Combined Effect Of High Depressive Symptom Burden And Hypertension On Incident Cardiovascular Disease And Change In Self-rated Health

BackgroundCardiovascular disease(CVD)is a major contributor to the disease burden in our country and worldwide,due to its high incidence,prevalence,mortality and disability rates.Unlike CVD is an objective physical condition,self-rated health(SRH),a personal perception of individuals’ health status,has been reportedly be an independent and robust predictor of CVD.Accordingly,identifying and intervening the risk factors of CVD and change in SRH may be instructive to improve the quality of life and help to achieve the target of forward shift in cardiovascular disease prevention among the middle-aged and elderly Chinese population.However,high depressive symptom burden(HDSB)and hypertension have been found to be associated with CVD respectively,few literatures have reported the combined effect of HDSB and hypertension on the risk of new-onset CVD in the general population so far.Furthermore,no studies conducted in China evaluate whether HDSB and hypertension could be treated as an independent influencing factor on the change in SRH.ObjectiveTo investigate whether the combination of HDSB and hypertension increased the risk of CVD among the middle-aged and elderly Chinese using a nationwide prospective study.Meanwhile,we try to assess the relationship of HDSB and hypertension with change in SRH prospectively,with the aim of providing a new reference for improving SRH status and achieving the goal of early prevention in CVD.Objects and methodsWe used data from the China Health and Retirement Longitudinal Study(CHARLS).CHARLS is designed to collect a wide range of information on the economic standing,physical and psychological health,demographics and social networks of middle aged and elderly persons.The aim of CHARLS is to better understand the socioeconomic determinants and consequences of aging.In this study,a total of 11,692 subjects were included in the first chapter.According to depressive symptom burden and hypertension at baseline,we divided all participants into four groups:low depressive symptom burden(LDSB)and non-hypertension(Group 1),HDSB and non-hypertension(Group 2),LDSB and hypertension(Group 3)and HDSB and hypertension(Group 4).Median(25th-75th percentile)and frequency(percentage)were used for description of continuous and categorical variables,respectively.Pearson chi-square test was conducted to evaluate differences of categorical variables and Kruskal-Wallis test was used to determine the differences of continuous variables among the four groups.Kaplan-Meier curves and the log-rank test were used to compare the cumulative risk of events among different groups.To evaluate the association between HDSB,hypertension and new-onset CVD,heart problems and stroke,we estimated hazard ratios(HRs)and 95%confidence intervals(CIs)through multivariate Cox proportional hazards regression and competing risk model.In Chapter 2,a total of 7,440 individuals were eligible for analysis.Firstly,a percent bar graph was used to reveal the distributions of change in SRH from 2011 to 2013 and from 2011 to 2015.The association between baseline HDSB,hypertension and follow-up change in SRH was evaluated by odds ratio(OR)and 95%confidence interval(CI)using multinomial logistic regression models.Moreover,we used the restricted cubic spline regression models to detect any possible linear or non-linear dependency and interpret the relationship between CESD-10 score,the value of SBP,DBP and change in SRH.In addition,multinomial logistic regression and generalized linear mixed model were used to further evaluate the combined effect of HDSB and hypertension on 2-and 4-year change in SRH.All statistical analyses were performed in SAS version 9.4 and R software.Statistical significance was set as 0.05(two-tailed).Results1.A study on the combined effect of high depressive symptom burden and hypertension on CVD found that:1.1 Among 11,692 participants included for analysis,4341 subjects had neither HDSB nor hypertension,2307 had HDSB alone,3213 had hypertension alone,and 1831 had both HDSB and hypertension.We found that sex,age,living place,household income per capital,education level,smoking,drinking and BMI showed significant differences among the four groups(P<0.05).In addition,the prevalence rates of chronic diseases(except cancer)were all higher in Group 4.1.2 During the follow-up,a total of 1041,889 and 187 respondents experienced CVD,heart problems and stroke events,respectively.The cumulative incidences of CVD,heart disease and stroke in Group 1 were 4.98%,4.45%and 