Antidepressants do not improve event-free survival in patients with heart failure when depressive symptoms remain

Effects of a video-viewing intervention with positive word stimulation on the depressive symptoms of older patients with cardiac disease and subthreshold depression: a pilot randomized controlled trial protocol

BACKGROUND

Intervention for older patients with cardiac disease and subthreshold depression (StD) may be an effective strategy to prevent the development of major depressive disorder. The subliminal priming with supraliminal reward stimulation (SPSRS) website developed by us is an advanced intervention that can improve depressive symptoms in individuals with StD by presenting positive word stimuli in videos. However, its efficacy for treating depressive symptoms in older patients with cardiac disease and StD has not been investigated. Here, we present a pilot randomized controlled trial protocol to investigate the preliminary efficacy of an intervention for older patients with cardiac disease with StD.

METHODS

The study was designed as a single-center, open-label, pilot, randomized, parallel-group trial. The participants will include 30 older patients with cardiac disease and StD who are hospitalized in acute wards. The Experimental group received the SPSRS intervention (video viewing with positive word stimuli; n = 15) and the Control group will receive the YouTube intervention (video viewing without positive word stimuli; n = 15). In both groups, the intervention will be administered for 10 min per day, five times per week for 1 week. The primary outcome will be the change in the scores on the Japanese version of the Beck Depression Inventory-II at 1 week after the baseline assessment. The secondary outcomes will be the changes in the Specific Activity Scale, New York Heart Association functional classification, as well as grip strength at 1 week after the baseline assessment.

DISCUSSION

This pilot randomized controlled trial will be the first to evaluate the SPSRS intervention for depressive symptoms in older patients with cardiac disease and StD who are admitted to acute wards. The results will provide tentative indications regarding the impact of the intervention on depressive symptoms among older patients with cardiac disease and StD who are admitted to acute wards, and will contribute to the planning of a full-scale study.

TRIAL REGISTRATION

UMIN, UMIN000052155. Registered September 8, 2023, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000059526 . This study was registered with the University Hospital Medical Information Network (UMIN) (UMIN000052155) in Japan.

Effect of antidepressants on death in patients with heart failure: a systematic review and meta-analysis

Depression is associated with an increased risk of death in patients with heart failure (HF); however, the association between the use of antidepressants and HF prognoses remains controversial. Therefore, this meta-analysis aimed to evaluate the effect of antidepressants on the risk of death in HF patients. We retrieved data from the PubMed and EMBASE databases until August 2019 for studies reporting the use of antidepressants in HF patients. Data were extracted from the eligible articles, and a random effects model was used to pool the effect estimates (risk ratios (RRs) and 95% confidence intervals (CIs)). A total of 8 studies were included in this meta-analysis. Overall, the use of antidepressants was associated with increased risks of all-cause death (RR = 1.27; 95% CI, 1.21-1.34) and cardiovascular death (RR = 1.14; 95% CI, 1.08-1.20) in HF patients with or without depression. Specifically, HF patients with depression taking antidepressants had increased risks of all-cause death (RR = 1.21; 95% CI, 1.16-1.27) and cardiovascular death (RR = 1.21; 95% CI, 1.13-1.30). Compared with nonusers, the use of selective serotonin reuptake inhibitors (SSRIs), tricyclics (TCAs), and selective serotonin reuptake inhibitors (SNRIs) significantly increased the rate of all-cause death (SSRIs (RR = 1.26; 95% CI, 1.19-1.32), TCAs (RR = 1.30; 95% CI, 1.16-1.46), and SNRIs (RR = 1.17; 95% CI, 1.08-1.26)) but not cardiovascular death (SSRIs (RR = 1.03; 95% CI, 0.84-1.26), TCAs (RR = 1.02; 95% CI, 0.86-1.21), and SNRIs (RR = 0.92; 95% CI, 0.48-1.78)). Based on current publications, the use of antidepressants could increase the risk of all-cause death in HF patients, regardless of whether they have depression or the type of antidepressants they use. Further study is needed to determine the relationship between antidepressant use and cardiovascular death.

