Depression associated with 5-fold increased mortality risk in heart failure patients

Heart Failure 2015 is the main annual meeting of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) and takes place 23 to 26 May in Seville, Spain.

Professor John Cleland, chief investigator of OPERA-HF and professor of cardiology at Imperial College London and the University of Hull, UK, said: "Patients with heart failure are at high risk of recurrent hospital admissions and death. Approximately 25% of patients admitted to hospital with heart failure are readmitted for a variety of reasons within one month. Within one year, most patients will have had one or more readmissions and almost half will have died.1"

He added: "OPERA-HF was designed to investigate in a more holistic fashion than previously the predictors of and reasons for readmission and death amongst patients with heart failure. This included social, mental and physical frailty, as well as comorbidities and the severity of heart failure. Depression has been reported to predict death in patients with heart failure but until now it was thought that this could be because depressed patients have more severe heart failure and more comorbidities."

OPERA-HF is an ongoing observational study enrolling patients hospitalised with heart failure. Depression was assessed using the Hospital Anxiety and Depression Scale (HADS-D) questionnaire and comorbidity was examined using the Charlson Comorbidity Index (CCI).

The results of the HADS-D questionnaire showed that 103 patients were not depressed (score 0-7), 27 had mild depression (score 8-10) and 24 had moderate to severe depression (score 11-21). Over a mean follow up of 302 days, 27 patients died.

Patients with moderate to severe depression had a 5-fold increased risk of death compared to those with no or mild depression. Moderate to severe depression remained an important predictor of all-cause mortality even after controlling for sex, age, hypertension, severity of heart failure (assessed by NT-proBNP) and comorbidities. Patients with a low HADS-D score (0-7) had an 80% lower risk of death.

Professor Cleland said: "Our results show that depression is strongly associated with death during the year following discharge from hospital after an admission for the exacerbation of heart failure; we expect that the link persists beyond one year. The association was independent of the severity of heart failure or the presence of comorbidities."

He added: "We know that depression is common in heart failure and affects 20-40% of patients.1 Depression is often related to loss of motivation, loss of interest in everyday activities, lower quality of life, loss of confidence, sleep disturbances and change in appetite with corresponding weight change. This could explain the association we found between depression and mortality."

Professor Cleland continued: "As doctors we are members of a caring profession and should be sympathetic to our patients' plight but I am not in favour of immediately prescribing anti-depressants. Studies suggest that they are not effective in reducing depression in patients with heart failure. Clinicians should, however, screen patients with heart failure for depression and consider referring those affected for counselling."

He concluded: "Our research clearly shows a strong association between depression and risk of death in the year after discharge from hospital. Recognition and management of depression may reduce mortality for patients with heart failure. More research is needed to find out what clinicians and patients themselves can do to manage depression. Better treatments for heart failure, co-morbidities as well as depression itself may be required."

The HFA White Paper "Heart failure: preventing disease and death worldwide" is available here: http://www.escardio.org/static_file/Escardio/Subspecialty/HFA/WHFA-whitepaper-15-May-14.pdf