Prognosis in Heart Failure and the Value of β-Blockers Are Altered by the Use of Antidepressants and Depend on the Type of Antidepressants Used

Comparative analysis of treatment options for chronic heart failure and depression: a systematic review and Bayesian network meta-analysis

Different interventions have been evaluated for the treatment of depression in heart failure (HF) patients. However, clear and established recommendations are lacking. PubMed, Scopus, and Web of Science databases were systematically searched for randomized controlled trials (RCT) evaluating the effect of various treatment options on depression scores in heart failure patients. The primary outcome was a change in depression scores presented as standardized mean difference (SMD). A Bayesian network for meta-analysis was constructed. Twenty-five RCTs were included, randomizing 6014 patients with confirmed heart failure and depression between 2003 and 2022. Compared to treatment as usual (TAU), only cognitive behavioral therapy (CBT) (SMD - 0.60, CI95% [- 1.0, - 0.17]) leads to a significant reduction in depression scores. Other interventions did not improve depression scores significantly. Our results show that for patients with HF and depression, CBT can significantly improve measures of depression, being the most efficacious treatment.

Association between Psychiatric Disorders and the Incidence of Heart Failure in Women

BACKGROUND

Depression and anxiety occur more frequently in women and are associated with an increased risk of cardiovascular disease.

OBJECTIVES

Data on the association between these psychiatric conditions and the incidence of acute heart failure (HF) and how they influence heart failure outcomes in women are lacking. We investigated this potential relationship using data from the National Inpatient Sample.

METHODS

We used ICD-10 codes to extract encounters for acute heart failure and/or the acute exacerbation of chronic heart failure, anxiety, and depression from the discharge data of the NIS from 2019 to 2020. We compared baseline characteristics and length of stay (LOS), cost of care (COC) and acute HF by depression/anxiety status for males and females and employed regression models to assess the influence of these psychiatric conditions on the outcomes.

RESULTS

There were 6,394,136 encounters involving females, which represented 56.6% of the sample. The prevalence of depression and anxiety were 15.7% and 16.8%, respectively. Among females, the occurrence of acute CHF did not differ by depression or anxiety status. However, Takostubo cardiomyopathy was more prevalent in those with depression (0.3% vs. 0.2%, p = 0.003) and anxiety (0.3% vs. 0.2%, p = 0.03) compared to those without these conditions. Among those with depression, LOS was significantly longer (3 days IQR: 2-6, vs. 3 days IQR:2-5 days, p < 0.001). The COC was USD 1481 more in patients with depression. On the contrary, LOS and COC were significantly lower in those without anxiety.

CONCLUSIONS

Depression was associated with an increased LOS among both men and women and an increased cost of care among women. Anxiety was associated with a decreased LOS and cost of care among women, which may be related to an increased rate of against medical advice (AMA) discharges among this population. Further research is necessary to identify optimal management strategies for depression and anxiety among patients hospitalized with HF.

Exploring the use of psychotropic medication in cardiac patients with and without anxiety and its association with 1-year mortality

AIMS

Comorbid psychiatric disorders and the use of psychotropic medication are common among cardiac patients and have been found to increase the risk of mortality. The aims of this study were: (i) to describe the use of psychotropic medication among cardiac patients with and without symptoms of anxiety, (ii) to estimate the association between use of psychotropic medication prior to hospital admission and all-cause, 1-year mortality following discharge, and (iii) to estimate the risk of mortality among users and non-users of psychotropic medication with or without self-reported symptoms of anxiety.

METHODS AND RESULTS

Cardiac patients from the DenHeart survey were included, providing information on self-reported symptoms of anxiety. From national registers, information on the use of psychotropic medication 6 months prior to hospitalization and mortality was obtained. By logistic regression analyses, the association between the use of psychotropic medication, anxiety, and all-cause, 1-year mortality was estimated. The risk of subsequent incident use of psychotropic medication among patients with and without anxiety was furthermore explored. All analyses were fully adjusted. A total of 12 913 patients were included, of whom 18% used psychotropic medication, and 3% died within 1 year. The use of psychotropic medication was found to be associated with increased 1-year all-cause mortality [odds ratio 1.90 (95% confidence interval, 1.46-2.46)]. Patients with symptoms of anxiety were significantly more likely to use psychotropic medication following hospital discharge [2.47 (2.25-2.72)].

CONCLUSION

The use of psychotropic medication was associated with 1-year mortality. Thus, the use of psychotropic medication might explain some of the association between anxiety and mortality; however, the association is probably mainly a reflection of the underlying mental illness, rather than the use of psychotropic medication.

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.

Antidepressant treatment in patients following acute coronary syndromes: a systematic review and Bayesian meta-analysis

AIMS

The aim of this study is to investigate the effect of antidepressant therapy on mortality and cardiovascular outcomes in patients with acute coronary syndrome (ACS).

