Milani RV.  Cardiac rehabilitation and exercise training in secondary coronary heart disease prevention.  Prog Cardiovasc Dis 2011;53(6):397-403.
11.    Lavie CJ, Thomas RJ, Squires RW, Allison TG, Milani RR.  Exercise training and cardiac rehabilitation in primary and secondary prevention of coronary heart disease.  Mayo Clin Proc 2009;84(4):373-383.
12.    Milani RV, Lavie CJ, Mehra MR, Ventura HO.  Impact of exercise training and depression on survival in heart failure due to coronary heart disease. Am J Cardiol;2011 107(1):64-68.