Effect of Depression on Late (8 years) Mortality After Myocardial Infarction

doi:10.1016/j.amjcard.2007.10.021

The American Journal of Cardiology

Volume 101, Issue 5, 1 March 2008, Pages 602-606

https://doi.org/10.1016/j.amjcard.2007.10.021 Get rights and content

Depression during hospitalization for myocardial infarction (MI) is associated with subsequent mortality, but whether this risk persisted long term is not well studied. This study was performed to determine whether depression during hospitalization for MI, which predicted mortality at 4 months, predicted mortality 8 years later. This was a prospective observational study of 284 hospitalized patients with MI. Major depression and dysthymia were assessed using structured interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, and depressive symptoms, using the Beck Depression Inventory. Mortality was determined using the Social Security Death Index. Mean age during MI hospitalization was 64.8 years, 43.0% of patients were women, 66.7% had hypertension, and 35.7% had diabetes mellitus. Any depression (major depression, dysthymia, and/or Beck Depression Inventory score ≥10) was present in 76 patients (26.8%). The 8-year mortality rate was 47.9% (136 deaths). Any depression at the time of MI was not associated with mortality at 8 years in unadjusted (hazard ratio 1.25, 95% confidence interval 0.87 to 1.81, p = 0.22) or multivariate models (hazard ratio 0.76, 95% confidence interval 0.47 to 1.24, p = 0.27). In conclusion, depression after MI was associated with increased short-term mortality, but its relation with mortality over time appeared to wane, at least in a group of older patients who had multiple co-morbidities.

Section snippets

Methods

Patients with acute MI admitted to the cardiology service at the Johns Hopkins Bayview Medical Center, Baltimore, Maryland, from July 1, 1995, to December 31, 1996, were eligible for inclusion in the study if they had no major problems with cognition, were clinically stable enough to complete the interview, and did not have co-morbid noncardiac illness likely to cause death within the next 6 months.² Acute MI was defined as ≥2 of typical ischemic chest pain lasting ≥20 minutes, presence of new

Results

A total of 284 patients were enrolled in the study and assessed using structured interview (n = 280), the BDI (n = 280), or both (n = 276). Details of numbers of patients meeting enrollment criteria and excluded patients were previously reported.² Of 280 patients, major depression was diagnosed in 29 (10%), 26 (9%) had dysthymia, and 56 of 280 (20%) had a BDI score ≥10. Patients with any depression (n = 76; 27%) were significantly more likely to be white, have had a previous MI, have renal

Discussion

The major finding of this study was that any depression (defined as major depression, dysthymia, and/or BDI score ≥10) at the time of MI was not associated with long-term mortality, although it predicted 4-month mortality in a previous study in this cohort.²

To the best of our knowledge, 3 previous studies examined the relation of depression at the time of MI and mortality ≥5 years later,22, 23, 24 and each found an association between depression and long-term mortality. The discrepancy between

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Cited by (37)

