Heart attack-related depression puts patients at risk for further cardiovascular emergencies

New research suggests need for more targeted depression screenings, treatment strategies

People who experience their first-ever bout of depression after having a heart attack are at greater risk for future heart problems than are patients who either don’t become clinically depressed after the medical emergency or who were depressed even before the incident, new research shows.

As a result, new depression-related screening protocols and treatment strategies may be needed to help reduce the likelihood of future heart problems in these patients, according to the research, which appears in the Dec. 5, 2006 edition of the Journal of the American College of Cardiology.

Known as the DepreMI Study, the research was conducted in the Netherlands at University Medical Centre Groningen, part of the University of Groningen. Lead researcher Peter de Jonge, PhD, said the team was seeking to determine whether all types of depression could be considered a direct cause of heart attack. What the group found was a bit surprising.

“We found that only incident (first-time) depression – no other type – was related to a poor prognosis,” said Dr. de Jonge, an assistant professor of internal medicine and psychiatry at the University of Groningen. “In other words, our findings suggest that patients who experience depression after a heart attack, but never before, are at particular risk for future incidents.

“Based on other studies, it appears that standard antidepressive treatment may not be sufficient for this category of patients,” Dr. de Jonge continued. “We feel that especially in these cases, antidepressive treatment should be integrated into cardiac after-care and made a prominent part of the rehabilitation program.”

Standard antidepressive treatment, which frequently includes medications to affect mood, may be insufficient, Dr. de Jonge explained, because incident post-heart attack depression is different than typical depression.

Patients with post-heart attack depression often have survived more severe medical emergencies than other heart attack patients, he said. As a result, these patients may be physically more exhausted and vulnerable than their peers.

“[T]his finding may explain the relatively high effectiveness of psychoeducational interventions, including stress management and relaxation, to prevent cardiac events in coronary artery disease patients,” the researchers state in their manuscript.

For the study, the researchers observed 468 patients hospitalized for heart attack for a mean follow-up period of 2.5 years. Patients were clinically evaluated for depression while in the hospital and again at three months and 12 months post-heart attack. Those with heart attack-related depression experienced more fatal and non-fatal cardiovascular emergencies than did patients who either did not become depressed or who were depressed before having a heart attack.

Based on these findings, Dr. de Jonge said, researchers need to create interventional studies in which non-standard treatments for depression are evaluated in patients with post-heart attack depression to determine which methods are most effective in protecting long-term health.

Roland von Känel, MD, a professor of medicine and head of the psychosomatic division at University Hospital Berne in Switzerland, did not participate in the study, but said it provides important information on “cardiotoxic” subtypes of depression and clues on improving care. Dr. von Känel is the first author of an editorial comment about heart attack and depression that will be published in conjunction with the new research.

“Given what we now know, I believe that screening for depression should be part of today’s clinical practice in a cardiology setting any time a patient is referred to the ICU with a heart attack,” Dr. von Känel said. “Depressed patients should be treated with counseling, referral to a psychotherapist and/or antidepressant medication – preferably an SSRI (selective serotonin reuptake inhibitor) – depending upon the severity of their depression.”

SSRI medications seek to improve mood by slowing the reuptake of the neurotransmitter serotonin in the brain; the medications have been shown to be safe and efficient in patients with heart disease. Serotonin affects emotions, mood and thought.

“In addition, improving social support, establishing a physical exercise regimen and addressing psychosocial issues, such as job situation, family conflicts and stress-causing health concerns, also may be necessary,” Dr. von Känel said. “All of these things will work together to benefit quality of life, improve adherence to cardiac treatment and reduce health care costs.”

The next steps, Dr. von Känel said, are to conduct additional research to ensure that patients receive the most effective treatments and to determine which of these treatments improve hard cardiovascular end-points, such as recurrent heart attack.

“There is no study showing to date that treatment of depression with psychotherapy improves cardiac or overall survival,” he said. “Non-randomized studies show, however, that SSRIs may benefit depressed patients after a heart attack in terms of improving cardiovascular outcome. A randomized double-blind, placebo-controlled trial with an antidepressant as well as an individually tailored psychotherapeutic intervention study are badly needed to resolve these issues.”

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Dr. de Jonge reports no disclosures with this research. Funding for the DepreMI study was provided by the Netherlands Organization for Scientific Research.

Also in this issue of JACC
Researchers at seven U.S. universities used non-invasive magnetic resonance imaging to examine the heart’s left ventricle – its main pumping chamber – to determine how the chamber was affected by various risk factors for heart disease in patients without clinical evidence of heart disease.

The researchers examined 4,869 patients in a multiethnic study that included African-Americans, Caucasians, Hispanics and Asians of Chinese descent. Risk factors included high blood pressure, obesity and smoking – all of which have been linked to an enlarged left ventricle in patients with heart disease. An enlarged left ventricle, in turn, has been linked to a greater likelihood that patients will go on to suffer a cardiac emergency, such as a heart attack, heart failure or even a stroke.

In looking at patients without clinical evidence of heart disease, the researchers found that a higher systolic blood pressure and a higher body mass index were associated with larger left ventricular (LV) mass and volumes. They also found that current smoking and diabetes were associated with greater LV mass and lower stroke volume, although these differences tended to be small.

Overall, the researchers concluded that “[a]dditional study of these modifiable risk factors and their treatment in relation to the new development or progression of LV dysfunction is needed.”

Institutions participating in this study were: the University of Washington, Seattle; Johns Hopkins University, Baltimore; Columbia University, New York; University of Alabama, Birmingham; University of California, Los Angeles; University of Minnesota, Minneapolis; and Wake Forest University, Winston-Salem, N.C.

The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 34,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at www.acc.org.

The American College of Cardiology (ACC) provides these news reports of clinical studies published in the Journal of the American College of Cardiology as a service to physicians, the media, the public and other interested parties. However, statements or opinions expressed in these reports reflect the view of the author(s) and do not represent official policy of the ACC unless stated so.


Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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