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Depression Predicts Outcome In Patients With AF And Heart Failure

Symptoms of depression are related to cardiovascular mortality even after adjustment for other prognostic indicators in optimally treated patients with comorbid atrial fibrillation (AF) and congestive heart failure (CHF).

It remains controversial whether or not comorbid AF-CHF results in an increased risk of mortality above the risk associated with CHF alone. Furthermore, little is known about potentially treatable risk factors for mortality in this population.

Numerous studies have found that depression predicts prognosis in other cardiac conditions, including post-myocardial infarction, post-unstable angina, CHF, coronary artery bypass grafting, and stable coronary artery disease (CAD). There is also evidence that depression may be a risk factor for stroke, ventricular arrhythmias, and sudden death.

Several pathophysiological mechanisms hypothesized to explain the link between depression and cardiac prognosis are also characteristic of CHF.Similarly, there is evidence that these mechanisms, including changes in platelet function, endothelial function, inflammation and autonomic balance, may play important roles in the origin and/or persistence of AF. Despite the evidence suggesting a potentially important role for depression, apparently, only one study has evaluated the prognostic importance of depression in AF patients, and none has specifically investigated patients with comorbid AF and CHF.

This substudy, from the AF-CHF Trial of rate-versus rhythm-control strategies, investigated whether depression predicts long-term cardiovascular mortality in patients with left ventricular ejection fraction < 35%, CHF symptoms, and AF history who receive optimal medical care.

Depression symptoms (Beck Depression Inventory-II) were assessed in 974 participants (833 men), with 32.0% showing elevated scores (Beck Depression Inventory-II > 14). Over a mean follow-up of 39 months, there were 246 cardiovascular deaths (111 presumed arrhythmic; 302 all-cause deaths). Cox proportional hazards models adjusted for other prognostic factors (including age, marital status, cause of CHF, creatinine level, left ventricular ejection fraction, paroxysmal AF, previous AF hospitalization previous electrical conversion, and baseline medications) showed that elevated depression scores significantly predicted cardiovascular mortality (primary outcome), arrhythmic death, and all-cause mortality. The adjusted hazard rates were 1.57 (95% confidence interval 1.20 to 2.07, P<0.001), 1.69 (P=0.01) and 1.38 (95% confidence interval 1.07 to 1.77 (P=0.01), respectively. The risks associated with depression and marital status were additive, with the highest risk in depressed patients who were unmarried.

The Canadian authors conclude therefore that elevated depression symptoms are related to cardiovascular mortality even after adjustment for other prognostic indicators in patients with comorbid AF and CHF who receive optimized treatment. Unmarried patients are also at increased risk. Mechanisms and treatment options deserve additional study.


Elevated Depression Symptoms Predict Long-Term Cardiovascular Mortality in Patients With Atrial Fibrillation and Heart Failure, Frasure-Smith N, Lespérance F, Habra M, et al. (Circulation. 2009;120:134-140)

Published on: August 19, 2009

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  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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