Association of anxiety or depression with risk of recurrent cardiovascular events and death after myocardial infarction: A nationwide registry study
2023, International Journal of Cardiology
Depression and anxiety are risk factors for patients with myocardial infarction (MI). However, the association of a previous psychiatric diagnosis of anxiety or depression, or only such self-reported symptoms, with cardiovascular outcomes and mortality post-MI has not been previously examined in the same nationwide cohort.
We linked demographic, socioeconomic and clinical data from four nationwide Swedish registries for patients enrolled in cardiac rehabilitation (CR) after first-time MI (2006–2015, N = 45,096). After multiple imputation, we applied Cox regression to estimate the post-MI outcome risk for patients with a previous psychiatric diagnosis of anxiety/depression (Diagnosis), patients with no formal diagnosis but self-reported symptoms of anxiety/depression (Symptoms), versus patients with neither Diagnosis nor Symptoms (Reference).
During one-year follow-up, fully adjusted models showed that patients with Diagnosis had a higher risk (hazard ratio [95%CI]) of all-cause mortality (1.86 [1.36, 2.53]), reinfarction (1.14 [1.06, 1.22]), their composite (1.15 [1.07, 1.23]), and an extended cardiovascular composite (1.19 [1.12, 1.26]), versus Reference, even though 77% reported no symptoms at the time of MI. In patients with Symptoms, estimates were also elevated yet somewhat attenuated compared to Reference. Findings were overall robust across multiple sensitivity analyses.
Both a previous diagnosis, and present self-reported symptoms of anxiety or depression are associated with an increased risk of death and recurrent cardiovascular events in adults with first-time MI. Only screening for present symptoms is inadequate for assessing this excessive risk. Assessment of both psychiatric history and self-reported symptoms seems warranted for these patients.
Predictive value of depression and anxiety for long-term mortality: differences in outcome between acute coronary syndrome and stable angina pectoris
2018, International Journal of Cardiology
Citation Excerpt :
However, since the early 2000s treatment for ACS has moved from thrombolytic therapy to primary PCI (pPCI) and the association between depression or anxiety and long-term outcome has not been thoroughly investigated since then [1–3]. Prevalence rates of depression and anxiety in patients with coronary artery disease (CAD) in general vary from 10% to 50% [4–10]. Targeting psychological symptoms may provide improvements to the prognosis and quality of life in patients with CAD [11].
Since the early 2000s the treatment of choice for an acute myocardial infarction has moved from thrombolytic therapy to primary PCI (pPCI). As a result, the majority of patients undergoing PCI shifted from stable angina pectoris (SA) to acute coronary syndrome (ACS). Additionally the previously observed association between depression and anxiety and long-term outcome in patients who underwent a PCI may have been changed. The main objective of this study was to investigate the predictive value of depression and anxiety for 10-year mortality, in a cohort with post-PCI patients treated for SA versus patients treated for ACS.
This prospective single center cohort consists of a consecutive series of patients (n = 528) treated with PCI. At 1 month post-PCI, patients completed the Dutch version of the Hospital Anxiety and Depression Scale (HADS).
After adjustment for baseline characteristics depression was associated with higher 10-year mortality post-PCI (HR 1.58 95% Confidence Interval [95% CI] 1.04–2.40). In the ACS population no association between depression and 10-year mortality was found (HR 1.05 95% CI 0.62–1.79), in contrast to the SA population (HR 1.97 95% CI 1.09–3.57). After additional adjustment for anxiety, depression was no longer associated with higher mortality.
Anxiety at baseline was associated with an increased 10-year mortality rate after PCI. Depression was also associated with higher 10-year mortality, however the association disappeared after additional adjustment for anxiety. This finding was more pronounced in patients presenting with SA as compared to those presenting with ACS, which might be a result of the increasing number of ACS patients treated with pPCI.
Relation of Anxiety and Depressive Symptoms to Coronary Artery Calcium (from the ELSA-Brasil Baseline Data)
2016, American Journal of Cardiology
Previous studies of the association between symptoms of anxiety or depression and coronary artery calcium (CAC) have produced heterogeneous results. Our aim was to investigate whether psychopathological symptoms were associated with CAC in a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline. We analyzed data from 4,279 ELSA-Brasil subjects (aged 35 to 74 years) from the São Paulo site without previous cardiovascular disease who underwent CAC score assessment at baseline. Prevalent CAC was defined as a CAC score >0. Anxiety and depressive symptoms were assessed using the Clinical Interview Schedule–Revised (CIS-R). We built binary logistic regression models to determine whether CIS-R scores, anxiety, or depression were associated with prevalent CAC. Prevalent CAC was found in 1,211 subjects (28.3%). After adjustment for age and gender, a direct association between CIS-R scores and prevalent CAC was revealed (odds ratio for 1-SD increase: 1.12; 95% confidence interval [CI] 1.04 to 1.22). This association persisted after multivariate adjustment (odds ratio for 1-SD increase 1.11; 95% CI 1.02 to 1.20). No independent associations were found for specific diagnoses of anxiety or depression and prevalent CAC. In post hoc models, a significant interaction term (p = 0.019) suggested a stronger association in older subjects. In conclusion, psychopathological symptoms were directly associated with coronary atherosclerosis in the ELSA-Brasil baseline in adjusted models, and this association seems to be stronger in older subjects.
Depression is independently associated with 7-year mortality in patients treated with percutaneous coronary intervention: Results from the RESEARCH registry
2013, International Journal of Cardiology
Citation Excerpt :
