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[Depression after first myocardial infarction. A prospective study on incidence, prognosis, risk factors and
Jacqueline J Strik1, Herman M van Praag, Adriaan Honig
1Afdeling Psychiatrie Academisch Ziekenhuis Maastricht.
Insights
Depression after first myocardial infarction (MI) predicts increased healthcare use but not cardiac events. Anxiety symptoms, however, do predict cardiac mortality and recurrent MI in these patients.
Area of Science:
- Cardiology
- Psychiatry
- Epidemiology
Background:
- Depression is a common comorbidity following myocardial infarction (MI).
- Previous research suggests depression may be a risk factor for adverse cardiac outcomes.
- The specific impact of depression on outcomes after a *first* MI requires further investigation.
Purpose of the Study:
- To investigate the epidemiology, risk factors, and treatment of depression post-first MI.
- To determine if depression predicts major cardiac events and healthcare consumption.
- To evaluate the cardiac safety and efficacy of fluoxetine in treating post-MI depression.
Main Methods:
- Two cohorts of first MI patients (n=412) were followed for up to 6 years.
- Depression screening using validated questionnaires (SCL-90, Zung, BDI, HADS) at 3-month intervals.
- Standardized interviews for DSM-IV diagnosis; cardiac events and healthcare consumption were assessed.
- A subset of patients with depression received fluoxetine in a double-blind, placebo-controlled trial.
Main Results:
- Depression predicted increased healthcare consumption but not major cardiac events (cardiac death, recurrent MI) up to 6 years post-first MI.
- Anxiety symptoms, unlike depression, predicted cardiac mortality and recurrent MI independently of other risk factors.
- Complications during admission (arrhythmias, angina) and benzodiazepine use were identified as risk factors for post-MI depression.
- Fluoxetine was found to be cardiac-safe and more effective than placebo in mild depression, but overall treatment effect on cardiac prognosis remains unproven.
Conclusions:
- Depression following a first MI is associated with higher healthcare utilization, not necessarily increased cardiac mortality.
- Anxiety symptoms are a significant predictor of adverse cardiac outcomes in first MI patients.
- Identifying and screening at-risk patients for depression is crucial; fluoxetine appears safe and potentially beneficial for mild cases.
Abstract:
In these studies patients with first myocardial infarction (MI) were selected for studies focusing on epidemiology, risk factors and treatment of depression post-MI. Two consecutive cohorts of first MI patients were included. The first cohort was selected between May 1994 and May 1997 (n = 206), and the second between May 1997 and October 1999 (n = 206). All patients were screened every 3 months for depression using the SCL-90 and the Zung (cohort 1) or SCL-90, BDI and HADS (cohort 2) until 12 months post-MI. Patients scoring above the cut-off of one of the questionnaires were interviewed using a standardised interview in order to evaluate whether DSM-IV criteria for major depression were met; patients of the second cohort were also interviewed 1 month post-MI, independently of the score of the questionnaires. Of both cohorts data concerning major cardiac events and increased health care consumption were assessed during a 1 to 6 years follow-up period. Patients with major depression were offered treatment in the double-blind placebo-controlled trial with fluoxetine (n = 54). Depression appeared to be a predictor of increased health care consumption, but not of major cardiac events such as cardiac death and recurrent infarction in first myocardial infarction (MI) patients up to 6 years post-MI. This finding is in contrast to findings in the literature indicating that in patient populations with mixed first and recurrent MI, depression is a risk factor for cardiac mortality. In contrast to depression, symptoms of anxiety do predict cardiac mortality and recurrent MI in patients following first MI independently of other risk factors of cardiac mortality. Recognition of risk factors for post-MI depression may help the cardiologist to identify patients at risk for depression. Examples of such risk factors are, according to our studies, complications during admission, such as arrhythmic disorders and recurrent angina pectoris, and prescription of benzodiazepines. Patients at risk can be screened for depression using a 4-item questionnaire, and, if scoring is positive, be referred for psychiatric evaluation. Although the effectivity of antidepressive treatment in MI patients has as yet not been proven, we found that fluoxetine is a cardiac-safe antidepressive agent, but only in mild depression more effective than placebo. The positive effect of antidepressive treatment on cardiac prognosis has as yet not been shown.