The Influence of Emotion Regulation on the Association Between Depression and Heart Rate Variability in Cardiac Patients.

OBJECTIVE: Poor vagally mediated heart rate variability (vmHRV) is a mechanism linking depression to coronary heart disease (CHD). Reduced vmHRV is also considered an index of emotion dysregulation-the frequent use of maladaptive emotion regulation strategies, one of the most important being expressive suppression-which is a key component of depression. Therefore, this study aimed to investigate the moderating role of expressive suppression in the relation between depression and vmHRV in patients with CHD. METHODS: The sample included 235 patients with CHD (mean [standard deviation] age = 61.6 [9.8] years; 12% women) admitted to cardiac rehabilitation after a cardiac intervention. The Beck Depression Inventory-II was administered to assess depressive symptoms. Emotion regulation strategies based on either expressive suppression or cognitive reappraisal were assessed through the Emotion Regulation Questionnaire. Resting electrocardiographic recordings were collected for 5 minutes to compute HRV indices. RESULTS: Expressive suppression moderated the relation between depressive symptoms and vmHRV ( b = -0.03, p = .012). Patients with lower expressive suppression scores showed no association between depressive symptoms and vmHRV ( b = -0.00, p = .94), whereas those with higher expressive suppression scores showed a significant negative association between depressive symptoms and vmHRV ( b = -0.05, p = .015). CONCLUSIONS: The use of expressive suppression is likely to potentiate the relation between depressive symptoms and poor vmHRV, which could increase the cardiac risk in these patients. Targeting emotion regulation skills in cardiac rehabilitation programs may be useful for reducing the impact of depression in cardiac patients.

Do catastrophizing and autonomic-reduced flexibility mediate pain outcomes in chronic headache?

OBJECTIVES: Maladaptive cognitive strategies and reduced autonomic flexibility have been reported in chronic pain conditions. No study to date addressed the effects of maladaptive coping and reduced autonomic flexibility, as indexed by heart rate variability (HRV), in chronic headaches. The present study aimed to assess the mediating role of pain catastrophizing and HRV on pain outcomes in patients with chronic headache. METHODS: Thirty-two chronic headache patients and 28 healthy controls were recruited. Self-reported pain severity, pain interference on daily activity, and pain catastrophizing were assessed through the Multidimensional Pain Inventory and the Pain-Related Self Statements Scale. HRV was recorded at rest. Correlations and mediation analysis between self-report, HRV, and pain outcomes were run. RESULTS: Patients with chronic headache reported significantly higher pain severity (p < .001; d = - 1.98), pain interference on daily activity (p < .001; d = - 1.81), and pain catastrophizing (p < .001; d = - 0.96) compared to controls. They also presented significantly lower HRV (p < .05; d = 0.57). Both pain catastrophizing and HRV were associated with pain interference on daily activity. However, from mediation analysis, pain catastrophizing only emerged as the mediator for pain severity (p < .001; b = 0.30) and pain interference (p < .001; b = 0.14). CONCLUSION: Present results showed that chronic headache patients are characterized by high catastrophizing and lower physiological adaptability. Pain catastrophizing emerged as the only mediator of pain outcomes, suggesting that cognitive factors might have a major influence on the severity of pain and its interference on daily activities. Further studies are needed to evaluate these autonomic-cognitive interactions in chronic pain.

Depressive symptoms and cognitive control: the role of affective interference.

Depressive symptoms are characterised by reduced cognitive control. However, whether depressive symptoms are linked to difficulty in exerting cognitive control in general or over emotional content specifically remains unclear. To better differentiate between affective interference or general cognitive control difficulties in people with depressive symptoms, we employed a non emotional (cold) and an emotional (hot) version of a task-switching paradigm in a nonclinical sample of young adults (N = 82) with varying levels of depressive symptoms. Depressive symptoms were linked to greater difficulties in exerting cognitive control in complex situations (mixed-task blocks) compared to simple and semiautomatic situations (single-task blocks) in both task versions. Moreover, greater depressive symptoms were associated with longer latencies in the emotional version of the task across all trial types. Thus, the emotion-specific effect was not modulated by the degree of cognitive control required to perform the task. In sum, depressive symptoms were characterised by a general difficulty to exert cognitive control in both emotional and non emotional contexts and by greater difficulty in even simple attentional processing of emotional material. This study granted novel insights on the extent of cognitive control difficulties in emotional and non emotional contexts for people with depressive symptoms.