The Use of Antidepressants in Patients with Heart Failure

Background

Heart failure (HF) is a chronic disease affecting patients' quality of life (QoL) and may cause depression. Recent studies reported that the prevalence of depression in patients with HF is 21.5%. Antidepressants, mainly selective serotonin reuptake inhibitors, are usually prescribed for HF patients diagnosed with depression. Some evidence supports antidepressant's role in improving symptoms by enhancing the psychological aspect of their QoL. Depression screening and treatment are important in the multidisciplinary management; however, their survival benefits are inconsistent. In our study, we aim to investigate the prevalence of depression and the use of antidepressants in patients with HF as well as to determine the acceptance of using antidepressants in such patients.

Methods

This is a cross-sectional study conducted by interviewing HF outpatients at National Guard Hospital in Riyadh. Patients were assessed using Hamilton depression rating scale.

Results

A total of 306 patients were included, with the majority (69%) being male and aged >61 years (60%). Patients' medical history was classified into different groups, with the largest proportion (39.9%) in the diabetic-hypertensive group, followed by a diabetic group (21.2%) and a hypertensive group (10.8%). Patients were classified according to the New York Heart Association Functional Classification, and most patients were in Class I (61.8%). Some of the patients (8.5%) had been diagnosed with depression. There was no statistically significant association between HF and depression (p > 0.05). However, 5.6% of patients had been prescribed antidepressants and 17.1% of patients believed that they required antidepressants. Moreover, there was a statically significant association between medical history and development of depression (p = 0.014).

Conclusions

The prevalence of depression in HF patients in our population was lower than reported. There was no association between HF stage, depression, and antidepressant use.

The impact of antidepressants on depressive symptom severity, quality of life, morbidity, and mortality in heart failure: a systematic review

OBJECTIVE

The purpose of this paper is to review the literature on the impact of antidepressants on depressive symptom severity, quality of life (QoL), morbidity, and mortality in patients with heart failure (HF).

METHODS

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies published from December 1969 to December 2019 that pertain to depression and HF were identified through the use of the PubMed and PsycINFO databases, using the keywords: 'antidepressant*' and 'heart failure.' Two authors independently conducted a focused analysis and reached a final consensus on 17 studies that met the specific selection criteria and passed the study quality checks.

RESULTS

Studies varied in types of antidepressants used as well as in study designs. Ten studies were analyzed for the impact of antidepressant medications on depressive symptom severity. Five of these were randomized controlled trials (RCTs), out of which sertraline and paroxetine showed a significant reduction in depressive symptoms despite the small samples utilized. Four of the 17 studies addressed QoL as part of their outcomes showing no difference for escitalopram (RCT), significantly greater improvements for paroxetine controlled release (RCT), statistical significance for sertraline compared to control (pilot study), and showing significant improvement before and after treatment (open-label trial) for nefazodone. Thirteen of the 17 studies included measures of morbidity and mortality. Although early analyses have pointed to an association of antidepressant use and mortality particularly with fluoxetine, the reviewed studies showed no increase in mortality for antidepressants, and secondary analyses showed improved mortality in patients who achieved remission of depressive symptoms.

CONCLUSION

Out of the various antidepressants studied, which included sertraline, paroxetine, escitalopram, citalopram, bupropion, nefazodone, and nortriptyline, selective serotonin reuptake inhibitors seem to be a safe treatment option for patients with depression and HF. However, due to the variety of study designs as well as the mixed results for each antidepressant, more information for reducing depression severity, morbidity, and mortality and improving quality of life in patients with HF should be examined using robust large sample RCTs.

Antidepressant use in patients with heart failure

OBJECTIVE

There is little evidence that antidepressants are efficacious for depression in patients with heart failure (HF), and equivocal evidence that they are safe. This study identified characteristics that are associated with antidepressant use in hospitalized patients with HF.

