Prognostic Value of Depressive Symptoms for Cardiovascular Events in Female Patients With Heart Failure With Reduced Ejection Fraction and Heart Failure With Preserved Ejection Fraction

Abstract

Background: Among those with heart failure (HF), women are more likely to develop depression than men. Few studies have focused on the outcomes of female patients with HF with depressive symptoms.

Methods and results: A total of 506 female patients with HF with preserved ejection fraction were included in this secondary analysis from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) cohort, and 439 female patients with HF with reduced ejection fraction were included from the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) cohort. Depressive symptoms were measured using the Patient Health Questionnaire-9 and Beck Depression Inventory-II. The depression class was categorized by severity, and the change in clinical depression class was defined as aggravated (1-grade increase) or improved (1-grade decrease). The prognostic value of depressive symptoms was determined by using multivariable Cox proportional hazards models. Female patients with improved depressive symptoms had worse depressive status at baseline and lower baseline Kansas City Cardiomyopathy Questionnaire scores. Depression class at the 12-month visit and depression class change were the dominant prognostic factors for cardiovascular death in female patients with HF with preserved ejection fraction (hazard ratio [HR], 1.43 [95% CI, 1.02-2.01], P=0.036; HR, 1.71 [95% CI, 1.14-2.55], P=0.009). Among the patients with HF with reduced ejection fraction, both the depression class at baseline and depression class change had significant prognostic effects on cardiovascular death (HR, 3.30 [95% CI, 1.70-6.39], P<0.001; HR, 2.21 [95% CI, 1.28-3.80], P=0.004). However, the prognostic value of depressive assessments for hospitalization in patients with HF is unclear.

Conclusions: In female patients with HF with reduced ejection fraction, the depression class at baseline was most strongly associated with cardiovascular death, whereas in female patients with HF with preserved ejection fraction, the change in depression class exhibited a more significant prognostic trend.

Keywords: Beck Depression Inventory‐II; HFpEF; HFrEF; Patient Health Questionnaire‐9; depression; female.

Figure 1. Study cohort.

In the TOPCAT trial, only female patients with LVEF ≥50% and a complete PHQ‐9 were included in this study. In the HF‐ACTION trial, only female patients with LVEF ≤40% and a complete BDI‐II were included in this study. BDI‐II indicates Beck Depression Inventory‐II; HF‐ACTION, Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LVEF, left ventricular ejection fraction; PHQ‐9, Patient Health Questionnaire‐9; and TOPCAT, Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist.

Figure 2

The prognostic value of depressive symptoms for cardiovascular death in female patients with HFpEF and HFrEF. Female patients with HFpEF from TOPCAT and with HFrEF from HF‐ACTION were included in this secondary analysis. For the outcome of cardiovascular death, both depression class at the 12‐month visit and depression class change were the dominant prognostic factors in female HFpEF patients. In female HFrEF patients, depression class at baseline and depression class change showed a significant prognostic effect on cardiovascular death. HF‐ACTION indicates Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; and TOPCAT, Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist.