http://hwmaint.circ.ahajournals.org/cgi/reprint/110/9/e82.pdf

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction

Depression is commonly present in patients with coronary heart disease (CHD) and is independently associated with increased cardiovascular morbidity and mortality. Screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment. This multispecialty consensus document reviews the evidence linking depression with CHD and provides recommendations for healthcare providers for the assessment, referral, and treatment of depression.

https://focus.psychiatryonline.org/doi/pdf/10.1176/foc.7.3.foc406

Depression and Coronary Heart Disease Recommendations for Screening, Referral, and Treatment: A Science Advisory From the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Psychiatric Association

Background Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29-2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis. Objective To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality. Method English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]). Results Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37-3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12-2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27-2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82-5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53-4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models. Conclusions Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD.

Depression as a risk factor for mortality in patients with coronary heart disease: a meta-analysis.

Aims: With negative treatment trials, the role of depression as an aetiological or prognostic factor in coronary heart disease (CHD) remains controversial. We quantified the effect of depression on CHD, assessing the extent of confounding by coronary risk factors and disease severity.

Methods and results: Meta-analysis of cohort studies measuring depression with follow-up for fatal CHD/incident myocardial infarction (aetiological) or all-cause mortality/fatal CHD (prognostic). We searched MEDLINE and Science Citation Index until December 2003. In 21 aetiological studies, the pooled relative risk of future CHD associated with depression was 1.81 (95% CI 1.53-2.15). Adjusted results were included for 11 studies, with adjustment reducing the crude effect marginally from 2.08 (1.69-2.55) to 1.90 (1.49-2.42). In 34 prognostic studies, the pooled relative risk was 1.80 (1.50-2.15). Results adjusted for left ventricular function result were available in only eight studies; and this attenuated the relative risk from 2.18 to 1.53 (1.11-2.10), a 48% reduction. Both aetiological and prognostic studies without adjusted results had lower unadjusted effect sizes than studies from which adjusted results were included (P < 0.01).

Conclusion: Depression has yet to be established as an independent risk factor for CHD because of incomplete and biased availability of adjustment for conventional risk factors and severity of coronary disease.

/pdf/depression-as-an-aetiologic-and-prognostic-factor-in-3aivs7t0nk.pdf

Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies

Clinical and health services relationships between major depression, depressive symptoms, and general medical illness

Objective: The objective of this study was to investigate the significance of emotional distress immediately after e myocardial infarction as a predictor of physical, psychological, and social outcomes and resource use. Methods: In an epidemiological survey, demographic and cardiological data were obtained for all patients from a defined geographical area who had had a myocardial infarction (according to diagnostic criteria of the Monitoring Trends and Determinants in Cardiovascular Disease [MONICA] trial). Hospital survivors were interviewed and were asked to complete self-report assessments on mental state and quality of life. Full replies were available at baseline for 347 subjects. Self-report follow-up questionnaire information was collected 3 months and 1 year later. Results: Fifteen percent of patients scored as probable cases of anxiety or depression. They were more likely than noncases to report preinfarct distress and poor adjustment (as indicated on the 36-item Medical Outcome Study short form) There was an improvement at 3 months, but there was little overall or individual change after that time. Anxiety and depression did not predict subsequent mortality but did significantly predict poor outcome at 1 year on all dimensions of the 36-item short form quality-of-life measure and on specific measures of everyday activity ant reports of chest pain, use of primary care resources, and secondary prevention lifestyle changes. Conclusions: Subjects who are distressed in the hospital are at high risk of adverse psychological and quality-of-life outcomes during the ensuing year. Our findings strengthen the argument for in-hospital identification and treatment of patients with depression and anxiety after myocardial infarction.

Andrew Neil

Papers

Depression and anxiety as predictors of outcome after myocardial infarction.