METHOD

Logistic regression models were used to identify independent correlates of antidepressant use in 400 patients hospitalized with HF between 2014 and 2016. The measure of depression in the primary analysis was a DSM-5 diagnosis based on a structured interview; this was replaced by a PHQ-9 depression score in a secondary analysis.

RESULTS

In the primary analysis, there were positive associations between antidepressant use and white race, younger age, unemployment, non-ischemic HF, number of other prescribed medications, current minor depression, history of major depression, and functional impairment. In the secondary analysis, there were positive associations with white race, unemployment, number of other prescribed medications, and functional impairment; the effect of current severity of depression differed between patients with vs. without a history of major depression.

CONCLUSIONS

Current depression is only one of several factors that influence the use of antidepressant medications in patients with HF. Further research is needed to ensure that these agents are being used appropriately in this patient population.

Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States-based retrospective claims database analysis

Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010-2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.

The effect of diet, lifestyle and psychological factors in the prognosis of ischemic heart failure

Background/Objective

Dietary patterns may play an important role in the prognosis of heart failure.

Methods

Dietary habits, sleeping habits, physical activity and anxiety and depression status were recorded in 326 patients (90 females, mean age 73.45 ± 10.9 years) with ischemic heart failure prospectively followed for 30 months.

Results

Lower ΗADS-depression scores (p = 0.03), a low-fat meat diet (p = 0.035) and moderate coffee consumption (p = 0.005) were associated with better prognosis. Non-significant differences were recorded in outcomes with regard to consumption of other dietary categories.

Conclusions

A balanced diet as well as emphasis on the treatment of depression may improve outcomes in ischemic heart failure.

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Coffee consumption is associated with better outcomes in ischemic heart failure.

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A low fat meat diet is associated with better outcomes in ischemic heart failure.

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High ΗADS depression score is related to worst prognosis in ischemic heart failure.

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Sedentary lifestyle is related to worst outcomes in ischemic heart failure.

Heart rate variability alterations in late life depression: A meta-analysis

OBJECTIVE

There is strong evidence for a bi-directional relationship between heart-health and depression in later life, but the physiological mechanisms underlying this relationship remain unclear. Heart rate variability is one promising factor that might help explain this relationship. We present results of a meta-analysis that considers heart rate variability alterations in older adults with depression.

METHODS

Literature search of Embase, PsychInfo and Medline revealed five clinical studies and six observational studies that examined the relationship between heart rate variability and depression in adults with a mean age over 60. These studies were included in this meta-analysis.

RESULTS

Heart rate variability was reduced among older adults with clinical depression (N = 550), relative to healthy controls (Hedges' g = -0.334, 95%CI [-0.579, -0.090], p = .007). When high-frequency and low-frequency heart rate variability were investigated separately, only low-frequency heart rate variability was significantly reduced in depressed patients (Hedges' g = -0.626, 95%CI [-1.083, -0.169], p = .007). A similar but weaker pattern of results was found in the observational studies. Most findings remained significant among unmedicated depressed older adults.

LIMITATIONS

Evidence of effect-size heterogeneity was found in the clinical studies, indicating the need for more well-designed research in the area.

CONCLUSION

Heart rate variability is reduced among older adults with depression, and this effect is not fully attributable to antidepressant medication use. Specifically, low-frequency heart rate variability may be reduced in depressed older adults. Heart rate variability warrants further attention, as it could help inform research into the prevention and treatment of depression in later life.

Vitamin D supplements reduce depressive symptoms and cardiac events in heart failure patients with moderate to severe depressive symptoms

Background:

Depressive symptoms and vitamin D deficiency predict cardiac events in heart failure patients, but whether vitamin D supplements are associated with depressive symptoms and cardiac events in heart failure patients remains unknown.

Purpose:

The purpose of this study was to compare the association of vitamin D supplement use with depressive symptoms and cardiac events in heart failure patients with mild or moderate to severe depressive symptoms.

