Patients with heart failure who also suffer from moderate to severe depression have a five-fold increased risk of all-cause mortality in the year following discharge from hospital, compared to those who were not or mildly depressed. This increased risk is independent of severity of heart disease or presence of co-morbidities, which have previously been proposed as reasons for the known association of depression with mortality following heart failure. These are findings from the OPERA-HF (Observational study to assess and Predict the in-patient course, risk of Re-Admission and mortality for patients hospitalised for or with Heart Failure) study from researchers in Philips Research in Eindhoven in The Netherlands and the University of Hull in the United Kingdom. OPERA-HF is led by Professor John Cleland, chief investigator of OPERA-HF and professor of cardiology at Imperial College London and the University of Hull. The findings were presented at the Heart Failure 2015 conference, the main annual meeting of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) taking place from 23rd to 26th May in Seville, Spain.
The OPERA-HF study is an ongoing observational study in which patients hospitalised with heart failure are assessed and followed up. Prof Cleland explained: "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."
In this study, depression was assessed using the Hospital Anxiety and Depression Scale (HADS-D) questionnaire and comorbidity by the Charlson Comorbidity Index (CCI). The results on 154 patients hospitalised for heart failure indicated 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). The patients were followed up for an average period of 302 days, during which 27 of them died.
Strikingly, the results showed that for patients with moderate to severe depression, there was a five-fold higher all-cause mortality risk than for those with no or mild depression. This higher risk remained after controlling for potentially confounding factors including sex, age, hypertension, severity of heart failure (assessed by NT-proBNP) and comorbidities. Professor Cleland commented: "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…We know that depression is common in heart failure and affects 20-40% of patients (HFA White Paper). 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."
Despite the link between depression and mortality, Prof Cleland would not be in favour of immediately placing these patients on anti-depressants, as studies have indicated they are ineffective in depression reduction in heart failure patients. He said: “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."
Depression as an independent risk factor for all-cause mortality in heart failure patients. Abstract P320; Heart Failure Association (HFA) of the European Society of Cardiology (ESC), Seville, Spain, 23-26 May 2015; http://spo.escardio.org/
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