Profiles of vagal withdrawal to challenging interactions: Links with preschoolers' conceptual shifting ability.

The current study investigated profiles of vagal withdrawal in response to a challenging task in preschoolers. Also, the association between those profiles and conceptual shifting ability was assessed. Electrocardiogram of 43 four-year-olds was registered during a sequence of games including a win phase and a lose phase, while conceptual shifting ability was assessed via a standardized test. Cluster analyses revealed three profiles of cardiac vagal response to the task. Children in the first cluster displayed significant vagal withdrawal, children in the second cluster showed nonsignificant vagal withdrawal, while children in the third group displayed vagal augmentation to the challenge. These profiles differentiated preschoolers' conceptual shifting ability. Specifically, children with vagal withdrawal had the best performance in categorization and flexibility tasks and committed fewer perseverative errors compared to children who showed blunted vagal withdrawal or vagal augmentation to the challenge. Implications for theory and practice are discussed.

Somatic-Affective, But Not Cognitive-Depressive Symptoms are Associated With Reduced Health-Related Quality of Life in Patients With Congestive Heart Failure.

BACKGROUND: Depression has been associated with poor health-related quality of life (HRQoL) in patients with congestive heart failure (CHF). However, to date, whether somatic-affective and cognitive-depressive symptoms differently contribute to poor HRQoL and behavioral functional capacity in patients with CHF has yet to be investigated. OBJECTIVE: To examine the differential influence of somatic-affective vs cognitive-depressive symptoms on HRQoL and behavioral functional capacity in CHF patients. METHOD: Overall, 55 patients with CHF completed a psychologic evaluation, including the Minnesota Living with Heart Failure Questionnaire, the Beck Depression Inventory-II, and the Beck Anxiety Inventory for HRQoL, depressive, and anxiety symptoms, respectively. The patients completed the Instrumental Activities of Daily Living Questionnaire and the 6-minute walk test for behavioral functional capacity. Hierarchical regression analyses were used to predict HRQoL and behavioral functional capacity from Beck Depression Inventory-II and Beck Anxiety Inventory scores. RESULTS: Somatic-affective depressive symptoms were associated with physical (ß = 0.37, p = 0.005) and emotional (ß = 0.39, p = 0.008) Minnesota Living with Heart Failure Questionnaire subscale scores. Likewise, somatic-affective depressive symptoms predicted Instrumental Activities of Daily Livings Scores (ß = 0.43, p = 0.004) and distance ambulated during the 6-minute walk test (ß = -0.36, p = 0.029). By contrast, cognitive-depressive symptoms and anxiety were unrelated to HRQoL and behavioral functional capacity (all p > 0.05). CONCLUSIONS: These findings showed that somatic-affective depressive symptoms, but not cognitive-depressive symptoms and anxiety, are associated with poor HRQoL and behavioral functional capacity independent of age, clinical functional status, and medical comorbidities. This study suggests that patients with CHF with somatic-affective rather than cognitive-depressive symptoms or anxiety may be at greater risk of poor HRQoL and behavioral functional capacity.

The role of cardiac vagal tone and inhibitory control in pre-schoolers' listening comprehension.

This study investigated the role of basal cardiac activity and inhibitory control at the beginning of the school year in predicting oral comprehension at the end of the year in pre-schoolers. Forty-three, 4-year-olds participated in the study. At the beginning of the school year children's electrocardiogram at rest was registered followed by the assessment of inhibitory control as well as verbal working memory and verbal ability. At the end of the year all children were administered a listening comprehension ability measure. A stepwise regression showed a significant effect of basal cardiac vagal tone in predicting listening comprehension together with inhibitory control and verbal ability. These results are among the first to show the predictive role of basal cardiac vagal tone and inhibitory control in pre-schoolers' oral text comprehension, and offer new insight into the association between autonomic regulation of the heart, inhibitory control, and cognitive activity at a young age.

Unpleasant stimuli differentially modulate inhibitory processes in an emotional Go/NoGo task: an event-related potential study.

