Depression and Subclinical Coronary Atherosclerosis in Adults Without Clinical Coronary Artery Disease

Abstract

Background

The relationship between depression and subclinical coronary atherosclerosis in asymptomatic individuals is not clear. We evaluated this relationship in a Korean population.

Methods and Results

We analyzed 3920 individuals (mean age 54.7±7.9 years and 2603 men [66.4%]) with no history of coronary artery disease who voluntarily underwent coronary computed tomographic angiography and screening for depression using the Beck Depression Inventory as part of a general health examination. The degree and extent of subclinical coronary atherosclerosis were evaluated by coronary computed tomographic angiography, and ≥50% diameter stenosis was defined as significant. Participants were categorized into groups of those with or without depression using the Beck Depression Inventory scores ≥16 as a cutoff value. Of the study participants, 272 (6.9%) had a Beck Depression Inventory score of 16 or higher. After adjustment for cardiovascular risk factors, depression was not significantly associated with any coronary plaque (adjusted odds ratio [OR], 1.05 [95% CI, 0.78–1.41]; P=0.746), calcified plaque (OR, 0.95 [95% CI, 0.71–1.29]; P=0.758), noncalcified plaque (OR, 1.31 [95% CI, 0.79–2.17]; P=0.305), mixed plaque (OR, 1.16 [95% CI, 0.60–2.23]; P=0.659), or significant coronary artery stenosis (OR, 1.22 [95% CI, 0.73–2.03]; P=0.450). In the propensity score‐matched population (n=1318) as well, none of the coronary artery disease measures of subclinical coronary atherosclerosis were statistically significantly associated with depression (all P>0.05).

Conclusions

In this large cross‐sectional study with asymptomatic individuals undergoing coronary computed tomographic angiography and Beck Depression Inventory evaluation, depression was not associated with an increased risk of subclinical coronary atherosclerosis.

Nonstandard Abbreviations and Acronyms

CACS

coronary artery calcium score

IMT

intima‐media thickness

Clinical Perspective.

What Is New?

• This cohort study analyzed 3920 participants who underwent both coronary computed tomography angiography and Beck Depression Inventory evaluation as a general health examination.

• The results showed that depression did not increase the risk of subclinical coronary atherosclerosis as determined by coronary computed tomography angiography.

What Are the Clinical Implications?

• Similar primary preventive strategies for coronary artery disease may be used to care for asymptomatic individuals with and without depression.

Coronary artery disease (CAD) is the leading cause of death worldwide. ¹ Coronary atherosclerosis causes CAD, such as angina pectoris and myocardial infarction (MI). ² Over the past several decades, epidemiologic studies have revealed numerous risk factors for CAD, such as age, male sex, hypertension, hyperlipidemia, diabetes, current smoking status, obesity, family history of CAD, and several inflammatory markers. ³ , ⁴ , ⁵ Based on these risk factors, clinical practice guidelines are outlined for primary prevention of CAD. ⁶ , ⁷ However, the absence of these traditional risk factors in an individual does not exclude the occurrence of future CAD events. ⁸ Thus, the evolving role of psychosocial status as a nontraditional risk factor has been increasingly recognized. ⁹ Depression is a prevalent mental disorder, affecting approximately 6.7% of the general population. ¹⁰ The prevalence of depression in patients with known CAD ranges from 15% to 30%. ¹¹ Depression is considered a potentially modifiable and independent risk factor in patients with established CAD that may increase the risk of cardiac events. ¹¹ , ¹²

With the advent of multidetector row computed tomography, coronary computed tomography angiography (CCTA) has proven to be effective in providing a comprehensive evaluation of coronary atherosclerosis, including lesion location, disease severity, and plaque characteristics. ¹³ However, there are limited data regarding the association between depressive symptoms and subclinical coronary atherosclerosis detected by CCTA in asymptomatic individuals. Therefore, we sought to assess the association between depressive symptoms and subclinical coronary atherosclerosis in a sizable population of asymptomatic Korean individuals who had CCTA for the early detection of CAD.

METHODS

The data that support the findings of this study are available from the corresponding authors upon reasonable request.

Study Population

Between March 2014 and December 2019, 4208 consecutive Korean individuals aged 20 years and older, who had undergone both CCTA and depression evaluation using the Beck Depression Inventory (BDI) as part of a general medical checkup at the Health Promotion Center in Ulsan University Hospital, were retrospectively analyzed. The detailed study participant selection process is shown in the Figure. After exclusion of ineligible participants, 3920 participants were enrolled in this study. This retrospective study was approved by the local institutional review board of the Ulsan University Hospital, Ulsan, Korea. The informed consent requirement was waived due to the retrospective design of the study.