METHODS AND RESULTS

We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and performed a Bayesian random-effects meta-analysis of randomized controlled trials that investigated antidepressant pharmacotherapy in patients following ACS. The primary outcome was all-cause mortality. Secondary outcomes were repeat hospitalizations and recurrent myocardial infarctions (MIs). Ten randomized controlled trials with a total of 1935 patients qualified for inclusion. Selective serotonin reuptake inhibitors were investigated in six, bupropion in three, and mirtazapine in one trial. Placebo was used as control in eight trials. There was no difference in all-cause mortality [odds ratio (OR) 0.97, 95% credible interval (CrI) 0.66-1.42] and recurrent MI (OR 0.64, 95% CrI 0.40-1.02) between patients receiving antidepressants compared with controls, whereas antidepressant therapy was associated with less repeat hospitalizations (OR 0.62, 95% CrI 0.40-0.94). In patients with ACS and concomitant depression, antidepressants reduced the odds of recurrent MI compared with usual care/placebo (OR 0.45, 95% CrI 0.25-0.81). Extended funnel plots suggest robustness of the observations.

CONCLUSIONS

Antidepressants in patients following ACS have no effect on mortality but reduce repeat hospitalizations; in patients with depression, there is a reduced risk of recurrent MI with antidepressant therapy.

Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF)

Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.

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.

Effectiveness of cognitive behavior therapy for patients with heart failure and depression: A systematic review protocol

The objective of this review is to determine the effectiveness of cognitive behavior therapy for patients with heart failure and depression, aged ≥18 years, in institutionalized healthcare settings. More specifically, the review aims to identify which cognitive behavior therapy strategy/strategies, including the method of delivery, is the most effective for the management of depression in hospitalized patients with heart failure. The review question is as follows: Is cognitive behavior therapy effective in reducing symptoms of depression in patients with heart failure? This systematic review will be conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness evidence. This review only includes randomized controlled trials assessing the effectiveness of cognitive behavior therapy as a treatment for depression in adults (aged ≥18 years) with heart failure, compared with usual care, which might include medications.

Palliative Care in Patients with Advanced Heart Failure

The heart failure (HF) guidelines recommend palliative care; however, it can often be difficult to determine the timing of palliative care referral. Because HF with fluid retention and low-cardiac output may trigger several unpleasant symptoms, continuous HF treatment is required to alleviate these symptoms in advanced HF. The patients with HF often suffer from total pain; therefore, the support from a multidisciplinary team plays a crucial role to improve quality of life of the patients and their families not only in the terminal phase but also from the early stage.

Antidepressants Reduced Risk of Mortality in Patients With Diabetes Mellitus: A Population-Based Cohort Study in Taiwan

CONTEXT

The effect of antidepressant (ATD) use on mortality in patients with diabetes mellitus (DM) has not yet been sufficiently studied, although comorbid depression is common in this population.

OBJECTIVE

To explore the impact of ATDs on mortality among DM patients.

DESIGN

A retrospective cohort study in a national database.

SETTING

This population-based study used the National Health Insurance Research Database in Taiwan. Since 2000, we identified 53,412 cases of newly diagnosed patients with DM and depression. Patient cases were followed for assessing mortality until 2013.

MAIN OUTCOME MEASURE

The association between mortality and ATD use was explored adjusting for cumulative dosing.

RESULTS

Using the time-dependent Cox regression model, ATD use was associated with significantly reduced mortality among patients with DM [in the highest dose group: hazard ratio (HR), 0.65; 95% CI, 0.59 to 0.71]. Further analysis showed that differences in mortality existed across ATD categories: selective serotonin reuptake inhibitors (HR, 0.63; 95% CI, 0.56 to 0.71), serotonin-norepinephrine reuptake inhibitors (HR, 0.58; 95% CI, 0.44 to 0.78), norepinephrine-dopamine reuptake inhibitors (HR, 0.20; 95% CI, 0.07 to 0.63), mirtazapine (HR, 0.60; 95% CI, 0.45 to 0.82), tricyclic/tetracyclic antidepressants (HR, 0.73; 95% CI, 0.54 to 0.97), and trazodone (HR, 0.52; 95% CI, 0.29 to 0.91). However, reversible inhibitor of monoamine oxidase A (RIMA) was found to be associated with an increase, rather than a decrease, in total mortality (HR, 1.48; 95% CI, 1.09 to 1.99).

CONCLUSION

Most ATDs, but not RIMA, were associated with significantly reduced mortality among a population with comorbid DM and depression.

