Clinical Investigation
Depressive Symptoms Affect the Relationship of N-Terminal Pro B-Type Natriuretic Peptide to Cardiac Event-Free Survival in Patients With Heart Failure

https://doi.org/10.1016/j.cardfail.2010.01.006Get rights and content

Abstract

Background

Both N-terminal pro B-type natriuretic peptide (NT-pro BNP) and depressive symptoms independently predict cardiac events in heart failure (HF) patients. However, the relationship among NT-pro BNP, depressive symptoms, and cardiac event is unknown.

Methods and Results

Blood was drawn to measure NT-pro BNP and depressive symptoms were measured by the Patient Health Questionnaire 9 (PHQ-9) among 210 patients with HF. Data about cardiac event-free survival were collected for the average follow-up period of 397 days. Cox proportional hazards regression with survival curves were used to determine the relationship of NT-pro BNP and depressive symptoms to cardiac event-free survival. Higher NT-pro-BNP confers greater risk of cardiac events among those with depressive symptoms than those without depressive symptoms (P for the interaction = .029). Patients with NT-pro BNP >581 pg/mL and total PHQ-9 score ≥10 had a 5.5 times higher risk for cardiac events compared with patients with NT-pro BNP ≤581 pg/mL and total PHQ-9 score < 10 (P = .001).

Conclusions

The prognostic association of NT-pro BNP with cardiac event-free survival in patients with HF differed by the presence of depressive symptoms. Monitoring and treatment of depressive symptoms may be important for improving cardiac event-free survival in patients with HF.

Section snippets

Design and Procedure

This was a prospective study of patients with HF recruited from outpatient HF clinics between January 1, 2004, and December 31, 2007. Patients were recruited from 1 regional tertiary medical center and several community hospitals located in Lexington, KY. Approval from the Institutional Review Board at each of the hospitals was obtained before the study. Written informed consent was obtained from patients. At baseline, all patients visited the General Clinical Research Center to have blood

Sample Characteristics

Sample characteristics are displayed in Table 1. The majority of the patients were older than 60 years old with an age range of 24 to 87 years. As a group, patients were primarily in NYHA functional Class II/III. Nearly two thirds had ischemic heart disease as the underlying etiology of HF. Almost one third of the patients had preserved systolic function with LVEF >40%. The common comorbidities were hypertension and diabetes mellitus. The mean value of NT-pro BNP was 733 pg/mL, whereas the

Discussion

This is the first study to demonstrate that the prognostic relationship of NT-pro BNP to cardiac event-free survival of patients with HF differed by the presence of depressive symptoms after controlling for age, gender, etiology of HF, BMI, NYHA functional class, LVEF, total comorbidity score, and the interaction between level of NT-pro BNP and the presence of depressive symptoms. The most compelling finding of this study was the relationship of NT-pro BNP and cardiac event-free survival among

Conclusions

Coexistence of elevated NT-pro BNT and severe depressive symptoms predicted shorter cardiac event-free survival in patients with HF. NT-pro BNP was a nonsignificant predictor of cardiac event-free survival in the absence of depressive symptoms. Depressive symptoms were a strong predictor of cardiac event-free survival as well as more widely used biological marker such as NT-pro BNP. Monitoring and treatment of depressive symptoms are important for improving cardiac event-free survival in

Disclosures

None.

References (39)

  • R.T. Yan et al.

    Usefulness of temporal changes in neurohormones as markers of ventricular remodeling and prognosis in patients with left ventricular systolic dysfunction and heart failure receiving either candesartan or enalapril or both

    Am J Cardiol

    (2005)
  • M. Richards et al.

    Comparison of B-type natriuretic peptides for assessment of cardiac function and prognosis in stable ischemic heart disease

    J Am Coll Cardiol

    (2006)
  • R. Aboufakher et al.

    Incidence, risk factors, and prognosis of inhospital heart failure after percutaneous coronary intervention: insight from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2)

    Am Heart J

    (2005)
  • A. Elhendy et al.

    Effect of myocardial ischemia during dobutamine stress echocardiography on cardiac mortality in patients with heart failure secondary to ischemic cardiomyopathy

    Am J Cardiol

    (2005)
  • G.C. Fonarow et al.

    An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry

    Am Heart J

    (2007)
  • S. Orn et al.

    Recurrent infarction causes the most deaths following myocardial infarction with left ventricular dysfunction

    Am J Med

    (2005)
  • B. Lowe et al.

    Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses

    J Affect Disord

    (2004)
  • D. McManus et al.

    Screening for depression in patients with coronary heart disease (data from the Heart and Soul Study)

    Am J Cardiol

    (2005)
  • W. Rosamond et al.

    Heart disease and stroke statistics--2008 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

    Circulation

    (Jan 29 2008)
  • Cited by (19)

    • Depression in heart failure: Can PHQ-9 help?

      2016, International Journal of Cardiology
      Citation Excerpt :

      PHQ-9 contains 9 items, each corresponding to a diagnostic criterion from the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), and it diagnoses major depression with a sensitivity and specificity of 88% [17–20]. Despite its clinical utility in other populations, PHQ-9 has only recently begun to be utilized in research studies to evaluate depression in HF [21–25]. Furthermore, associations between PHQ-9 scores and measures of healthcare utilization, cardiovascular endpoints, and patient-centered outcomes remain under-studied in stable HF outpatients.

    • Health Literacy Predicts Morbidity and Mortality in Rural Patients with Heart Failure

      2015, Journal of Cardiac Failure
      Citation Excerpt :

      Both clinically diagnosed depression and depressive symptoms are linked, independently, to morbidity and mortality.41–44 We have previously demonstrated that depressive symptoms are an even stronger predictor for poor outcomes among patients with heart failure than B-type natriuretic peptide levels.45 The independent association of both health literacy and depression with poor outcomes highlights the importance of cognitive and psychologic variables in the clinical management of heart failure.

    • The Association of Co-morbid Symptoms of Depression and Anxiety With All-Cause Mortality and Cardiac Rehospitalization in Patients With Heart Failure

      2015, Psychosomatics
      Citation Excerpt :

      The Patient Health Questionnaire (PHQ-9) was used to measure depressive symptoms in this study.29,30 The PHQ-9 is a 9-item, self-reported measure of depression that reflects the severity of depressive symptoms over the past 2 weeks.31,32 Patients respond to each item using a Likert scale in which responses range from 0 (not at all) to 3 (nearly every day).

    • Antidepressants do not improve event-free survival in patients with heart failure when depressive symptoms remain

      2013, Heart and Lung: Journal of Acute and Critical Care
      Citation Excerpt :

      Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), a valid and reliable instrument for the measurement of depressive symptoms.24,25 The PHQ-9 has been used to predict quality of life and mortality in HF.23,26 The PHQ-9 has 9 items that reflect the criteria for diagnosis of clinical depression from the Diagnostic and Statistical Manual-IV.

    View all citing articles on Scopus

    See page 577 for disclosure information.

    The project described was supported by grant number R01 NR008567, R01 NR 009280 from the National Institute of Nursing Research (NINR), by a Center grant, P20NR010679 from National Institutes of Health (NIH), NINR, by a grant from American Acute Critical Nurses Phillips Medical Research Award, and by grant number M01RR02602 from University of Kentucky General Clinical Research Center. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.

    View full text