Figure 1. Overview of the study population.

BDI indicates Beck Depression Inventory; CCTA, coronary computed tomographic angiography; MI, myocardial infarction; and PCI, percutaneous coronary intervention.

Clinical and Laboratory Measurements

We obtained the clinical and laboratory data through the electronic medical records and clinical data warehouse platform of Ulsan University Hospital. ¹³ , ¹⁴ Height, body weight, waist circumference, and blood pressure were measured in a standard manner during the general health examination, as previously described. ¹³ , ¹⁴ Blood samples after overnight fasting were analyzed for total cholesterol, low‐density lipoprotein cholesterol, high‐density lipoprotein cholesterol, triglycerides, fasting glucose, hemoglobin A1c, creatinine, uric acid, and C‐reactive protein. Standard 12‐lead electrocardiogram was performed on each participant. Echocardiography was used to calculate the left ventricular ejection fraction.

Obesity was defined as a body mass index ≥25 kg/m². Diabetes was defined as fasting plasma glucose ≥126 mg/dL, hemoglobin A1c ≥6.5%, or a self‐reported history of diabetes or treatment of diabetes with dietary modification or use of antidiabetic medication. Hypertension was defined as systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or a self‐reported history of hypertension or use of antihypertensive medication. Hyperlipidemia was defined as total cholesterol ≥240 mg/dL or a self‐reported history of hyperlipidemia or use of an antihyperlipidemic treatment. ¹³ , ¹⁴ A first‐degree relative of any age with CAD was considered to have a family history of CAD. ¹⁵ Each participant's 10‐year CAD risk was calculated using the Framingham risk model. ⁵

Coronary Computed Tomography Angiography Image Acquisition and Analysis

CCTA was conducted using single‐source 256‐slice CT equipment (Brilliance iCT, Philips Healthcare, Best, the Netherlands) or dual‐source CT equipment (Somatom Definition Flash, Siemens, Erlangen, Germany). A standard scanning protocol was used, as previously described. ¹³ , ¹⁴ All CCTA image interpretation and calcium scoring were performed by an experienced cardiovascular radiologist and cardiologist (S.H.C. and G.M.P., each with more than 10 years of experience) using a dedicated workstation (Syngo.via, Siemens or Aquarius iNtuition, Terarecon). We analyzed CCTA images according to the Society of Cardiovascular Computed Tomography guideline. ¹⁶ Coronary artery calcium score (CACS) was measured as described, with study participants categorized by scores of 0, 1 to 10, 11 to 100, 101 to 400, and >400. ¹⁷ CACS >10 was defined as having coronary artery calcification. ¹⁸ Plaques occupied by calcified tissue >50% of the plaque area (density>130 Hounsfield units) were classified as calcified, plaques with <50% calcium were classified as mixed, and plaques without any calcium were classified as noncalcified. ¹⁹ Diameter stenosis ≥50% was defined as significant.

Evaluation of Depression

The BDI, a self‐report questionnaire, was developed to assess the severity of depression. The inventory contains a 21‐item, 4‐point Likert scale. The scores for the response to each item range from 0 to 3. The total score ranges from 0 to 63, with higher scores indicating more severe depressive symptoms. ²⁰ The BDI has high internal consistency, with alpha coefficients of 0.86 and 0.81 for psychiatric and nonpsychiatric populations, respectively. ²¹ The Korean version of the BDI has been validated in a previous study, ²² and 16 points was suggested as the optimal cutoff value for depression. ²³ The depression evaluation using BDI was conducted through the systemized self‐report questionnaire that was distributed before the general health examination.

Statistical Analysis

Categorical variables were compared with the chi‐square test or Fisher's exact test, and continuous variables were compared with the unpaired Student's t test or nonparametric Mann–Whitney test, as appropriate. From the previous epidemiologic studies, ³ , ⁴ , ⁵ we selected clinically important variables that included age, men, hypertension, hyperlipidemia, diabetes, current smoking status, obesity, family history of CAD, and C‐reactive protein level. Using these covariates, we performed multivariable logistic regression analyses. To reduce the impact of potential confounding effects between the comparison groups, we performed propensity score matching analysis based on the variables in Table 1. The 1:4 nearest‐neighbor propensity score matching method with a caliper size of 0.2 was used. The standardized mean differences between the matched groups were used to assess the covariate balance. The baseline variables' standardized mean differences were less than 0.2 (20%). The risks of subclinical coronary atherosclerosis in the propensity score‐matched population were analyzed by logistic regression using generalized estimating equations for categorical variables that took into account the clustering of matched pairs. The SPSS software version 24 (SPSS Inc, Chicago, IL, USA) and R software version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria; www.r‐project.org) were used to manage data and conduct statistical analyses. The propensity score matching was done using the R ‘MatchIt’ package. All reported P values are 2 sided, and a P value of <0.05 was considered to show a statistically significant relationship.