Antidepressants-related cardiovascular adverse events using the adverse event reporting system

The aim of this study was to evaluate clinical manifestations and the age and sex distribution of cardiovascular adverse events (CVAEs) related to antidepressants. The FDA Adverse Event Reporting System (FAERS) and Korea Adverse Event Reporting System (KAERS) database records on patients prescribed antidepressants were used. The frequency of CVAEs was compared between adults (19-64 years) and an older (age ≥ 65 years) group. In total, 75,608 CVAEs from 43,824 patients and 325 CVAEs from 313 patients in FAERS and KAERS, respectively, were included in the analysis. Among them, 7066 (16.08%) and 103 (32.91%) patients were 65 years of age or older in FAERS and KAERS, respectively. Serious AEs were significantly more common among older patients compared to adults in both the FAERS and KAERS datasets. CVAEs were frequently reported with paroxetine and duloxetine in the FAERS, while amitriptyline and duloxetine were reported in the KAERS. The two most frequent CVAEs were "ventricular arrhythmias and cardiac arrest" and "rate and rhythm disorders" in the FAERS, while "hypotension", and "oedema", were found in the KAERS. Several CVAEs were detected by the reporting odds ratios and proportional reporting ratios methods. The serious AEs associated with antidepressants might have a significant impact on older patients.

The effect of antidepressant medications in the management of heart failure on outcomes: mortality, cardiovascular function and depression - a systematic review

OBJECTIVE

Depression is associated with increased morbidity, mortality and hospital readmission in patients with heart failure (HF). This systematic review aimed to compile studies examining whether the use of antidepressants could improve outcome in patients with HF and concomitant depression.

METHODS

The electronic libraries Embase, OVID MEDLINE(R) and PsychInfo were used to search the following terms 'heart failure' AND 'anti-depressants'; 'heart failure' AND 'TCA' OR 'SSRI' OR 'SNRI'. The result of this database search was analysed to select papers that satisfied our inclusion criteria.

RESULTS

Of the 180 papers found in the original database search, only three met the inclusion criteria. A further two papers were added from hand-searching through the references. Three of these papers are randomised controlled trials (RCT); the other two, cohort studies. All studies show that antidepressants are well tolerated in this group. There was no significant difference in depressive symptoms between the test and placebo. The cardiac outcomes of patients with HF are not improved by the use of antidepressants relative to placebo.

CONCLUSIONS

Antidepressants are not associated with increased mortality rate as established in previous papers. However, there is inadequate evidence that the use of antidepressants effects significant improvement in depression or cardiac outcomes.

Depression and chronic heart failure in the elderly: an intriguing relationship

Chronic heart failure and depressive disorders have a high prevalence and incidence in the elderly. Several studies have shown how depression tends to exacerbate coexisting chronic heart failure and its clinical outcomes and vice versa, especially in the elderly. The negative synergism between chronic heart failure and depression in the elderly may be approached only taking into account the multifaceted pathophysiological characteristics underlying both these conditions, such as behavioural factors, neurohormonal activation, inflammatory mediators, hypercoagulability and vascular damage. Nevertheless, the pathophysiological link between these two conditions is not well established yet. Despite the high prevalence of depression in chronic heart failure elderly patients and its negative prognostic value, it is often unrecognized especially because of shared symptoms. So the screening of mood disorders, using reliable questionnaires, is recommended in elderly patients with chronic heart failure, even if cannot substitute a diagnostic interview by mental health professionals. In this setting, treatment of depression requires a multidisciplinary approach including: psychotherapy, antidepressants, exercise training and electroconvulsive therapy. Pharmacological therapy with selective serotonin reuptake inhibitors, despite conflicting results, improves quality of life but does not guarantee better outcomes. Exercise training is effective in improving quality of life and prognosis but at the same time cardiac rehabilitation services are vastly underutilized.

Antidepressant Use by Class: Association with Major Adverse Cardiac Events in Patients with Coronary Artery Disease

BACKGROUND

To assess use of antidepressants by class in relation to cardiology practice recommendations, and the association of antidepressant use with the occurrence of major adverse cardiovascular events (MACE) including death.

METHODS

This is a historical cohort study of all patients who completed cardiac rehabilitation (CR) between 2002 and 2012 in a major CR center. Participants completed the Patient Health Questionnaire (PHQ-9) at the start and end of the program. A linkage system enabled ascertainment of antidepressant use and MACE through 2014.

RESULTS

There were 1,694 CR participants, 1,266 (74.7%) of whom completed the PHQ-9 after the program. Depressive symptoms decreased significantly from pre- (4.98 ± 5.20) to postprogram (3.57 ± 4.43) (p < 0.001). Overall, 433 (34.2%) participants were on antidepressants, most often selective serotonin reuptake inhibitors (SSRI; n = 299; 23.6%). The proportion of days covered was approximately 70% for all 4 major antidepressant classes; discontinuation rates ranged from 37.3% for tricyclics to 53.2% for serotonin-norepinephrine reuptake inhibitors (SNRI). Antidepressant use was significantly associated with lower depressive symptoms after CR (before, 7.33 ± 5.94 vs. after, 4.69 ± 4.87; p < 0.001). After a median follow-up of 4.7 years, 264 (20.9%) participants had a MACE. After propensity matching based on pre-CR depressive symptoms among other variables, participants taking tricyclics had significantly more MACE than those not taking tricyclics (HR = 2.46; 95% CI 1.37-4.42), as well as those taking atypicals versus not (HR = 1.59; 95% CI 1.05-2.41) and those on SSRI (HR = 1.45; 95% CI 1.07-1.97). There was no increased risk with use of SNRI (HR = 0.89; 95% CI 0.43-1.82).