Threat stimuli typically elicit a psychophysiological response pattern supporting the organism's preparation for active defence. Differently, blood stimuli prompt a distinctive autonomic response pattern and sustained processing, which do not call for clear-cut mobilisation for action. However, the contribution of motor disposition in these response patterns remains unclear. One way to address this issue is to investigate whether threat and blood stimuli differentially affect the active suppression of an ongoing motor activity. Thirty-two undergraduates were presented with threat, mutilation, pleasant, and neutral pictures in an emotional Go/NoGo task. The amplitudes of the NoGo-N2 and NoGo-P3 components of the event-related potentials were analysed as indices of conflict monitoring and inhibition of motor response, respectively. Reaction times to Go trials were significantly faster for threat than for mutilations. The NoGo-N2 was significantly larger to threat than to mutilations, whereas the NoGo-P3amplitude did not differ between the two conditions. These findings suggest that threat stimuli facilitated the execution of a prepotent response and enhanced conflict monitoring when action must be withheld. In contrast, blood stimuli did not either promote action in the Go trials or increase conflict in the NoGo condition, suggesting a response pattern compatible with defensive immobility.

Improving Managers' Psychophysical Well-Being: Effectiveness of Respiratory Sinus Arrhythmia Biofeedback.

High work stress has been consistently associated with disturbed autonomic balance, specifically, lowered vagal cardiac control and increased sympathetic activity, which may lead to increased cardiovascular risk. Stress management procedures have been proposed to reduce autonomic dysfunctions related to work stress in different categories of workers exposed to heightened work demands, while a limited number of studies addressed this issue in managers. The present study was aimed at evaluating the effectiveness of a respiratory sinus arrhythmia (RSA) biofeedback (BF) intervention on psychological and physiological outcomes, in managers with high-level work responsibilities. Thirty-one managers leading outstanding private or public companies were randomly assigned to either a RSA-BF training (RSA-BF; N = 16) or a control group (N = 15). The RSA-BF training consisted of five weekly 45 min sessions, designed to increase RSA, whereas controls had to provide a daily stress diary once a week. After the training, managers in both groups reported reduced heart rate at rest, lower anxiety levels and improvement in health-related quality of life. More importantly, managers in the RSA-BF group showed increased vagal control (as indexed by increased RSA), decreased sympathetic arousal (as indexed by reduced skin conductance and systolic blood pressure) and lower emotional interferences, compared to managers in the control group. Results from this study showed that RSA-BF training was effective in improving cardiac autonomic balance at rest. Moreover, findings from this study underline the effectiveness of biofeedback in reducing psychophysiological negative outcomes associated with stress in managers.

Biofeedback in the prophylactic treatment of medication overuse headache: a pilot randomized controlled trial.

BACKGROUND: Medication overuse headache (MOH) is a major clinical concern and a common health risk. Recent literature stressed the need to manage chronic headache by using integrated biobehavioral approaches. Few studies evaluated how biofeedback can be useful in MOH. The aim of the study is to evaluate in a randomized, controlled, single-blind trial the effects of biofeedback associated with traditional pharmacological therapy in the prophylactic treatment of MOH. METHOD: Twenty-seven subjects were randomized to frontal electromyographic (EMG) biofeedback associated with prophylactic pharmacological therapy (Bfb Group) or to pharmacological treatment alone (Control Group). The primary outcome was to evaluate the number of patients that return episodic after treatment. Secondly we evaluate the effects of frontal EMG BFB on frequency of headache and analgesic intake. Changes in coping strategies and in EMG frontalis tension were also evaluated. ANOVA was performed on all the variables of interest. RESULTS: Our results indicate that at the end of treatment the number of patients that returned episodic in the Bfb group was significantly higher than in the Control group. Patients in the Bfb group differed from the Control group in headache frequency, amount of drug intake and active coping with pain. These outcomes were confirmed also after 4 months of follow-up. No significant effects were observed in EMG recordings. CONCLUSIONS: Biofeedback added to traditional pharmacological therapy in the treatment of MOH is a promising approach for reducing headache frequency and analgesic intake. Modification of coping cognitions in the Bfb group, as an adjunct mechanism of self-regulation, needs more evaluations to understand the role of biofeedback in changing maladaptive psychophysiological responses.

Evaluation of the legal consequences of action affects neural activity and emotional experience during the resolution of moral dilemmas.