The results of the current study corroborate those of previous studies in cardiac patients, demonstrating that depression is independently associated with an increased risk for short-term mortality [1,2,6–9,12,13]. The impact of depression on long-term mortality (> 5 years) has been studied previously, with these studies mainly focusing on post-MI patients [4,21], CABG patients [5,14], and patients referred for exercise testing [22], rather than PCI patients. The results of three of these previous studies were in line with the current study, showing a significant association between depression and long-term mortality [5,14,21], whereas other studies demonstrated that depression was significantly associated with short-term prognosis, but not with long-term prognosis [4,22].
Depression has been associated with poor prognosis in patients with coronary artery disease (CAD), but little is known about the impact of depression on long-term mortality. We examined whether depression was associated with 7-year mortality in patients treated with percutaneous coronary intervention (PCI), after adjusting for socio-demographic and clinical characteristics, anxiety, and the distressed (Type D) personality.
The sample comprised a cohort of consecutive PCI patients (N = 1234; 72.0% men; mean age 62.0 ± 11.1 years, range [26–90] years) from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. At baseline (i.e., 6 months post-PCI), patients completed the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression and the Type D scale (DS14) to assess Type D personality. The endpoint was defined as all-cause mortality.
The prevalence of depression (HADS-D ≥ 8) was 26.2% (324/1236). After a median follow-up of 7.0 ± 1.6 years, 187 deaths (15.2%) from any cause were recorded. The incidence of all-cause mortality in depressed patients was 23.5% (76/324) versus 12.2% (111/910) in non-depressed patients. Cumulative hazard functions differed significantly for depressed versus non-depressed patients (log-rank X² = 25.57, p < .001). In multivariable analysis, depression remained independently associated with all-cause mortality (HR = 1.63; 95% CI [1.05–2.71], p = .038), after adjusting for socio-demographic and clinical characteristics, anxiety, and Type D personality.
Depression was independently associated with a 1.6-fold increased risk for 7-year mortality, above and beyond anxiety and Type D personality. Future studies are warranted to further elucidate the potential pathways linking depression to long-term mortality following PCI.
Depression screening in patients with coronary heart disease: A critical evaluation of the AHA guidelines
2011, Journal of Psychosomatic Research
Citation Excerpt :
However, Carney et al. [26] suggest that the first episode of depression after the coronary event may have a stronger cardiac prognostic impact than recurring depression with previous onset. Also, it is not clear if depression arising within a few months of an ACS has the same cardiac prognostic implications as depression arising several months or a year later [27,28]. Both the period of onset of depression relative to the onset of CHD and the trajectory of depressive symptoms impact prognosis.
We lack evidence that routine screening for depression in patients with coronary heart disease (CHD) improves patient outcome. This lack has challenged the advisory issued by the American Heart Association (AHA) to routinely screen for depression in CHD patients. We assess the AHA advisory in the context of well-established criteria of screening for diseases.
Using principles and criteria for screening developed by the World Health Organization and the United Kingdom National Screening Committee, we generated criteria pertinent to screening for depression in CHD patients. To find publications relevant to these criteria and clinical setting, we performed a broadly based literature search on “depression and CHD,” supplemented by more focused literature searches.
Evidence for an association between depression and CHD is strong. Despite this, the AHA advisory has several limitations. It did not account for the complexity of the association between depression and CHD. It acknowledged there was no evidence that screening for depression leads to improved outcomes in cardiovascular populations but still recommended routine screening without providing an alternative evidence-based explanation. It ignored the paucity of literature about the safety and cost-effectiveness of routine screening for depression in CHD and failed to define the nature and extent of resources needed to implement such a program effectively.
We conclude that the AHA advisory is premature. We must first demonstrate the efficacy, safety, and cost-effectiveness of screening and define the resources necessary for its implementation and monitoring. Meanwhile, organizations representing cardiologists, psychiatrists, and general practitioners must coordinate efforts to manage depression and CHD through collaborative care, and work with the policy makers to develop the necessary infrastructure and services delivery system needed to optimize the outcome of depressed and at-risk-for-depression patients suffering from CHD.
Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: A meta-analysis of 25 years of research
2011, General Hospital Psychiatry

View all citing articles on Scopus

¹: Dr. Ziegelstein was supported by grant R21 NS048593 from the National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, and the Miller Family Scholar Program.

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Coronary artery diseaseEffect of Depression on Late (8 years) Mortality After Myocardial Infarction

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

Am J Cardiol

Clin Psychol Rev

Psychosomatics

J Clin Epidemiol

Ann Epidemiol

Am Heart J

Am J Cardiol

Kidney Int

Am J Cardiol

Beck Depression Inventory manual

An inventory for measuring clinical anxiety: psychometric properties

J Consult Clin Psychol

SF-36 Physical and Mental Health Summary Scales: a user’s manual

Measures of perceived social support from friends and from family: three validation studies

Am J Community Psychol

Coronary artery disease
Effect of Depression on Late (8 years) Mortality After Myocardial Infarction