CONCLUSION

The use of antidepressants was associated with lower depression, but the use of all antidepressants except SNRI was associated with more adverse events.

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.

Depression in heart failure: Intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies

Heart failure (HF) is a burgeoning chronic health condition affecting more than 20million people worldwide. Patients with HF have a significant (17.1%) 30-day readmission rate, which invites substantial penalty in payment to hospitals from Centers for Medicare and Medicaid Services, as per the newly introduced Hospital Readmissions Reduction Program. Depression is one of the important risk factors for readmission in HF patients. It has a significant prevalence in patients with HF and contributes to the overall poor quality of life in them. Several behavioral (smoking, obesity, lack of exercise and medication noncompliance) and pathophysiological factors (hypercortisolism, elevated inflammatory biomarkers, fibrinogen, and atherosclerosis) have been found responsible for the adverse outcome in patients with HF and concomitant depression. Hippocampal volume loss noted in patients with acute HF exacerbations may contribute to the development of depressive symptoms in them. Screening for depression in HF patients continues to be challenging due to a considerable overlap in symptoms. Published trials on the use of antidepressants and cognitive behavioral therapy (CBT) have shown variable outcomes. Newer modalities like internet-based CBT have been tried in small studies, with promising results. A recent meta-analysis observed the beneficial role of aerobic exercise training in patients with HFrEF. Future long-term prospective studies may contribute to the formulation of a detailed screening and management guideline for patients with HF and depression. Our review is aimed to summarize the intricate relationship between depression and heart failure, with respect to their epidemiology, pathophysiological aspects, and optimal management approach.

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.

A happy valve in a happy patient? Serotonergic antidepressants and the risk of valvular heart disease (SERVAL). A case-control study

OBJECTIVES

The objective was to investigate the risk of valvular heart disease in humans in relation to the use of selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors.

DESIGN

A case-control study. We conducted a case-control study within this cohort in which patients with newly diagnosed cardiac valve regurgitation were age-matched to controls. Patient demographics, their cardiovascular risk factors and medication use were extracted in both series. Use of SSRIs, serotonin and noradreline reuptake inhibitors (SNRIs) and other pro-serotonergic agents, their dose and treatment duration were recorded. Logistic regression analysis was used to establish the strength of the association between SSRI/SNRI use and valvular heart disease.

SETTING

Outpatient clinic of the cardiology department at the Ghent University Hospital, East-Flanders in Belgium.

PARTICIPANTS

Total of 2911 persons 21-58 years of age who had undergone an echocardiogram in the period 2006-2010 and had no known cardiovascular disease or previous cardiac intervention. Two hundred and six echocardiographically proven cases of valvular regurgitation and 195 matched controls.

MAIN OUTCOME MEASURE

Odd ratio of valvular disease associated with intake of serotonergic drugs.

RESULTS

Of the 206 patients with newly diagnosed cardiac valve regurgitation, 11.6% were exposed to serotonergic agents compared to 4.1% in the 195 control patients, leading to an odds ratio of 3.08 (95% confidence interval [CI] 1.35-7.04). The analysis of doses and treatment durations revealed a dose-relationship pattern between SSRI/SNRI use and prevalent valvular heart disease.

CONCLUSIONS

In this study, use of serotonergic antidepressants was associated with an increased rate of valvular regurgitation in humans.

The prognostic impact and optimal timing of the Patient Health Questionnaire depression screen on 4-year mortality among hospitalized patients with systolic heart failure

OBJECTIVE

An American Heart Association (AHA) Science Advisory recommends patients with coronary heart disease undergo routine screening for depressive symptoms with the two-stage Patient Health Questionnaire (PHQ). However, little is known on the prognostic impact of a positive PHQ screen on heart failure (HF) mortality.

METHODS

We screened hospitalized patients with systolic HF (left ventricle ejection fraction≤40%) for depression with the two-item Patient Health Questionnaire (PHQ-2) and administered the follow-up nine-item Patient Health Questionnaire (PHQ-9) both immediately following the PHQ-2 and by telephone 1 month after discharge. Later, we ascertained vital status at 4-year follow-up on all patients who completed the inpatient PHQ-9 and calculated mortality incidence and risk by baseline PHQ.

RESULTS

Of the 520 HF patients we enrolled, 371 screened positive for depressive symptoms on the PHQ-2. Of these, 63% scored PHQ-9≥10 versus 24% of those who completed the PHQ-9 1 month later (P<.001). PHQ-2 positive status was an independent predictor of 4-year all-cause mortality (HR: 1.50; P=.04), and mortality incidence was similar by baseline PHQ-9 score.