Table 1.

Baseline Characteristics of the Study Participants According to the Presence or Absence of Depression

Characteristics	Overall population (n=3920)			Propensity score matched population (n=1318)
	Depression (n=272)	Nondepression (n=3648)	P value	Depression (n=270)	Nondepression (n=1048)	P value
Age, y	54.8±8.4	54.7±7.8	0.837	54.8±8.4	54.7±7.7	0.836
Male sex, n (%)	141 (51.8)	2462 (67.5)	<0.001	139 (51.5)	549 (52.4)	0.783
Body mass index, kg/m2	23.5±3.0	24.3±2.9	<0.001	23.6±2.9	23.6±2.9	0.933
Waist circumference, cm	83.5±8.2	86.0±7.8	<0.001	83.5±8.1	83.4± 7.6	0.822
Systolic blood pressure, mm Hg	124.5±15.5	126.1±13.2	0.060	124.5±15.5	124.1±13.7	0.647
Diastolic blood pressure, mm Hg	80.2±10.2	79.3±9.2	0.229	80.2±10.2	79.8±9.5	0.648
Diabetes, no. (%)	43 (15.8)	514 (14.1)	0.433	41 (15.2)	141 (13.5)	0.462
Hypertension, no. (%)	99 (36.4)	1295 (35.5)	0.765	99 (36.7)	366 (34.9)	0.603
Hyperlipidemia, no. (%)	43 (15.8)	641 (17.6)	0.460	43 (15.9)	177 (16.9)	0.718
Current smoker, no. (%)	70 (25.7)	805 (22.1)	0.162	68 (25.2)	250 (23.9)	0.923
Obesity, no. (%)	77 (28.3)	1360 (37.3)	0.003	76 (28.1)	293 (28.0)	0.966
Family history of coronary artery disease*, no. (%)	23 (8.5)	340 (9.3)	0.635	23 (8.5)	74 (7.1)	0.416
Fasting blood glucose, mg/dL	93.0±25.0	96.0±22.6	0.038	92.7±24.7	91.9±21.5	0.632
Glycated hemoglobin, %	5.8±1.0	5.7±0.8	0.001	5.8±1.0	5.7±0.9	0.392
Total cholesterol, mg/dL	187.6±38.9	191.9±37.9	0.072	188.2±38.5	189.8±37.4	0.540
Low‐density lipoprotein cholesterol, mg/dL	126.2±35.4	132.6±35.3	0.004	126.6±35.2	128.3±34.6	0.504
High‐density lipoprotein cholesterol, mg/dL	54.0±16.9	52.9±15.4	0.460	54.2±16.9	54.7±16.3	0.607
Triglyceride, mg/dL	101.9±71.7	111.9±74.6	0.032	102.2±71.9	101.5±71.5	0.918
Creatinine, mg/dL	0.77±0.17	0.84±0.18	<0.001	0.77±0.18	0.78±0.17	0.728
Uric acid, mg/dL	5.1±1.4	5.4±1.3	<0.001	5.1±1.4	5.2±1.3	0.722
C‐reactive protein ≥2 mg/L, no. (%)	3 (1.1)	28 (0.8)	0.472	2 (0.7)	9 (0.9)	0.849
Ejection fraction, %	64.5±4.1	64.0±4.7	0.120	64.6±3.9	64.6±4.3	0.928
Framingham risk score	8.1±6.1	8.7±6.0	0.132	8.1±6.1	7.8±6.1	0.513

Values are shown as mean±SD or number (%).

^*Coronary artery disease in a first‐degree relative of any age.