0.62%respectively,while those in Group 2 were 8.54%,7.33%and 1.30%,respectively,those in Group 3 were 11.52%,9.59%and 2.37%,respectively and those in Group 4 were 14.09%,11.96%and 2.95%,respectively.Compared with those in Group 1,participants in Group 2,3 and 4 had adjusted HRs(95%CIs)of 1.79(95%CI:1.44-2.22),2.15(95%CI:1.77-2.62)and 2.35(95%CI:1.89-2.92)for developing new-onset CVD,had adjusted HRs(95%CIs)of 1.79(95%CI:1.39-2.30),2.10(95%CI:1.68-2.62)and 2.24(95%CI:1.74-2.90)for developing heart problems,had adjusted HRs(95%CIs)of 2.74(95%CI:1.51-4.95),3.34(95%CI:1.94-5.76)and 4.72(95%CI:2.68-8.34)for developing stroke.Furthermore,compared with the conventional model,the addition of HDSB and hypertension significantly improved the discriminatory power and risk reclassification in the whole population.1.3 Compared with Group 1,people with coexistence of HDSB and hypertension have a higher risk of CVD in subgroups of middle aged,male,rural place,smoking,drinking and those with BMI under 24,with HR(95%CI)was 2.91(95%CI:2.13-3.97),3.04(95%CI:2.15-4.29),2.64(95%CI:2.02-3.45),2.92(95%CI:2.05-4.15),2.64(95%CI:1.85-3.75)and 2.97(95%CI:2.24-3.93),respectively.When heart problems and stroke were treated as outcome respectively,similar results were also found in our research.2.A study on the longitudinal relation between HDSB,hypertension and change in SRH found that:2.1 In the analysis cohort of 7,440 respondents,1774,1918 and 3778 subjects experienced decline,improvement and no change in SRH from 2011 to 2013,respectively.Over a 4-year period,SRH in 1903 declined,SRH in 3662 were unchanged,and SRH in 1915 improved.Moreover,gender,household income per capital,basic activities of daily(BADL),instrumental activities of daily living(IADL),CESD-10 score and the most chronic diseases were statistically different among the three groups with different changes in SRH over a 4-year period(P<0.05).2.2 Compared with the group of no change in SRH,there was a significant association between baseline HDSB and 2-year decline(OR:1.38,95%CI:1.16-1.63)and improvement in SRH(OR:0.74,95%CI:0.65-0.85),respectively.Likewise,the adjusted ORs(95%CIs)were changed to 1.42(1.20-1.68)and 0.70(0.60-0.80)for the 4-year decline and improvement in SRH,respectively.We also found significant linear doseresponse relationships between CESD-10 score and change in SRH(all P<0.05 for linearity).In addition,hypertension was significantly associated with 2-year improvement in SRH(OR:0.86,95%CI:0.75-0.98)and 4-year decline(OR:1.20,95%CI:1.03-1.40)and improvement(OR:0.81,95%CI:0.71-0.93)in SRH.2.3 Compared with normotensive individuals with LDSB,normotensive individuals with HDSB,hypertensive individuals with LDSB and hypertensive individuals with HDSB all had a higher risk of 4-year decline in SRH.Among them,Group 4 had the highest risk of decline in SRH with an adjusted OR(95%CI)of 1.62(1.27-2.07),by contrast with 1.42(1.14-1.77)in Group 2 and 1.18(0.97-1.43)in Group 3.Moreover,the likelihood of improvement in SRH was also lowest in Group 4,with an adjusted OR(95%CI)of 0.58(0.47-0.72).In contrast,Group 2 only had adjusted OR(95%CI)of 0.63(0.52-0.76)and Group 3 had adjusted OR(95%CI)of 0.77(0.65-0.92).In addition,adding both HDSB and hypertension to the conventional model also significantly improved the predictive value of future SRH changes(P<0.05).Conclusion1.Comorbid hypertension and HDSB could significantly increase the risk to experience incident cardiovascular disease,heart disease and stroke.2.The addition of HDSB and hypertension to the conventional model significantly improved the discriminatory power and risk reclassification for future cardiovascular disease,heart disease and stroke.3.HDSB could be treated as an independent predictor of change in SRH among the middle-aged and elderly Chinese people,and there was a significant linear dose-response relationship between CESD-10 score and outcome.In contrast,hypertension was only significantly associated with 2-year improvement in SRH and 4-year decline and improvement in SRH.4.The combined effect of hypertension and HDSB on 4-year change in SRH was stronger than the effect of two exposures alone.Moreover,the combination of HDSB and hypertension could predict change in SRH better than each component individually.5.In general practice of clinical and public health,screening depressive symptoms and frequent blood pressue measurement should be incorporated into routine physical examinations,which may be imperative to maintain a positive SRH status in the middle-aged and elderly people,as well as ultimately achieve the goal of early prevention in cardiovascular disease.