Depression and cardiac morbidity 5 years after coronary artery bypass surgery
Borowicz Jr. L, Royall R, Grega M, Selnes O, Lyketsos C, and McKhann G;
Commented by , 16 Dec 2002
Background
One-third of patients experience depression following coronary artery bypass grafting (CABG) surgery.
Purpose
To determine whether depression 1-month post-CABG is associated with increased cardiac morbidity, specifically angina, at 5-year follow-up. Secondary cardiac outcomes included functional status, myocardial infarction (MI), angioplasty, dysrhythmias, transient ischemic attack, cerebrovascular accident (CVA), rehospitalization and death.
Methods
172 patients (134 men, 38 women) enrolled. Interviews were obtained pre-CABG and at 1 month (N=149), 1 year (N=136) and 5 years (N=132) post-CABG. Baseline demographic and detailed clinical characteristics were obtained.
At each time point, the following data were collected: interim medical histories including mortality, angina using a structured questionnaire, functional status using the Beth Israel Functional Status Questionnaire, and depressive symptoms using the self-report Center for Epidemiologic Studies Depression (CES-D) Scale.
Univariate and multiple logistic regression analyses for demographic, medical, operative factors, CES-D Scale scores were performed relative to the described outcomes.
Results
32% of patients were depressed preoperatively, 28% at 1 month, 21% at 1 year and 16% at 5 years.
38% had a recurrence of angina at 5 years; at 1-month post-CABG, these patients had a mean CES-D score of 17.7 compared with 9.7 in those without angina at 5 years, a highly significant difference. While CES-D scores at all times were associated with angina at 5 years, the 1-month score was the most significant.
Additional variables associated with angina at 5 years (male sex, preoperative history of smoking, angioplasty, CVA) were no longer significant when combined in multiple regression analyses with 1-month CES-D scores. Separate analyses for the smaller group of women failed to yield a relationship between depression and angina at 5 years.
For 5-year secondary outcomes, a CES-D score ≥ 16 was used to distinguish depressed from non-depressed. The depressed group at 1-month had significantly lower functional status and were statistically more likely to have had subsequent angioplasty (21% versus 6%). They also had more dysrhythmias, strokes and deaths, although these differences were non-significant.
Discussion
In a previous study by the same group (1), preoperative depression was a strong predictor of post-operative depression up to 1 year, and newly acquired depression was uncommon.
The current study extends beyond previous findings, indicating that patients depressed pre-operatively and at 1-month post-CABG have higher long-term cardiac morbidity.
The study has important implications for the 800,000 patients worldwide who undergo CABG surgery annually. A careful evaluation for depression pre-operatively and at 1-month post-CABG should be routine.
While SSRIs appear safe and effective with cardiac patients (2), the impact of psychotherapeutic and/or pharmacologic treatment of depression on cardiac outcomes remains to be determined.
While this study builds on the association between depression and coronary artery disease, whereby depression has gained appreciation as an independent risk factor for both first MI and cardiovascular mortality (3,4), several limitations exist.
The major limitation was the use of self-report as opposed to more objective measures for the diagnosis of angina and depression, such as the Diagnostic Interview Schedule or stress echocardiography, for example.
The lack of association between depression and cardiac outcomes in women should also be interpreted with caution given the small numbers.
- McKhann GM, Borowicz LM, Goldsborough MA, Enger C and Selnes OA. Depression and cognitive decline after coronary artery bypass grafting. Lancet 1999; 349; 1282-1284
- Glassman AH, O’Connor CM, et al. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002; 288; 701-709
- Ford DE, Mead LA, Chang PP, Cooper-Patrick L, Wang NY and Klag MJ. Depression is a risk factor for coronary artery disease in men: the precursors study. Archives of Internal Medicine 1998; 158; 1422-1426
- Frasure-Smith N, Lesperance F, Talajic M. Depression following myocardial infarction: impact on 6-month survival. JAMA 1993; 270; 1819-1825