CONCLUSIONS

Among hospitalized patients with systolic HF, a positive PHQ-2 screen for depressive symptoms is an independent risk factor for increased 4-year all-cause mortality. Our findings extend the AHA's Science Advisory for depression to hospitalized patients with systolic HF.

Antidepressant use and risk for mortality in 121,252 heart failure patients with or without a diagnosis of clinical depression

BACKGROUND

Depression is a risk factor for mortality in patients with heart failure (HF), however, treating depression with antidepressant therapy does not seem to improve survival. We examined the prevalence of antidepressant use in HF patients, the correlates of antidepressant use subsequent to hospital discharge and the relation between antidepressant use, clinical depression and mortality in patients with HF.

METHODS

121,252 HF patients surviving first hospitalization were stratified by antidepressant use and a diagnosis of clinical depression.

RESULTS

In total, 15.6% (19,348) received antidepressants at baseline, of which 86.7% (16,780) had no diagnosis of clinical depression. Female gender, older age, higher socio-economic status, more comorbidities, increased use of statins, spironolactone and aspirin, lower use of beta-blockers and ACE-inhibitors, greater HF severity and a diagnosis of clinical depression were independently associated with antidepressant use. Patients using no antidepressants with clinical depression and patients using antidepressants, with or without clinical depression, had a significantly higher risk for all-cause mortality (HR, 1.25; 95% CI, 1.15-1.36; HR, 1.24; 95% CI, 1.22-1.27; HR, 1.21; 95% CI, 1.16-1.27, respectively) and CV-mortality (HR: 1.17; 95% CI, 1.14-1.20, P<.001; HR: 1.20; 95% CI, 1.08-1.34, P<.001; HR: 1.21; 95% CI, 1.12-1.29, P<.001, respectively) as compared to patients not using antidepressants without depression in adjusted analysis.

CONCLUSION

Patients with HF taking antidepressants had an increased risk for all-cause and CV-mortality, irrespectively of having clinical depression. These results highlight the importance of further examining the antidepressant prescription pattern in patients with HF, as this may be crucial in understanding the antidepressant effects on cardiac function and mortality.

Antidepressants, autonomic function and mortality in patients with coronary heart disease: data from the Heart and Soul Study

BACKGROUND

Antidepressants reduce depressive symptoms in patients with coronary heart disease, but they may be associated with increased mortality. This study aimed to examine whether the use of tricyclic antidepressants (TCA) or selective serotonin reuptake inhibitors (SSRI) is associated with mortality in patients with coronary heart disease, and to determine whether this association is mediated by autonomic function.

METHOD

A total of 956 patients with coronary heart disease were followed for a mean duration of 7.2 years. Autonomic function was assessed as heart rate variability, and plasma and 24-h urinary norepinephrine.

RESULTS

Of 956 patients, 44 (4.6%) used TCA, 89 (9.3%) used SSRI, and 823 (86.1%) did not use antidepressants. At baseline, TCA users exhibited lower heart rate variability and higher norepinephrine levels compared with SSRI users and antidepressant non-users. At the end of the observational period, 52.3% of the TCA users had died compared with 38.2% in the SSRI group and 37.3% in the control group. The adjusted hazard ratio (HR) for TCA use compared with non-use was 1.74 [95% confidence interval (CI) 1.12-2.69, p = 0.01]. Further adjustment for measures of autonomic function reduced the association between TCA use and mortality (HR = 1.27, 95% CI 0.67-2.43, p = 0.47). SSRI use was not associated with mortality (HR = 1.15, 95% CI 0.81-1.64, p = 0.44).

CONCLUSIONS

The use of TCA was associated with increased mortality. This association was at least partially mediated by differences in autonomic function. Our findings suggest that TCA should be avoided in patients with coronary heart disease.

Reduced functionality in everyday activities of patients with self-reported heart failure hospitalization--population-based study results

AIM

To assess daily functioning and geriatric conditions of older subjects suffering from heart failure (HF) as compared to the general population.

METHODS AND RESULTS

The data were collected as part of the nationwide PolSenior project (2007-2011). Of 4979 individuals (age range 65-104 years), data on self-reported HF hospitalization were available for 4795 subjects (96%). Geriatric assessment (GA) included functional status (ADL, Activities of Daily Living and IADL, Instrumental ADL scales), cognitive function, mood disorders, sensory organ impairment, falls and comorbidity. Mean age ± SD of the study population was 73.8 ± 6.5 years; 62% were female. The proportion of subjects with HF hospitalizations increased from 8% in subjects aged 65-69 years up to 13% in the age group of 85-89 years, and decreased in nonagenarians (11%). Subjects with the HF hospitalization were older, used more drugs, and were characterized by a higher prevalence of comorbid conditions, mood disorders, hearing impairment and functional limitations. In logistic regression, HF hospitalization increased the age-sex adjusted risk of disability by 40%, both in ADL and IADL. After adjustment to other clinical and geriatric conditions, HF hospitalization remained an independent predictor of disability in both ADL (OR=1.36, 95%CI: 1.00-1.84) and IADL (OR=1.40, 95%CI: 1.01-1.93).