RESULTS

Baseline Characteristics of the Study Population

The mean age of the study population was 54.7±7.9 years, and 2603 (66.4%) of them were men. Of the study population, 272 (6.9%) had a BDI score of 16 or higher. Table 1 presents the baseline characteristics of the participants with and without depression. The mean BDI of participants with and without depressive symptoms was 20.7±5.1 and 2.5±4.2, respectively. The group of individuals with depression had fewer men and a lower prevalence of obesity, lower body mass index and waist circumference, and lower fasting blood glucose, low‐density lipoprotein cholesterol, triglyceride, creatinine, and uric acid levels than those without depression. Although higher levels of hemoglobin A1c were observed among those with depression, there was no significant difference in the prevalence of diabetes between the 2 groups. A total of 1318 participants were matched after the 1:4 propensity score matching. The mean age of the matched subjects was 54.7±7.9 years, and 688 (52.2%) were men. In the matched pairs, there were no significant differences in any of the covariates between participants with and without depression (Table 1).

Coronary Computed Tomography Angiography Findings

Table 2 shows the CCTA findings of the participants according to the presence or absence of depression. The mean CACS of the study population was 46.0±169.8. Coronary plaques were detected in 1482 (37.8%) participants. Specifically, calcified, noncalcified, and mixed plaques were found in 1395 (35.6%), 222 (5.7%), and 152 (3.9%) individuals, respectively. In addition, significant coronary artery stenosis in at least 1 coronary artery was found in 254 participants (6.5%). However, the prevalence of CACS, coronary plaques, and significant coronary artery stenosis did not differ between participants with and without depression (all P>0.05).

Table 2.

Comparison of the Coronary Computed Tomography Angiography Findings of Participants With and Without Depression

Variables	Overall (n=3920)	Depression (n=272)	Nondepression (n=3648)	P value
Mean coronary artery calcium score	46.0±169.8	41.5±136.9	46.3±172.0	0.655
Coronary artery calcium score, no. (%)				0.280
0	2501 (63.8)	185 (68.0)	2316 (63.5)
1–10	398 (10.2)	26 (9.6)	372 (10.2)
11–100	620 (15.8)	32 (11.8)	588 (16.1)
101–400	285 (7.3)	23 (8.5)	262 (7.2)
>400	116 (3.0)	6 (2.2)	110 (3.0)
Any coronary plaque, no. (%)	1482 (37.8)	96 (35.3)	1386 (38.0)	0.376
Plaque characteristics, no. (%)
Calcified plaque	1395 (35.6)	86 (31.6)	1309 (35.9)	0.156
Noncalcified plaque	222 (5.7)	18 (6.6)	204 (5.6)	0.480
Mixed plaque	152 (3.9)	11 (4.0)	141 (3.9)	0.883
Significant stenosis, no. (%)	254 (6.5)	19 (7.0)	235 (6.4)	0.725

Values are shown as mean±SD or number (%).

Association Between Depression and Subclinical Coronary Atherosclerosis

In the univariable analyses, the odds of coronary artery calcification, any coronary plaque, calcified plaque, noncalcified plaque, mixed plaque, and significant coronary artery stenosis were not statistically significantly different between individuals with and without depression (all P>0.05; Table 3). After adjustments for cardiovascular risk factors (age, men, hypertension, hyperlipidemia, diabetes, current smoking status, obesity, family history of CAD, and C‐reactive protein), depression was not significantly associated with any coronary plaque (adjusted odds ratio [OR], 1.05 [95% CI, 0.78–1.41]; P=0.746), calcified plaque (OR, 0.95 [95% CI, 0.71–1.29]; P=0.758), noncalcified plaque (OR, 1.31 [95% CI, 0.79–2.17]; P=0.305), mixed plaque (OR, 1.16 [95% CI, 0.60–2.23]; P=0.659), or significant coronary artery stenosis (OR, 1.22 [95% CI, 0.73–2.03]; P=0.450) (Table 3). In the propensity score‐matched population (n=1318) as well, none of the CAD measures of subclinical coronary atherosclerosis were statistically significantly associated with depression (all P>0.05; Table 3).

Table 3.