In any modern society killing is regarded as a severe violation of the legal codes that is subjected to penal judgment. Therefore, it is likely that people take legal consequences into account when deciding about the hypothetical killing of one person in classic moral dilemmas, with legal concerns contributing to decision-making. In particular, by differing for the degree of intentionality and emotional salience, Footbridge- and Trolley-type dilemmas might promote differential assignment of blame and punishment while implicating the same severity of harm. The present study was aimed at comparing the neural activity, subjective emotional reactions, and behavioral choices in two groups of participants who either took (Legal group) or did not take (No Legal group) legal consequences into account when deciding on Footbridge-type and Trolley-type moral dilemmas. Stimulus- and response-locked ERPs were measured to investigate the neural activity underlying two separate phases of the decision process. No difference in behavioral choices was found between groups. However, the No Legal group reported greater overall emotional impact, associated with lower preparation for action, suggesting greater conflict between alternative motor responses representing the different decision choices. In contrast, the Legal group showed an overall dampened affective experience during decision-making associated with greater overall action readiness and intention to act, reflecting lower conflict in responding. On these bases, we suggest that in moral dilemmas legal consequences of actions provide a sort of reference point on which people can rely to support a decision, independent of dilemma type.

Neural correlates of attention to emotional facial expressions in dysphoria.

The present study investigated whether dysphoric individuals have a difficulty in disengaging attention from negative stimuli and/or reduced attention to positive information. Sad, neutral and happy facial stimuli were presented in an attention-shifting task to 18 dysphoric and 18 control participants. Reaction times to neutral shapes (squares and diamonds) and the event-related potentials to emotional faces were recorded. Dysphoric individuals did not show impaired attentional disengagement from sad faces or facilitated disengagement from happy faces. Right occipital lateralisation of P100 was absent in dysphoric individuals, possibly indicating reduced attention-related sensory facilitation for faces. Frontal P200 was largest for sad faces among dysphoric individuals, whereas controls showed larger amplitude to both sad and happy as compared with neutral expressions, suggesting that dysphoric individuals deployed early attention to sad, but not happy, expressions. Importantly, the results were obtained controlling for the participants' trait anxiety. We conclude that at least under some circumstances the presence of depressive symptoms can modulate early, automatic stages of emotional processing.

Preoperative and perioperative predictors of reactive and persistent depression after cardiac surgery: a three-month follow-up study.

BACKGROUND: Depression is commonly reported in patients after cardiac surgery and increases the risk of postoperative cardiac morbidity or mortality or both. Although preoperative depression has been implicated as the strongest predictor of depression after surgery, the characteristics thought to influence reactive or persistent depression have been poorly investigated in cardiac surgery patients. OBJECTIVE: Therefore, the main aim of this study was to examine whether pre-existing depression rather than perioperative variables may predict postoperative reactive or persistent depression. METHODS: Overall, 96 patients completed a psychologic evaluation, including the Center for Epidemiologic Studies of Depression scale and the State and Trait Anxiety Inventory for depression and anxiety, respectively, before surgery and at 3-month follow-up. RESULTS: A total of 27 (28%) and 24 (25%) patients had depression preoperatively and at 3-month follow-up, respectively. Postoperative depression was predicted by preoperative scores in Center for Epidemiologic Studies of Depression scale (ß = 0.29, p < 0.05) and European System for Cardiac Operative Risk Evaluation (ß = 0.22, p < 0.04), but not by procedure-related variables (p > 0.75). Specifically, patients with reactive depression showed greater European System for Cardiac Operative Risk Evaluation than those without depression (p < 0.05), whereas patients with persistent depression had greater preoperative Center for Epidemiologic Studies of Depression scores than those whose depression improved after surgery (p < 0.01). CONCLUSIONS: The severity of pre-existing depression and biomedical risk factors can be markers of depression-related risk 3 months after cardiac surgery in patients with persistent and reactive depression, respectively. An integrated psychologic and biomedical evaluation is essential to anticipate which patients are likely to show depression after cardiac surgery.

Familial risk for depression is associated with reduced physical activity in young adults: evidence from a wrist-worn actigraphy study.

