Depression Identified as a Risk Factor for Poor Prognosis After ACS

Jeannette Y. Wick, RPh, MBA, FASCP
Published Online: Wednesday, April 23, 2014
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A scientific statement from the American Heart Association concludes that depression should be categorized as a risk factor for poor prognosis after acute coronary syndrome.

Cardiac disease and depression: When these occur together, the risk of recurrent cardiac events and death increases 3- to 4-fold. Experts believe that increased platelet reactivity leading to increased platelet aggregation and thrombus formation might be the link between depression and coronary heart disease.
 
Patients who are clinically depressed also have elevated inflammatory markers—markers that are similarly elevated in patients who experience congestive heart failure, atherosclerosis, myocardial infarction, and stroke. Although experts have emphasized the need to treat cardiovascular disease patients who are depressed with therapeutically effective doses of antidepressants, no guiding experts have formally recognized depression as a risk factor for poor prognosis in patients with acute coronary syndrome (ACS) yet.
 
The American Heart Association (AHA) has been concerned about this potential omission, so it assembled a writing group to create a scientific statement on depression and ACS. AHA asked for a recommendation as to whether depression should be elevated to risk factor status for patients with ACS. The writing group’s scientific statement appears in the March 25, 2014, edition of Circulation.
 
The group’s members performed a systematic literature review on depression and adverse medical outcomes after ACS. They tracked all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. They identified 53 studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses that met their strength, consistency, independence, and generalizability criteria for inclusion. The studies included heterogeneous demographic compositions, depression definitions and measurements, and follow-up.
 
This scientific statement identifies consistent associations between depression and ACS. Despite published studies’ heterogeneity, the group found the preponderance of evidence linked depression to adverse outcomes in patients with ACS. They indicated that cardiologists should use established methods to screen patients for depression, especially if it is severe or persistent, and refer them to mental health specialists for appropriate treatment.
 
However, the expert writing group found no strong evidence that treating depression improves survival after ACS. Nonetheless, the paper concludes with a recommendation that the AHA should elevate depression to the status of a risk factor for poor prognosis after acute coronary syndrome.
 
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.
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