Association Between Depression and Coronary Computed Tomography Angiographic Findings

	Univariable		Multivariable		Propensity score matching analysis
Variables	Odds ratio (95% CI)	P value	Adjusted odds ratio (95% CI)	P value	Odds ratio (95% CI)	P value
Coronary artery calcification*
Depression	0.81 (0.61–1.09)	0.165	0.89 (0.64–1.24)	0.503	0.98 (0.71–1.36)	0.915
Nondepression (reference)	1	…	1	…	1	…
Any coronary plaque
Depression	0.89 (0.69–1.15)	0.376	1.05 (0.78–1.41)	0.746	1.11 (0.84–1.47)	0.459
Nondepression (reference)	1	…	1	…	1	…
Calcified plaque
Depression	0.83 (0.63–1.08)	0.157	0.95 (0.71–1.29)	0.758	1.04 (0.78–1.38)	0.807
Nondepression (reference)	1	…	1	…	1	…
Noncalcified plaque
Depression	1.20 (0.73–1.97)	0.481	1.31 (0.79–2.17)	0.305	1.16 (0.66–2.02)	0.610
Nondepression (reference)	1	…	1	…	1	…
Mixed plaque
Depression	1.05 (0.56–1.96)	0.883	1.16 (0.60–2.23)	0.659	1.23 (0.60–2.51)	0.570
Nondepression (reference)	1	…	1	…	1	…
Significant stenosis
Depression	1.09 (0.67–1.77)	0.726	1.22 (0.73–2.03)	0.450	1.32 (0.76–2.27)	0.325
Nondepression (reference)	1	…	1	…	1	…

Covariates in the multivariable model include age, sex, obesity, diabetes, hypertension, hyperlipidemia, current smoking, family history of coronary artery disease, and C‐reactive protein ≥2 mg/L.

^*Coronary artery calcification is defined as coronary artery calcium score >10.

DISCUSSION

In this study, we evaluated the association between depressive symptoms and subclinical coronary atherosclerosis in asymptomatic individuals. The main finding of this study was that depressive symptoms are not associated with an increased risk of any subclinical coronary atherosclerosis. Specifically, multivariable logistic regression of overall and propensity score matched data showed that the risk of coronary artery calcification; calcified, noncalcified, or mixed plaques; and significant stenosis did not differ between participants with and without depressive symptoms. Additionally, to the best of our knowledge, this is the largest study of participants who underwent both CCTA and BDI evaluation for the assessment of the relationship between depression and subclinical coronary atherosclerosis.

Depression is an independent risk factor for major adverse cardiovascular events in patients with known CAD. ¹¹ , ¹² A previous observational study with 222 patients who had MI showed that depression is a significant predictor of short‐ and long‐term cardiac mortality. ²⁴ In another prospective study of 1873 patients with MI, depressive symptoms, irrespective of whether they persist, subside, or newly develop after hospitalization, were associated with worse cardiac outcomes after MI. ²⁵ Similarly, depression is reported to be associated with higher cardiovascular event rates after coronary artery bypass surgery. ²⁶ In a meta‐analysis that included 16 889 patients with MI, the presence of depression after MI was also independently associated with a 1.5‐fold to 3.0‐fold higher risk of subsequent cardiovascular events. ²⁷ Unhealthy lifestyle such as lower adherence to therapy and lower participation in cardiac rehabilitation, autonomic dysfunction, altered neurochemical function, inflammation, insulin resistance, and increased platelet reactivity and thrombosis have been proposed as mechanisms for the unfavorable prognosis of patients with both CAD and depression. ¹¹ , ¹² Considering this substantial evidence, it can be concluded that depression is one of the major prognostic determinants of established CAD.

Carotid intima‐media thickness (IMT) is a good predictor of future cardiovascular events. ²⁸ Carotid IMT has been widely used as a surrogate marker of subclinical atherosclerosis to evaluate the association between depressive symptoms and subclinical atherosclerosis, but the results remain controversial. ²⁹ In the Rotterdam study with 4019 participants 60 years and older, those with depressive symptoms showed a significantly thicker IMT (OR, 1.24 [95% CI, 1.02–1.51]) compared with controls. ³⁰ However, the Gutenberg Health Study, which enrolled 5000 participants, did not find a significant association between IMT and depressive symptoms. ³¹ A meta‐analysis analyzed 19 studies involving 4490 patients with depressive symptoms and 27 583 controls without depressive symptoms. Compared with controls, IMT of patients with depressive symptoms was significantly thicker (standardized mean differences, 0.137 [95% CI, 0.047–0.227], P=0.003). ²⁹ However, this meta‐analysis did not focus on asymptomatic individuals without CAD.