Depression is characterized by reduced physical activity and sleep-wake cycle disturbances, often considered important features of the disease. While a few studies have suggested that self-reported reduced physical activity and sleep-wake cycle disturbances might both be linked to depression vulnerability, actigraphy-based measures in vulnerable samples remain largely unexplored. This study relied on actigraphy-based parameters to test whether these disturbances characterize depression vulnerability. Seven-day actigraphy data were collected from 20 (13 female) university students with a high vulnerability to depression, which was determined by the presence of a family history of the condition but no current symptoms, and 32 (21 female) controls with neither a family history of depression nor current depressive symptoms. Daily physical activity, namely gross motor activity, was quantified as average daily acceleration and time spent engaging in moderate-vigorous physical activity (MVPA). The sleep-wake cycle and circadian rhythms were assessed as total sleep duration per night (in hours), sleep within sleep period time (in hours), sleep efficiency (%), and relative amplitude (i.e., the difference between the activity during the day and the night, which reflects circadian rhythms amplitude). Results showed that individuals with a familial risk for depression exhibited reduced daily acceleration and time spent in MVPA relative to the control group, particularly on the weekend during their free time away from scheduled activities. On the other hand, the two groups were comparable in terms of sleep estimates. Taken together, reduced physical activity, but not sleep-wake disturbances, seem to be associated with vulnerability to depression and might be a viable target for identification and prevention efforts.

Moral dilemmas and moral principles: when emotion and cognition unite.

Traditional studies on moral judgement used resolutions of moral dilemmas that were framed in terms of acceptability of the consequentialist action promoting a greater good, thus overlooking the deontological implications (choices cannot be justified by their consequences). Recently, some authors have suggested a parallelism between automatic, unreflective emotional responses and deontological moral judgements. In this study, we developed a novel experimental paradigm in which participants were required to choose between two resolutions of a moral dilemma (consequentialist and deontological). To assess whether emotions are engaged in each of the two resolutions, we asked participants to evaluate their emotional experience through the ratings of valence and arousal. Results showed that emotion is involved not only in deontological but also in consequentialist resolutions. Moreover, response times pointed out a different interplay between emotion and cognition in determining a conflict in the dilemma's resolution. In particular, when people were faced with trolley-like dilemmas we found that decisions leading to deontological resolutions were slower than decisions leading to consequentialist resolutions. We propose that this finding reflects the special (but not accepted) permission provided by the doctrine of the double effect for incidentally causing death for the sake of a good end.

Biofeedback assisted control of respiratory sinus arrhythmia as a biobehavioral intervention for depressive symptoms in patients after cardiac surgery: a preliminary study.

The current study investigated whether biofeedback training aimed at increasing respiratory sinus arrhythmia (RSA), a measure of cardiac vagal modulation, can reduce depressive symptoms in patients after cardiac surgery. This randomized controlled study enrolled 26 patients after first-time cardiac surgery. The patients were randomly assigned to an RSA-biofeedback group (N = 13) or to a treatment as usual group (N = 13). The biofeedback training consisted of five 45 min sessions designed to increase RSA. The outcome was assessed as changes in RSA and in the Centre for Epidemiologic Studies of Depression (CES-D) values from pre- to post-training. Both groups were comparable for demographic and biomedical characteristics. RSA increased significantly in patients who underwent RSA-biofeedback compared to controls. Moreover, the CES-D scores were reduced significantly from pre- to post-training in the RSA-biofeedback group compared to the controls. Changes in RSA were inversely related to changes in CES-D scores from pre- to post-training. These findings extend the effectiveness of RSA-biofeedback for increasing vagal modulation as well as for reducing depressive symptoms in post-surgical patients. Overall, the current study also suggests that this biobehavioral intervention may add to the efficacy of postoperative risk reduction programs and rehabilitation protocols in cardiac surgery patients.

Parenting stress and externalizing behavior symptoms in children: the impact of emotional reactivity.

This study investigated whether the parenting stress-child externalizing behavior link is moderated by children's emotional reactivity, as indexed by skin conductance responses (SCRs). Participants were 61 children aged 9-12 years and their mothers. Mothers completed measures of parenting stress and their children's externalizing symptoms; children also reported on their externalizing behavior. Children's SCRs were assessed during the viewing of standardized pleasant, unpleasant, and neutral pictures. Cluster analysis on SCRs identified two groups, labeled Lower SCRs and Higher SCRs. Regression analyses indicated that among children with lower SCRs, those exposed to increased parenting stress reported more externalizing symptoms, whereas those who experienced low parenting stress reported similar rates of externalizing problems as children with higher SCRs. No effect of parenting stress emerged for children with higher SCRs. Findings suggest that higher parenting stress renders children with lower, as opposed to higher, SCRs to emotional stimuli more vulnerable to externalizing problems.

Framing the ultimatum game: gender differences and autonomic responses.