CONCLUSIONS

Older people who reported HF admissions had a higher number of comorbidities and geriatric conditions: mood disorders, hearing impairment and functional limitations. Besides, in our study, HF hospitalization independently and significantly increased the risk of limitations in IADL and ADL. Therefore, further studies are needed to evaluate the benefits of GA in patients with HF.

Drug attrition during pre-clinical and clinical development: understanding and managing drug-induced cardiotoxicity

Cardiovascular toxicity remains a major cause of concern during preclinical and clinical development as well as contributing to post-approval withdrawal of medicines. This issue is particularly relevant for anticancer drugs where, the significant improvement in the life expectancies of patients has dramatically extended the use and duration of drug therapies. Nevertheless, cardiotoxicity is also observed with other classes of drugs, including antibiotics, antidepressants, and antipsychotics. This article summarizes the clinical manifestations of drug-induced cardiotoxicity by various cancer chemotherapies and novel drugs for the treatment of other diseases. Furthermore, it presents on overview of biomarker and imaging techniques for the detection of drug-induced cardiotoxicity. Guidelines for the management of patients exposed to drugs with cardiotoxic potential are presented as well as a checklist for collecting information when a safety signal is observed in clinical trials to more effectively assess the risk of cardiotoxicity and manage patient safety.

Management of intracranial hemorrhage in patients with left ventricular assist devices

OBJECT

The authors conducted a study to review outcomes and management in patients in whom intracranial hemorrhage (ICH) develops during left ventricular assist device (LVAD) therapy.

METHODS

This retrospective cohort study included all adult patients (18 years of age or older) at a single institution who underwent placement of an LVAD between January 1, 2003, and March 1, 2012. The authors conducted a detailed medical chart review, and data were abstracted to assess outcomes in patients in whom ICH developed compared to those in patients in whom ICH did not develop; to compare management of antiplatelet agents and anticoagulation with outcomes; to describe surgical management employed and outcomes achieved; to compare subtypes of ICH (intraparenchymal, subdural, and subarachnoid hemorrhage) and their outcomes; and to determine any predictors of outcome.

RESULTS

During the study period, 330 LVADs were placed and 36 patients developed an ICH (traumatic subarachnoid hemorrhage in 10, traumatic subdural hematoma in 8, spontaneous intraventricular hemorrhage in 1, and spontaneous intraparenchymal hemorrhage in 17). All patients were treated with aspirin and warfarin at the time of presentation. With suspension of these agents, no thromboembolic events or pump failures were seen and no delayed rehemorrhages occurred after resuming these medications. Intraparenchymal hemorrhages had the worst outcomes, with a 30-day mortality rate in 59% compared with a 30-day mortality rate of 0% in patients with traumatic subarachnoid hemorrhages and 13% in those with traumatic subdural hematomas. Five patients with intraparenchymal hemorrhages were managed with surgical intervention, 4 of whom died within 60 days. The only factor found to be predictive of outcome was initial Glasgow Coma Scale score. No patients with a Glasgow Coma Scale score less than 11 survived beyond 30 days. Overall, the development of an ICH significantly reduced survival compared with the natural history of patients on LVAD therapy.

CONCLUSIONS

The authors' data suggest that withholding aspirin for 1 week and warfarin for 10 days is sufficient to reduce the risk of hemorrhage expansion or rehemorrhage while minimizing the risk of thromboembolic events and pump failure. Patients with intraparenchymal hemorrhage have poor outcomes, whereas patients with traumatic subarachnoid hemorrhage or subdural hematoma have better outcomes.

A positive 2-item Patient Health Questionnaire depression screen among hospitalized heart failure patients is associated with elevated 12-month mortality

BACKGROUND

Given the association of depression with poorer cardiac outcomes, an American Heart Association Science Advisory has advocated routine screening of cardiac patients for depression using the 2-item Patient Health Questionnaire (PHQ-2) "at a minimum." However, the prognostic value of the PHQ-2 among HF patients is unknown.

METHODS AND RESULTS

We screened hospitalized HF patients (ejection fraction [EF] <40%) that staff suspected may be depressed with the PHQ-2, and then determined vital status at up to 12-months follow-up. At baseline, PHQ-2 depression screen-positive patients (PHQ-2+; n = 371), compared with PHQ-2 screen-negative patients (PHQ-2-; n = 100), were younger (65 vs 70 years) and more likely to report New York Heart Association (NYHA) functional class III/IV than class II symptoms (67% vs. 39%) and lower levels of physical and mental health-related quality of life (all P ≤ .002); they were similar in other characteristics (65% male, 26% mean EF). At 12 months, 20% of PHQ-2+ versus 8% of PHQ-2- patients had died (P = .007) and PHQ-2 status remained associated with both all-cause (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.4-6.7; P = .003) and cardiovascular (HR 2.7, 95% CI 1.1-6.6; P = .03) mortality even after adjustment for age, gender, EF, NYHA functional class, and a variety of other covariates.

