Depression as a Risk Factor for Poor Prognosis Among Patients With Acute Coronary Syndrome: Systematic Review and Recommendations: A Scientific Statement From the American Heart Association

Study Questions:

Does the available evidence suggest that depression should be elevated to the status of a risk factor for patients with acute coronary syndrome (ACS)?


Writing group members were approved by the American Heart Association’s Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after ACS was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies.


A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, the review identified generally consistent associations between depression and adverse outcomes.


Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with ACS.


The classic definition of an independent risk factor includes the epidemiologic association of a risk marker (hypertension) with a disease (e.g., stroke and myocardial infarction) and demonstration that treatment intervention reduces the risk. The close relationship between depression, anxiety, hypertension, inflammation, inactivity, diabetes, obesity and poor diet, smoking, the metabolic syndrome, and noncompliance with evidence-based treatment seriously compromises the ability to define it as an independent risk factor. The need for an adequately powered randomized controlled clinical trial to determine whether effective treatment of depression improves survival and other patient outcomes after ACS is sorely needed. Until such results are available, there is enough strong evidence for its relationship with an adverse outcome to encourage cardiologists to screen for depression (e.g., PHQ-2 or PHQ-9) and consider counseling or drug therapy to improve quality of life and compliance with evidence-based treatments for ACS.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Prevention, Diet, Hypertension, Smoking

Keywords: Depression, Inflammation, Myocardial Infarction, Acute Coronary Syndrome, Stroke, Depressive Disorder, Risk Factors, Smoking, Metabolic Syndrome X, Prognosis, Quality of Life, Cardiovascular Diseases, Obesity, Diet, Hypertension, Diabetes Mellitus

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