CACS reflects the overall plaque burden of coronary artery atherosclerosis, which is an excellent predictor of cardiovascular events. ³² Although the association between depression and coronary artery atherosclerosis has been investigated in previous studies using the CACS, the results reported are inconsistent. ³³ , ³⁴ , ³⁵ , ³⁶ In the Coronary Artery Risk Development in Young Adults study, which had 2171 middle‐aged participants, a prospective association between depressive symptoms and incident coronary artery calcification was noted. ³³ However, no association was found between depression and CACS in the Multi‐Ethnic Study of Atherosclerosis, which included 6789 middle‐aged to elderly men and women. ³⁴ In another prospective study, depression was also not related to coronary artery calcification. ³⁵ Furthermore, in a meta‐analysis of 24 studies with 30 067 participants, which evaluated subclinical atherosclerosis using CACS in people with symptoms of depression, 12 studies identified a positive association between depression and coronary artery calcification. However, no significant association was observed between depression and coronary artery calcification in 10 studies, whereas a negative association was detected in 2 studies. Therefore, the evidence on the relationship between depression and coronary artery calcification is mixed. ³⁶ To date, the association between depression and subclinical coronary atherosclerosis assessed using CACS is inconclusive.

The high diagnostic accuracy of CCTA for CAD in diverse populations as well as its long‐term prognostic utility in patients with asymptomatic and suspected CAD have been proven. ³⁷ , ³⁸ , ³⁹ It has been reported that the absence of coronary artery calcification does not exclude the presence of significant CAD. ⁴⁰ , ⁴¹ CCTA provides more comprehensive information regarding coronary artery atherosclerosis than CACS. However, only 1 small study (n=55) has looked into the association between depression and subclinical coronary atherosclerosis identified on CCTA. Although depression was associated with an increased calcified plaque proportion in that study, there was no statistically significant difference in total, calcified, and noncalcified plaque volume between the patients and controls. ⁴² Accordingly, whether depression is related to subclinical coronary atherosclerosis on CCTA is still unclear. This indicates a need for detailed analysis from a large cohort. Considering current CCTA findings, it is evident that the effect of depression on subclinical coronary atherosclerosis is less influential than traditional cardiovascular risk factors. As a result, in asymptomatic subjects without known CAD, conventional risk factors should be controlled to decrease the risk of subclinical coronary atherosclerosis regardless of the presence or absence of depressive symptoms.

In the relationship between depression and atherosclerosis, various factors beyond the traditional risk factors may play a role. Patients with a history of MI reported less depressive symptoms when they consumed vegetables, fruits, whole grains, fish, and low‐fat dairy products. ⁴³ In previous studies, subjects adhering to a healthy diet (eg, the Mediterranean diet) experienced fewer depressive symptoms ⁴⁴ , ⁴⁵ and were less likely to develop atherosclerotic cardiovascular disease. ⁴⁶ In addition, adopting or maintaining physical exercises significantly reduced depressive symptoms in a 6‐year follow‐up study. ⁴⁷ Physical exercise was effective in reducing depressive symptoms with a low rate of recurrence, ⁴⁸ and it has been used as a therapeutic tool for cardiovascular disease. ⁴⁹ Individuals with lower socioeconomic status also had a higher chance of being depressed. ⁵⁰ Patients with lower socioeconomic status, who visited a vascular prevention center, had a greater plaque area on carotid ultrasound as well as a higher rate of plaque progression. ⁵¹ Therefore, future studies should be designed to explore these various factors in‐depth and provide a more exquisite understanding of the relationship between depression and atherosclerosis.

This study has several limitations. First, it was performed at a single center. Because all study participants voluntarily underwent CCTA and BDI evaluation during a general medical checkup, there is a possibility that many participants who were more interested in their health than usual were included. Furthermore, the group with depression showed a lower prevalence of obesity, lower body mass index and waist circumference, and lower fasting blood glucose, low‐density lipoprotein cholesterol, and triglyceride levels than the group without depression. Therefore, there is a potential for selection bias in the present study. Future prospective studies with larger populations are required to confirm our findings. Second, our study participants were exclusively Korean, which means that the applicability of our findings to other ethnic groups may be limited. Third, the inflammatory theory has been proposed as one of the pathophysiology of depression. However, because of the very low prevalence (1.1%) of high C‐reactive protein (defined as ≥2 mg/dL) in our population, the analysis in the present study was limited. Finally, the systemized self‐report questionnaire did not contain information on medical history of depression, which may be an important potential confounder.

Conclusions

In conclusion, this large cross‐sectional study of asymptomatic individuals from general population who underwent CCTA and BDI evaluation showed that the depressive symptoms (BDI score >16) were not significantly associated with an increased risk of subclinical coronary atherosclerosis. However, the findings of this study need to be investigated further and validated in future prospective studies with larger populations.

Sources of Funding

This work was supported by the Dasol Life Science Inc. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the article.

Disclosures

None.