Methods:

A total of 177 heart failure patients with depressive symptoms (Patient Health Questionnaire-9 score ≥5) completed a three-day food diary to determine dietary vitamin D deficiency. Patients were split into four groups by dietary vitamin D adequacy versus deficiency and vitamin D supplement use versus non-use. The Patient Health Questionnaire-9 was used to reassess depressive symptoms at six months. Data on cardiac events for up to one year and vitamin D supplement use were obtained from patient interview and medical record review. Hierarchical linear and Cox regressions were used for data analysis.

Results:

Sixty-six patients (37.3%) had dietary vitamin D deficiency and 80 (45.2%) used vitamin D supplements. In patients with moderate to severe depressive symptoms, the group with dietary vitamin D deficiency and no supplements had the highest Patient Health Questionnaire-9 score at six months (β=0.542, p<0.001) and shortest cardiac event-free survival ( p<0.001) among the four groups, the group with dietary vitamin D deficiency and no supplements didn’t have the highest Patient Health Questionnaire-9 score at six months and shortest cardiac event-free survival in patients with mild depressive symptoms.

Conclusions:

Vitamin D supplements predicted lower depressive symptoms and reduced cardiac events for patients with moderate to severe depressive symptoms. Vitamin D deficiency was associated with higher risk of shorter cardiac event-free survival in heart failure patients regardless of vitamin D supplementation.

Relationship between depression and medication adherence in cardiovascular disease: the perfect challenge for the integrated care team

Many individuals with cardiovascular disease (CVD) experience depression that is associated with poor health outcomes, which may be because of medication nonadherence. Several factors influence medication adherence and likely influence the relationship between depression and medication adherence in CVD patients. This comprehensive study reviews the existing literature on depression and medication adherence in CVD patients, addresses the methods of and problems with measuring medication adherence, and explains why the integrated care team is uniquely situated to improve the outcomes in depressed CVD patients. This paper also explores how the team can collaboratively target depressive symptoms and medication-taking behavior in routine clinical care. Finally, it suggests the limitations to the integrated care approach, identifies targets for future research, and discusses the implications for CVD patients and their families.

Major Depression and Long-Term Survival of Patients With Heart Failure

OBJECTIVES

Previous studies have found that depression predicts all-cause mortality in heart failure (HF), but little is known about its effect on long-term survival. This study examined the effects of depression on long-term survival in patients with HF.

METHODS

Patients hospitalized with HF (n = 662) at an urban academic medical center were enrolled in a prospective cohort study between January 1994 and July 1999. Depression was assessed on a structured interview during the index hospitalization and on quarterly interviews for 1 year after discharge. Patients were classified at index as having Diagnostic and Statistical Manual, Fourth Edition major depressive disorder (n = 131), minor depression (n = 106), or no depression (n = 425). Clinical data and the National Death Index were used to identify date of death or last known contact through December 19, 2014, up to 20 years after the index hospitalization. The main outcome was time from enrollment to death from any cause.

RESULTS

A total of 617 (94.1%) patients died during the follow-up period. Major depressive disorder was associated with higher all-cause mortality compared with no depression (adjusted hazard ratio = 1.64, 95% confidence interval = 1.27-2.11, p = .0001). This association was stronger than that of any of the established predictors of mortality that were included in the fully adjusted model. Patients with persistent or worsening depressive symptoms during the year after discharge were at greatest risk for death. The association between minor depression and survival was not significant.

CONCLUSIONS

Major depression is an independent risk factor for all-cause mortality in patients with HF. Its effect persists for many years after the diagnosis of depression.

Clinical predictors of depression treatment outcomes in patients with coronary heart disease

OBJECTIVES

Patients with coronary heart disease (CHD) who respond to treatment for depression are at lower risk of mortality than are nonresponders. This study sought to determine whether variables that have been shown to predict both depression treatment outcomes in psychiatric patients and cardiac events in patients with CHD, also predict poor response to depression treatment in patients with CHD.

METHODS

One hundred fifty-seven patients with stable CHD who met the DSM-IV criteria for a major depressive episode were treated with cognitive behavior therapy (CBT) for 16weeks, either alone or in combination with an antidepressant.