The present study aimed at investigating whether the way offers are framed in the Ultimatum Game (UG) affects behavioral and autonomic responses in men and women. The "I give you" and "I take" expressions were used as gain and loss frames, respectively. Skin conductance and heart rate were recorded as indices of autonomic activation in response to unfair, mid-value, and fair offers. Acceptance rates were higher in men than in women under the gain frame. Moreover, men showed higher acceptance rates under the gain than under the loss frame with mid-value offers, whereas women's choices were not affected by frame. On the physiological level, men produced differential autonomic response patterns during decision-making when offers were presented under gain and loss framing. The "I take" frame, by acting as a loss frame, elicited in men the characteristic defensive response pattern that is evoked by aversive stimulation, in which increases in skin conductance are coupled with increases in heart rate. On the other hand, the "I give you" frame, by acting as a gain frame, elicited in men increases in skin conductance associated with prevailing heart rate deceleratory responses, reflecting a state of enhanced attention and orienting. In contrast, women's autonomic reactivity was not affected by frame, consistent with behavioral results. Phasic changes in heart rate were crucial in revealing differential functional significance of skin conductance responses under different frames in men, thus questioning the assumption that this autonomic measure can be used as an index of negative emotional arousal in the UG.

Rethinking the risk for depression using the RDoC: A psychophysiological perspective.

Considering that the classical categorical approach to mental disorders does not allow a clear identification of at-risk conditions, the dimensional approach provided by the Research Domain Criteria (RDoC) is useful in the exploration of vulnerability to psychopathology. In the RDoC era, psychophysiological models have an important role in the reconceptualization of mental disorders. Indeed, progress in the study of depression vulnerability has increasingly been informed by psychophysiological models. By adopting an RDoC lens, this narrative review focuses on how psychophysiological models can be used to advance our knowledge of the pathophysiological mechanisms underlying depression vulnerability. Findings from psychophysiological research that explored multiple RDoC domains in populations at-risk for depression are reviewed and discussed. Future directions for the application of psychophysiological research in reaching a more complete understanding of depression vulnerability and, ultimately, improving clinical utility, are presented.

Multidimensional components of (state) mathematics anxiety: Behavioral, cognitive, emotional, and psychophysiological consequences.

The present study aimed to analyze the different components of state mathematics anxiety that students experienced while solving calculation problems by manipulating their stress levels. A computerized mathematical task was administered to 165 fifth-graders randomly assigned to three different groups: positive, negative, and control conditions, in which positive, negative, or no feedback during the task was given, respectively. Behavioral (task performance), emotional (negative feelings), cognitive (worrisome thoughts and perceived competence), and psychophysiological responses (skin conductance and vagal withdrawal) were analyzed. Behavioral responses did not differ in the positive and negative conditions, while the latter was associated with children's reportedly negative emotional states, worries, and perceived lack of competence. The stress induced in the negative condition led to an increase in skin conductance and cardiac vagal withdrawal in children. Our data suggest the importance of considering students' interpretation of mathematics-related experiences, which might affect their emotional, cognitive, and psychophysiological responses.

The moderating role of depressive symptoms in the association between heart rate variability and cognitive performance in cardiac patients.

INTRODUCTION: Coronary heart disease (CHD) is strongly associated with cognitive impairment, which is a core feature of depression, highly prevalent in patients with CHD. Interestingly, patients with CHD and individuals with depression display reduced heart rate variability (HRV), which proxies a complex network integrating autonomic and attentional systems. This study investigated the moderating role of depressive symptoms in the relation between reduced HRV and cognitive performance in patients with CHD. METHOD: The sample included 274 patients with CHD (mean [standard deviation] age = 62 [9.5] years; 13 % women) admitted to cardiac rehabilitation units. Visual attention and task switching were assessed through the Trail Making Test (TMT). Depressive symptoms were assessed with the Beck Depression Inventory-II (BDI-II). Resting electrocardiographic recordings were collected to compute HRV indices. RESULTS: Patients with more severe depressive symptoms displayed an inverse association between HRV and cognitive performance (TMT-A: b = -0.08, p = .022; TMTB: b = -0.07, p = .042), whereas patients with milder depressive symptoms showed no significant association (TMT-A: b = -0.00, p = .90; TMTB: b = -0.02, p = .44). CONCLUSIONS: Depressive symptoms may strengthen the relation between reduced HRV and poorer cognitive performance in cardiac patients. The presence of depressive symptoms may signal the dysfunction of a network subserving autonomic and cognitive function.