The association of cognitive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction

Abstract

Background: Among patients with acute myocardial infarction (AMI), depression is both common and underrecognized. The association of different manifestations of depression, somatic and cognitive, with depression recognition and long-term prognosis is poorly understood.

Methods and results: Depression was confirmed in 481 AMI patients enrolled from 21 sites during their index hospitalization with a Patient Health Questionnaire (PHQ-9) score > or =10. Within the PHQ-9, separate somatic and cognitive symptom scores were derived, and the independent association between these domains and the clinical recognition of depression, as documented in the medical records, was evaluated. In a separate multisite AMI registry of 2347 patients, the association between somatic and cognitive depressive symptoms and 4-year all-cause mortality and 1-year all-cause rehospitalization was evaluated. Depression was clinically recognized in 29% (n=140) of patients. Cognitive depressive symptoms (relative risk per SD increase, 1.14; 95% CI, 1.03 to 1.26; P=0.01) were independently associated with depression recognition, whereas the association for somatic symptoms and recognition (relative risk, 1.04; 95% CI, 0.87 to 1.26; P=0.66) was not significant. However, unadjusted Cox regression analyses found that only somatic depressive symptoms were associated with 4-year mortality (hazard ratio [HR] per SD increase, 1.22; 95% CI, 1.08 to 1.39) or 1-year rehospitalization (HR, 1.22; 95% CI, 1.11 to 1.33), whereas cognitive manifestations were not (HR for mortality, 1.01; 95% CI, 0.89 to 1.14; HR for rehospitalization, 1.01; 95% CI, 0.93 to 1.11). After multivariable adjustment, the association between somatic symptoms and rehospitalization persisted (HR, 1.16; 95% CI, 1.06 to 1.27; P=0.01) but was attenuated for mortality (HR, 1.07; 95% CI, 0.94 to 1.21; P=0.30).

Conclusions: Depression after AMI was recognized in fewer than 1 in 3 patients. Although cognitive symptoms were associated with recognition of depression, somatic symptoms were associated with long-term outcomes. Comprehensive screening and treatment of both somatic and cognitive symptoms may be necessary to optimize depression recognition and treatment in AMI patients.

Figure 1. Overview of Study Design and Objectives

Abbreviations: AMI, acute myocardial infarction; PHQ, patient health questionnaire; PREMIER, prospective registry evaluating outcomes after myocardial infarctions: events and recovery; TRIUMPH, translational research investigating underlying disparities in acute myocardial infarction patients’ health Status.

Figure 2. Independent Predictors of Depression Recognition During Index AMI Hospitalization

Model estimates are presented as Relative Risks with 95% Confidence Intervals. Abbreviations: AMI, acute myocardial infarction; CHF, chronic heart failure; EF, ejection fraction; PHQ, patient health questionnaire; SD, Standard Deviation; STEMI, ST-elevation myocardial infarction.

Figure 3. Model Estimates of Risk for 4-Year Mortality and 1-Year Rehospitalization For Somatic and Cognitive Depressive Symptoms

Abbreviations: CI, confidence interval; HR, hazard ratio; PHQ, patient health questionnaire. Multivariable models adjusted for demographic (age, sex, race), clinical (diabetes mellitus, prior coronary artery disease, stroke, chronic renal failure, chronic lung disease, chronic heart failure, non-skin cancer, current smoking, body mass index) socioeconomic (marital status, education, insurance status and working status), AMI severity (ST elevation AMI, left ventricular ejection fraction <40%, heart rate), and treatment (angiography, revascularization, percent and number of quality of care indicators received) variables.