RESULTS

The mean Beck Depression Inventory (BDI-II) score was 30.2±8.5 at baseline and 8.5±7.8 at 16weeks. Over 50% of the participants were in remission (HAM-D-17 score ≤7) at the end of treatment. Of the hypothesized predictors, severe depression at baseline (p=0.02), stressful life events during the first (p=0.03) and last (p<0.0001) 8weeks of treatment, and the completion of CBT homework assignments (p=0.001) predicted depression outcomes. History of prior episodes, anxiety symptoms, antidepressant therapy at study enrollment, and medical hospitalizations or emergency department visits during treatment did not predict treatment outcome.

CONCLUSIONS

Patients who are under considerable stress do not respond as well to evidence-based treatments for depression as do patients with less stress. If future studies support these findings, more work will be needed to better address stressful life events in patients who may otherwise remain at high risk for mortality and medical morbidity following depression treatment.

Management of depression after myocardial infarction

Depression in patients who have had a myocardial infarction is an important clinical problem because it is extremely common and because the comorbidity complicates depression treatment and worsens the cardiovascular prognosis. Studies of psychotherapy, exercise, pharmacotherapy, and collaborative care demonstrate that effective treatment of depression is possible but the strength of the effects seen in most studies is low, and cardiovascular and all-cause morbidity and mortality benefits have not been proven. Recent collaborative care studies have had promising outcomes. For pharmacotherapy, side effects, including bleeding and arrhythmia risks, require special attention. Recovery from depression is associated with better long-term cardiovascular prognosis, while treatment per se is not.

Depressive Symptoms: Mediator of Event-Free Survival in Patients With Heart Failure

Depressive symptoms and poor health perceptions are predictors of higher hospitalization and mortality rates (heart failure [HF]). However, the association between depressive symptoms and health perceptions as they affect event-free survival outcomes in patients with HF has not been studied. The purpose of this secondary analysis was to determine whether depressive symptoms mediate the relationship between health perceptions and event-free survival in patients with HF. A total of 458 HF patients (61.6 ± 12 years, 55% New York Heart Association Class III/IV) responded to one-item health perception question and completed the Patient Health Questionnaire-9. Event-free survival data were collected for up to 4 years. Multiple regression and Cox proportional hazards regression analysis showed that depressive symptoms mediated the relationship between health perceptions and event-free survival. Decreasing depressive symptoms is essential to improve event-free survival in patients with HF.

Comorbid Depression and Heart Failure: A Community Cohort Study

Objective

To examine the association between depression and clinical outcomes in heart failure (HF) in a community cohort.

Patients and Methods

HF patients in Minnesota, United States completed depression screening using the 9-item Patient Health Questionnaire (PHQ-9) between 1^st Oct 2007 and 1^st Dec 2011; patients with PHQ-9≥5 were labelled “depressed”. We calculated the risk of death and first hospitalization within 2 years using Cox regression. Results were adjusted for 10 commonly used prognostic factors (age, sex, systolic blood pressure, estimated glomerular filtration rate, serum sodium, ejection fraction, blood urea nitrogen, brain natriuretic peptide, presence of diabetes and ischaemic aetiology). Area under the curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) compared depression as a predictor against the aforementioned factors.

Results

425 patients (mean age 74, 57.6% males) were included in the study; 179 (42.1%) had PHQ-9≥5. The adjusted hazard ratio of death was 2.02 (95% CI 1.34–3.04) and of hospitalization was 1.42 (95% CI 1.13–1.80) for those with compared to those without depression. Adding depression to the models did not appreciably change the AUC but led to statistically significant improvements in both the IDI (p = 0.001 and p = 0.005 for death and hospitalization, respectively) and NRI (for death and hospitalization, 35% (p = 0.002) and 27% (p = 0.007) were reclassified correctly, respectively).

Conclusion

Depression is frequent among community patients with HF and associated with increased risk of hospitalizations and death. Risk prediction for death and hospitalizations in HF patients can be improved by considering depression.