CONCLUSIONS

Among hospitalized HF patients, a positive PHQ-2 depression screen is associated with an elevated 12-month mortality risk.

Depression is associated with cognitive dysfunction in older adults with heart failure

Persons with heart failure (HF) frequently exhibit cognitive impairment with deficits in attention and memory. Depression is common in HF though its possible contribution to cognitive impairment is unknown. Cognitive dysfunction and depression may share common mechanisms in HF, as both are associated with similar abnormalities on neuroimaging. A total of 116 participants with HF (68.53 ± 9.30 years) completed a neuropsychological battery and self-report measures of depression. Regression models showed depression incrementally and independently predicted test performance in all cognitive domains. Follow-up partial correlations revealed that greater depressive symptoms were associated with poorer performance on tests of attention, executive function, psychomotor speed, and language. These results indicate that depressive symptoms are associated with poorer cognitive performance in HF though further work is needed to clarify mechanisms for this association and possible cognitive benefits of treating depression in persons with HF.

Prevalence of antidepressant prescription or use in patients with acute coronary syndrome: a systematic review

BACKGROUND AND OBJECTIVES

Depression is common among acute coronary syndrome (ACS) patients and is associated with poor prognosis. Cardiac side effects of older antidepressants were well-known, but newer antidepressants are generally thought of as safe to use in patients with heart disease. The objective was to assess rates of antidepressant use or prescription to patients within a year of an ACS.

METHODS

PubMed, PsycINFO, and CINAHL databases searched through May 29, 2009; manual searching of 33 journals from May 2009 to September 2010. Articles in any language were included if they reported point or period prevalence of antidepressant use or prescription in the 12 months prior or subsequent to an ACS for ≥100 patients. Two investigators independently selected studies for inclusion/exclusion and extracted methodological characteristics and outcomes from included studies (study setting, inclusion/exclusion criteria, sample size, prevalence of antidepressant prescription/use, method of assessing antidepressant prescription/use, time period of assessment).

RESULTS

A total of 24 articles were included. The majority were from North America and Europe, and most utilized chart review or self-report to assess antidepressant use or prescription. Although there was substantial heterogeneity in results, overall, rates of antidepressant use or prescription increased from less than 5% prior to 1995 to 10-15% after 2000. In general, studies from North America reported substantially higher rates than studies from Europe, approximately 5% higher among studies that used chart or self-report data.

CONCLUSIONS

Antidepressant use or prescription has increased considerably, and by 2005 approximately 10% to 15% of ACS patients were prescribed or using one of these drugs.

[Psychosomatic aspects of chronic heart failure. Nothing but depression?]

Psychosocial factors are bi-directionally associated with the pathophysiology, symptoms, and prognosis observed in heart failure. Cardiac symptom severity is both dependent on psychological appraisal processes and causally related to feelings of exhaustion and distress. Distress and depression have been shown to affect physiological processes involved in the pathogenesis and course of chronic heart failure as well as illness behaviors. Conversely, physiological consequences of heart failure such as inflammatory activation may lead to sickness behavior and depression. However, there are some indications that the secretion of natriuretic peptides observed in response to cardiac overload may also have beneficial psychological effects (e.g., anxiolysis). Quality of life is typically reduced in heart failure but functional impairment and psychological maladjustment seem to be more important for quality of life than cardiac severity markers such as systolic or diastolic function per se. Current guidelines therefore recommend complementing optimal medical care with good communication, the creation of a trustful physician-patient relationship, patient education and partnership building, as well as specialized mental health care in cases of severe or enduring mental disorders or inappropriate illness behavior. While the evidence for antidepressant drug treatment in heart failure appears inconclusive, behavioral treatments such as exercise and psychotherapy may be more promising in treating comorbid anxiety and depression.

Anti-depressant medication use and C-reactive protein: results from two population-based studies

The use of anti-depressant medication has been linked to cardiovascular disease (CVD). We examined the association between anti-depressant medication use and a marker of low grade systemic inflammation as a potential pathway linking anti-depressant use and CVD in two population based studies. Data were collected in a representative sample of 8131 community dwelling adults (aged 47.4±15.9 years, 46.7% male) from the Scottish Health Surveys (SHS). The use of anti-depressant medication was coded according to the British National Formulary and blood was drawn for the measurement of C-reactive protein (CRP). In a second study, we attempted to replicate our findings using longitudinal data from the Whitehall II study (n=4584, aged 55.5±5.9 years, mean follow-up 5.5 years). Antidepressants were used in 5.6% of the SHS sample, with selective serotonin reuptake inhibitors (SSRIs) being the most common. There was a higher risk of elevated CRP (>3 mg/L) in users of tricyclic antidepressant (TCA) medication (multivariate adjusted odds ratio (OR)=1.52, 95% CI, 1.07-2.15), but not in SSRI users (multivariate adjusted OR=1.07, 95% CI, 0.81-1.42). A longitudinal association between any antidepressant use and subsequent CRP was confirmed in the Whitehall cohort. In summary, the use of anti-depressants was associated with elevated levels of systemic inflammation independently from the symptoms of mental illness and cardiovascular co-morbidity. This might be a potential mechanism through which antidepressant medication increases CVD risk. Further data are required to explore the effects of dosage and duration of antidepressant treatment.

