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Depression Linked to Heart Failure After Diagnosis of Coronary Artery Disease

  • Authors: News Author: Laurie Barclay, MD
    CME Author: Désirée Lie, MD, MSEd
  • CME Released: 4/16/2009
  • Valid for credit through: 4/16/2010
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Target Audience and Goal Statement

This article is intended for primary care clinicians, cardiologists, psychiatrists, and other specialists who care for patients with coronary artery disease.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the association between depression after coronary artery disease and the risk for heart failure.
  2. Describe the association between depression with and without antidepressant medication use after coronary artery disease and the risk for heart failure.


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  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance writer and reviewer for Medscape.


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    Brande Nicole Martin, is the News CME editor for Medscape Medical News.


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

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Depression Linked to Heart Failure After Diagnosis of Coronary Artery Disease

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME Released: 4/16/2009

Valid for credit through: 4/16/2010


April 16, 2009 — Depression is linked to increased incidence of heart failure (HF) after diagnosis of coronary artery disease (CAD), regardless of antidepressant medication (ADM) treatment, according to the results of a cohort study reported in the April 21 issue of the Journal of the American College of Cardiology.

"Depression has been shown to be a risk factor for poor outcomes among CAD patients," write Heidi T. May, PhD, MSPH, from the Intermountain Medical Center in Murray, Utah, and colleagues. "However, little is known about the influence of depression on HF development in CAD patients."

The goal of this study was to examine the effect of post-CAD diagnosis of depression on the incidence of HF. The study sample consisted of 13,708 patients without International Classification of Diseases, Ninth Revision, diagnoses of HF and depression who were not prescribed ADM at the time of CAD diagnosis, defined as at least 70% stenosis. Among 7719 patients with available medication records, those subsequently diagnosed with depression were stratified by use of ADM.

Patients were followed up until clinician diagnosis or International Classification of Diseases, Ninth Revision, code diagnosis of HF or death, and data were analyzed with Cox proportional hazards regression models.

Clinical depression was diagnosed in 1377 patients (10.0%) after diagnosis of CAD. HF incidence in these patients was 16.4 per 100 vs 3.6 per 100 for those without a post-CAD diagnosis of depression. The risk for HF incidence was increased in those with depression (adjusted hazard ratio [HR], 1.50; P < .0001). Among those with available follow-up data regarding medication use, findings were similar. HR for depression without ADM use vs no depression was 1.68 (P < .0001), and HR for depression with ADM use was 2.00 (P < .0001). Incidence of HF was not different between depressed patients with and without use of ADM (HR, 0.84; P = .24).

"Depression diagnosis was shown to be associated with an increased incidence of HF after CAD diagnosis, regardless of ADM treatment," the study authors write. "This finding suggests the need to further study the effect of depression on HF risk among CAD patients."

Limitations of this study include possible residual confounding, nonrandomized design, inability to determine causality and temporality, patient selection, and determination of HF diagnosis only in hospitalized patients.

"Because both HF and depression are some of the most burdensome diseases in the world and are associated with high rates of health care utilization and severe limitations in daily functioning, this study's finding of an association between these 2 diseases could increase use of health care services, thus multiplying the burden via resources and cost," the study authors conclude. "Although this association needs further investigation, its consequences and future interventions could have a significant public health impact through the reduction of morbidity, mortality, quality of life, and health care expenditures."

The study authors have disclosed no relevant financial relationships.

J Am Coll Cardiol. 2009;53:1440-1447.

Clinical Context

Depression may be a risk factor for adverse outcomes after CAD. According to the World Health Association, depression is the one of the most burdensome diseases in the world. However, it is unclear if depression after CAD affects subsequent risk for HF.

This is a longitudinal cohort study of patients with a diagnosis of CAD to determine if depression after CAD was associated with higher risk for HF.

Study Highlights

  • Included were patients from the cardiac catheterization registry of the Intermountain Heart Collaborative Study with CAD (stenosis > 70%) and no antecedent diagnosis of depression or HF at index angiography.
  • Depression was defined as having a clinical diagnosis of depression by International Classification of Diseases, Ninth Revision, code in an outpatient, inpatient, or emergent setting.
  • ADM therapy was defined as use of any class of antidepressants at index hospitalization, subsequent hospitalization, or filling a prescription at the pharmacy.
  • The 2 cohorts studied, inpatient and outpatient pharmacy, were combined to evaluate the association between depression and HF.
  • Other covariates examined were age, sex; presence of comorbidities; and treatment type such as medications, percutaneous coronary intervention, or coronary bypass surgery.
  • Patients were followed up until a subsequent hospitalization, when they received a diagnosis of HF or until death.
  • Deaths were determined by telephone survey, hospital records, and state health records.
  • Average length of follow-up was 5.6 years among all study patients, and 6.1 and 3.6 years for the hospitalized and outpatient pharmacy cohort.
  • A total of 1377 (10%) of the 13,708 patients in the cohort had a post-CAD clinical depression diagnosis.
  • Mean age of the patients was 64 years, over two thirds were men, 60% had hypertension, 58% had hyperlipidemia, and one fifth had diabetes.
  • Mean body mass index was 29.5 kg/m2.
  • A total of 674 patients had a follow-up HF diagnosis.
  • Among this group, 448 had a no depression diagnosis and 226 had a diagnosis of depression post-CAD.
  • The incidence of HF was 3.6 per 100 for those without a post-CAD diagnosis of depression and 16.4 per 100 for those with a post-CAD diagnosis of depression.
  • 7719 patients had available follow-up medication information.
  • Among those with depression, those with ADM treatment were more likely to be men, have diabetes, be younger, and have greater ejection fraction.
  • The rates of HF among those without depression, with depression and no ADM treatment, and with depression and ADM treatment were 5.7%, 18.6%, and 16.1% respectively.
  • This corresponded to HRs of 1.68 without ADM use and 2.00 with ADM use vs risk for those with no depression.
  • The increase in the risk for HF was evidence at the start of follow-up and was not affected by ADM treatment.
  • A depression diagnosis was associated with a 2-fold increased risk in the incidence of HF (HR, 2.0; adjusted HR, 1.5; P < .0001).
  • Results were similar for patients with depression with and without ADM treatment.
  • Among patients who used ADMs but did not have a diagnosis of depression, there was no increased risk for HF.
  • Those who did not receive an ejection fraction measurement had a higher risk for the development of HF vs those who did.
  • The authors concluded that a post-CAD diagnosis of depression was associated with an increased risk for HF regardless of treatment with ADM, suggesting that ADM therapy is not able to alter the behavioral or physiologic risks underlying the association.

Pearls for Practice

  • A post-CAD diagnosis of depression is associated with higher risk for HF.
  • Among patients with CAD, use of ADM does not reduce the increased risk for HF associated with a diagnosis of depression.