Management of Noncardiac Comorbidities in Chronic Heart Failure

Prevalence of heart failure is increasing, especially in the elderly population. Noncardiac comorbidities complicate heart failure care and are increasingly common in elderly patients with reduced or preserved ejection fraction heart failure, owing to prolongation of patient's lives by advances in chronic heart failure (CHF) management. Common comorbidities include respiratory disease, renal dysfunction, anemia, arthritis, obesity, diabetes mellitus, cognitive dysfunction, and depression. These conditions contribute to the progression of the disease and may alter the response to treatment, partly as polypharmacy is inevitable in these patients. Cardiologists and other physicians caring for patients with CHF need to be vigilant to comorbid conditions that complicate the care of these patients. There is now more guidance on management of noncardiac comorbidities in heart failure, and this article contains a comprehensive review of the most recent updates on management of noncardiac comorbidities in CHF.

Cardiac Risk Markers and Response to Depression Treatment in Patients With Coronary Heart Disease

BACKGROUND

Depression is associated with an increased risk of mortality in patients with coronary heart disease. There is evidence that this risk may be reduced in patients who respond to depression treatment. The purpose of this study was to determine whether cardiac risk markers predict poor response to depression treatment and, second, whether they improve with successful treatment.

METHODS

One hundred fifty-seven patients with stable coronary heart disease who met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for a moderate to severe major depressive episode were treated with cognitive behavior therapy, either alone or combined with an antidepressant, for up to 16 weeks. Depression, physical activity, sleep quality, thyroid hormones (total thyroxine [T4] and free T4), and inflammatory blood markers (C-reactive protein, interleukin-6, tumor necrosis factor) were assessed at baseline and after 16 weeks of treatment.

RESULTS

The mean (SD) Beck Depression Inventory scores were 30.2 (8.5) at baseline and 8.5 (7.8) at 16 weeks. More than 50% of the participants met the criteria for depression remission (17-item Hamilton Rating Scale for Depression ≤ 7) at 16 weeks. Only free T4 thyroid hormone at baseline predicted poor response to depression treatment after adjustment for potential confounders (p = .004). Improvement in sleep quality (p = .012) and physical activity level (p = .041) correlated with improvement in depression. None of the inflammatory markers predicted posttreatment depression or changed with depression.

CONCLUSIONS

Thyroid hormone (T4) level predicted depression treatment outcome, and improvement in depression correlated with improvement in sleep and physical activity. More detailed studies of thyroid function and objective assessments of sleep and physical activity in relation to depression improvement and cardiac outcomes are needed.

Association of Depressive Symptoms and Micronutrient Deficiency With Cardiac Event-Free Survival in Patients With Heart Failure

BACKGROUND

Depressive symptoms and malnutrition independently predict cardiac events in heart failure (HF) patients. However, the relationships among depressive symptoms, nutritional intake, and cardiac event-free survival have not been examined.

METHODS AND RESULTS

A total of 232 patients with HF completed the Patient Health Questionnaire 9 (PHQ-9) to measure depressive symptoms and a 3-day food diary to determine the number of micronutrient deficiencies. Patients were followed for 2 years to collect data on cardiac event-free survival. Patients were divided into 4 groups by a PHQ-9 score of 10 and the median value of micronutrient deficiencies. Cox regressions were used to determine the relationships among depressive symptoms, micronutrient deficiency, and cardiac event-free survival. Depressive symptoms conferred greater risk of cardiac events in patients with a high number of micronutrient deficiencies than in those with a low number of micronutrient deficiencies. Patients with a PHQ-9 score ≥10 and number of micronutrient deficiencies >5 had 2.4 times higher risk for cardiac events compared with patients with a PHQ-9 score <10 and micronutrient deficiency ≤5 (P = .005).

CONCLUSIONS

There was a synergistic effect on the association of depressive symptoms with cardiac event-free survival in HF patients that differed by micronutrient deficiency.