Worsening depressive symptoms associated with adverse outcomes in patients with heart failure

Contact: Amanda Jekowsky, ajekowsk@acc.org, 202-375-6645

Patients with heart failure are more likely to experience adverse clinical outcomes if their depressive symptoms worsen, according to new research published in the January 25, 2011, issue of the Journal of the American College of Cardiology. Compared with patients showing little change or an improvement in depressive symptoms, those whose depressive symptoms worsened were at more than twice the risk of adverse outcomes, the analysis found, suggesting that routine assessment of depressive symptoms may help determine the appropriate medical management of this patient population.

Led by an individual from Duke University Medical Center, the research team analyzed the psychosocial and medical health of 147 patients with heart failure (HF), assessing them at baseline and at a 1-year follow-up point. Specifically, the team used the Beck Depression Inventory (BDI; a 21-item self-reported measure of depressive symptoms) to determine the severity of symptoms and tracked the primary endpoint (cardiovascular death or hospitalization due to cardiovascular causes, such as myocardial infarction, stroke, treatment for worsening HF, and cardiac surgery) through hospital and personal medical records across a median of 5 years. They also examined all-cause death and hospitalization.

The researchers found that patients who exhibited at least a 3-point increase in BDI score (indicating worsening depressive symptoms) were at more than twice the risk of adverse cardiovascular outcomes than study participants who showed minimal change (less than a 3-point increase in BDI), even after controlling for the severity of HF and other risk factors (hazard ratio: 2.12, 95% confidence interval: 1.31 to 3.43, p = 0.002). When looking at all-cause mortality and hospitalizations, the team once again saw that an increased risk was associated with worsening depressive symptoms, although this risk was not as strong as that seen with the cardiovascular endpoints.

While previous research ― including a study conducted by the current authors — has already illustrated a connection between depressive symptoms and adverse clinical outcomes for patients with HF, the study authors write that their examination is the first to prospectively evaluate how changing depressive symptoms impact outcomes. They add that the study results support the American Heart Association’s encouragement of depression screening “and further suggest that it may be prudent for clinicians to reassess symptoms of depression routinely in HF patients to determine better appropriate medical management of these patients.” According to the authors, 24% to 42% of the more than 5 million Americans living with HF are estimated to be diagnosed with depression.

Further examining the study’s implications, two researchers question in an accompanying editorial whether cardiologists should be involved in diagnosing and treating depression given the condition’s influence on cardiac outcomes. Writing that although depression is “a significant and debilitating disease,” Ingrid Connerney, Dr.P.H., from the Department of Organizational Systems and Adult Health at the University of Maryland School of Nursing, and Peter A. Shapiro, M.D., from the Department of Psychiatry at Columbia University College of Physicians and Surgeons, note that it remains underdiagnosed and undertreated in patients with HF and add “it is feasible” for cardiologists to regularly assess patients for depression. Specifically, the pair notes that “validated and brief” screening instruments exist—including a 2-item questionnaire—that can help cardiologists conduct frequent depression screenings and refer patients for further care, if necessary.


The American College of Cardiology is transforming cardiovascular care and improving heart health through continuous quality improvement, patient-centered care, payment innovation and professionalism. The College is a 39,000-member nonprofit medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers, and bestows credentials upon cardiovascular specialists who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at http://www.cardiosource.org/ACC.


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