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. 2024 Oct 24;3(11):101348.
doi: 10.1016/j.jacadv.2024.101348. eCollection 2024 Nov.

The Impact of Changes in Depression on Cardiovascular Outcomes in Patients With Coronary Heart Disease

Nishant Vatsa  1 , Josiah Bennett  2 , Sonika Vatsa  3 , Alireza Rahbar  1 , Daniel A Gold  1 , Vardhmaan Jain  1 , Matthew E Gold  1 , Alexander Razavi  1 , Adithya Yadalam  1 , Shivang Desai  1 , Muhammad Owais  1 , Joy D Hartsfield  1 , Yi-An Ko  4 , Laurence Sperling  1 , Viola Vaccarino  1   5 , Puja K Mehta  1 , Arshed A Quyyumi  1
Affiliations

The Impact of Changes in Depression on Cardiovascular Outcomes in Patients With Coronary Heart Disease

Nishant Vatsa et al. JACC Adv. .

Abstract

Background: Depression is associated with major adverse cardiovascular events (MACE). Whether longitudinal changes in depression affect MACE in patients with coronary heart disease (CHD) remains unknown.

Objectives: The authors evaluated the hypothesis that increasing or persistent depression predicts MACE in patients with CHD.

Methods: At baseline, 3,483 Emory Cardiovascular Biobank participants (median age 65.5 years, 31.6% female) completed the Patient Health Questionnaire 8 (PHQ8) for depression evaluation. At 1 year, 2,639 of these event-free participants repeated the questionnaire. Depression was defined as a PHQ8 score >9 and change in depressive symptoms ( Δ PHQ8) was year 1 score minus baseline PHQ8 scores. We categorized participants into never depression (both PHQ8 <10), new depression (baseline PHQ8 <10; 1-year PHQ8 >9), remitted depression (baseline PHQ8 >9; year 1 PHQ8 <10), and persistent depression (both PHQ8 >9) groups. Fine-Gray models with noncardiovascular death as the competing event and adjusted for demographics, CHD, and depression related factors evaluated how changes in depression affect MACE (cardiovascular death and MI).

Results: Overall, the incidence of MACE was 14%, with 8.7% of those with follow-up PHQ8 having MACE. 2.9% had persistent depression, 4.5% had new depression, 10.8% had remitted depression, and 81.8% never had depression. Increasing depressive symptoms independently predicted MACE ( Δ PHQ8 subdistribution HR: 1.06 [95% CI: 1.02-1.09], P < 0.001). Correspondingly, the incidence of MACE was higher in those with persistent (20.8%) or new depression (11.9%) than in those with remitted (9.4%) or never depression (8%) (P < 0.001). Compared to never depression, persistent depression independently predicted MACE (subdistribution HR: 2.78 [95% CI: 1.2-6.5], P = 0.017).

Conclusions: Increasing or persistent depression predicts MACE in individuals with CHD.

Keywords: cardiovascular outcomes; coronary heart disease; depression.

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Conflict of interest statement

Dr Vatsa is supported by the 10.13039/100013726Abraham J. & Phyllis Katz Foundation (Atlanta, GA), 10.13039/100000002NIH–10.13039/100000050NHLBI grant 1R01HL157311, and T32 HL130025. Dr Vaccarino is supported by R01 HL109413 and R01 HL163998. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Participant Selection Participant selection for analyses evaluating the impact of baseline, year-1, and change in depressive symptoms or status on CV death or MI. We excluded individuals with baseline depression assessments who did not complete follow-up depression assessments or had CV death or MI before follow-up from analyses evaluating the impact of year 1 and change depression or depressive symptoms on CV death or MI.
Figure 2
Figure 2
MACE Cumulative Incidence Curves by Depression Status Kaplan–Meier unadjusted cumulative incidence curves of participants with depression (PHQ8 >9, grey) and no depression (PHQ8 ≤9, blue) at enrollment (A) and year 1 follow-up (B). Significant differences are denoted by log-rank P < 0.05. PHQ8 = Patient Health Questionnaire 8.
Figure 3
Figure 3
sHR of Depressive Symptoms on MACE Ratios for baseline, year 1, and change in depressive symptoms (Δ PHQ8) were assessed by Fine and Gray models with the composite of CV death or MI as the event of interest and non-CV death as the competing event. Model 1 is the univariate model, model 2 is adjusted for demographics, model 3 is adjusted for model 2 covariates and cardiovascular risk factors, and model 4 is adjusted for model 3 covariates and depression risk factors. PHQ8 = Patient Health Questionnaire 8; sHR = subdistribution HR.
Figure 4
Figure 4
Interaction Between ΔPHQ8 and Covariates on MACE Pooled interaction effects between change in depressive symptoms (ΔPHQ8) and listed covariates on CV death or MI. Pooled forest plots showing adjusted log effect sizes of change in depressive symptoms (ΔPHQ8) on CV death or MI by subgroup strata, which were calculated by Cox proportional hazards models adjusted for demographics, cardiovascular risk factors, and depression risk factors. Significant interactions have P for interaction<0.05. PHQ8 = Patient Health Questionnaire 8.
Central Illustration
Central Illustration
The Impact of Changes in Depression on Cardiovascular Outcomes in Patients With Coronary Heart Disease Persistent depression is associated with MACE. Kaplan–Meier unadjusted cumulative incidence curves show a significantly higher incidence of MACE among those with persistent depression (gold) or new depression (black) versus those with remitted depression (red) or never depression (blue).
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