Antidepressant medication use and future risk of cardiovascular disease: the Scottish Health Survey

AIMS

The association between antidepressant use and risk of cardiovascular disease (CVD) remains controversial, particularly in initially healthy samples. Given that antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are now prescribed not only for depression, but also for a wide range of conditions, this issue has relevance to the general population. We assessed the association between antidepressant medication use and future risk of CVD in a representative sample of community-dwelling adults without known CVD.

METHODS AND RESULTS

A prospective cohort study of 14 784 adults (aged 52.4 ± 11.9 years, 43.9% males) without a known history of CVD was drawn from the Scottish Health Surveys. Of these study participants, 4.9% reported the use of antidepressant medication. Incident CVD events (comprising CVD death, non-fatal myocardial infarction, coronary surgical procedures, stroke, and heart failure) over 8-year follow-up were ascertained by a linkage to national registers; a total of 1434 events were recorded. The use of tricyclic antidepressants (TCAs) was associated with elevated risk of CVD [multivariate-adjusted hazard ratio (HR) = 1.35, 95% confidence interval (CI), 1.03-1.77] after accounting for a range of covariates. There was a non-significant association between TCA use and coronary heart disease events (969 events, multivariate-adjusted HR = 1.24, 95% CI, 0.87-1.75). The use of SSRIs was not associated with CVD. Neither class of drug was associated with all-cause mortality risk.

CONCLUSION

Although replication is required, the increased risk of CVD in men and women taking TCAs was not explained by existing mental illness, which suggests that this medication is associated with an excess disease burden.

Longitudinal evidence for unfavorable effects of antidepressants on heart rate variability

BACKGROUND

It was previously shown that antidepressants are associated with diminished vagal control over the heart. Longitudinal studies are needed to test the causality of this association further.

METHODS

Longitudinal data were obtained in the Netherlands Study of Depression and Anxiety. At baseline and at 2-year follow-up, heart rate and cardiac vagal control as indexed by respiratory sinus arrhythmia were measured in 2114 subjects (mean age = 42.0 years; 66.2% female), who either used antidepressants at one or two time points (n = 603) or did not use antidepressants at any time point (n = 1511). Linear mixed-model analyses were conducted to compare changes in respiratory sinus arrhythmia and heart rate over time across antidepressant-naive subjects, subjects who started using an antidepressant during follow-up, subjects who stopped using an antidepressant, and persistent antidepressant users. Analyses were adjusted for demographics, health, and lifestyle factors.

RESULTS

Compared with continuous nonusers, subjects who started the use of a tricyclic antidepressant or a serotonergic and noradrenergic antidepressant showed a significantly greater increase in heart rate and a decrease of respiratory sinus arrhythmia at 2 years. Subjects who started the use of selective serotonin reuptake inhibitors also showed a decrease in respiratory sinus arrhythmia, but their heart rate did not increase. Discontinuing antidepressants systematically caused opposite effects; levels returned in the direction of those observed among nonusers.

CONCLUSIONS

These 2-year longitudinal results indicate that all antidepressants cause a decrease in cardiac vagal control. After discontinuing antidepressants, autonomic function recovers, suggesting that the unfavorable effects are (partly) reversible.

Synthesis of dinucleoside tetraphosphates in transfected cells by a firefly luciferase reporter gene

The firefly luciferase gene is widely used as a reporter gene and its expression is generally considered to be non-toxic. In addition to its light-producing reaction, luciferase can synthesise dinucleoside polyphosphates, intracellular signalling molecules, in vitro. Here we show that COS-7 cells transfected with a luciferase expression vector accumulate up to 0.5 mM adenine-containing dinucleoside tetraphosphates (Ap4N) during the 24 h following luciferin addition. The optimal external concentration of luciferin was 0.4-0.6 mM. In agreement with its poor ability to synthesise adenine-containing dinucleoside triphosphates in vitro, the level of these compounds did not increase after transfection. Consequently, the results of experiments involving luciferase-mediated light production by live cells should now be viewed in the light of the possible effects of an increased intracellular Ap4N concentration on the properties of the system under investigation. This observation also points to a useful non-invasive procedure for the specific enhancement of intracellular Ap4N for studies directed at understanding the functions of these compounds.