Post-percutaneous coronary intervention psychological disorders predict poor adherence and cardiovascular events in elderly heart failure patients

Abstract

Background: Post-procedural psychological disorders are frequently overlooked in elderly patients undergoing percutaneous coronary intervention (PCI), despite their potential impact on long-term cardiovascular outcomes.

Aim: To evaluate the incidence and prognostic significance of post-PCI psychological disorders in elderly patients with heart failure, and to examine their association with medication adherence and major adverse cardiovascular events (MACE).

Methods: This retrospective cohort study included 330 consecutive patients aged ≥ 60 years with heart failure who underwent PCI between 2018 and 2021 at a single center, excluding those with prior psychiatric diagnoses. Psychological status within six months post-discharge was assessed using validated Chinese versions of the 9-item Patient Health Questionnaire and the 7-item Generalized Anxiety Disorder Scale, and medication adherence was measured by the 8-item Morisky Medication Adherence Scale (MMAS-8) scale. A subset of 145 patients with ≥ 24 months of follow-up were analyzed for MACEs. Multivariate logistic regression and Kaplan-Meier survival analyses were performed.

Results: Post-PCI psychological disorders were identified in 40% of patients, with anxiety (36%), depression (32%), and comorbid symptoms (22%) being most prevalent. Affected patients had lower MMAS-8 scores [median 5 (IQR 4-6) vs 6 (IQR 5-7), P = 0.002] and a higher rate of low adherence (51.5% vs 30.3%, P < 0.001). Among the 145 patients followed longitudinally, MACEs occurred in 17.9%, with 65.4% of events in those with psychological disorders. Psychological disorders (OR = 2.66, 95%CI: 1.11-6.41, P = 0.028) and low adherence (OR = 2.77, 95%CI: 1.17-6.56, P = 0.021) were independently associated with increased MACE risk. Kaplan-Meier analysis showed reduced MACE-free survival in patients with psychological disorders (HR = 2.68, 95%CI: 1.25-5.73; log-rank P = 0.008).

Conclusion: Post-PCI psychological disorders are common in elderly patients with heart failure and independently predict poorer adherence and worse cardiovascular outcomes. Routine psychological assessment and adherence interventions may improve prognosis in this vulnerable population.

Keywords: Major adverse cardiovascular events; Medication adherence; Percutaneous coronary intervention; Psychological disorders.

Figure 1

Incidence and subtype distribution of post-percutaneous coronary intervention psychological disorders by clinical subgroups. Incidence of psychological disorders within 6 months after percutaneous coronary intervention (PCI) across predefined clinical subgroups. A: Age group (≥ 70 years vs < 70 years); B: Sex (female vs male); C: Presence of diabetes mellitus; D: Baseline left ventricular ejection fraction (< 45% vs ≥ 45%); E: Renal function (estimated glomerular filtration rate < 60 mL/min/1.73 m² vs ≥ 60 mL/min/1.73 m²); F: Distribution of psychological disorder subtypes among patients with post-PCI psychological disorders (n = 132). Bars represent the proportion of patients in each subgroup who developed clinically confirmed psychological disorders within 6 months post-procedure. Error bars denote approximate 95% confidence intervals. LVEF: Left ventricular ejection fraction; eGFR: Estimated glomerular filtration rate.

Figure 2

Medication adherence (8-item Morisky Medication Adherence Scale) by psychological disorder subtype. Bar chart comparing mean 8-item Morisky Medication Adherence Scale scores across patient groups stratified by psychological disorder subtype (n = 330). Patients without psychological disorders demonstrated the highest medication adherence scores (mean 6.4 ± 1.4), while those with comorbid depression and anxiety showed the lowest (mean 4.5 ± 1.1). Other subgroups, including depression only, anxiety only, and adjustment disorder, exhibited intermediate adherence levels. Values represent mean ± SD. Psychological disorders were classified based on standardized assessments within 6 months after percutaneous coronary intervention. MMAS-8: 8-item Morisky Medication Adherence Scale.

Figure 3

Correlation between psychological symptom severity and medication adherence (8-item Morisky Medication Adherence Scale score). A: Scatterplot showing the relationship between depression severity, measured by Patient Health Questionnaire-9 score, and 8-item Morisky Medication Adherence Scale (MMAS-8 score) among patients with psychological disorders (n = 132). A significant inverse correlation was observed (r = -0.43, P < 0.001), indicating that higher depressive symptom burden was associated with poorer adherence; B: Scatterplot showing the relationship between anxiety severity, measured by Generalized Anxiety Disorder-7 score, and medication adherence (MMAS-8 score) in the same cohort. A similar negative correlation was found (r = -0.39, P < 0.001), supporting the impact of anxiety symptoms on treatment adherence behavior. Both correlations were estimated using Pearson’s correlation method. Patients were included only if psychological disorder was confirmed within 6 months post- percutaneous coronary intervention. MMAS-8: 8-item Morisky Medication Adherence Scale; PHQ-9: Patient Health Questionnaire-9; GAD-7: Generalized Anxiety Disorder-7.

Figure 4

Impact of post-procedural psychological disorders on long-term cardiovascular outcomes. A: Forest plot showing multivariate logistic regression analysis identifying independent predictors of major adverse cardiovascular events (MACE) within two years following percutaneous coronary intervention (n = 145). Post-procedural psychological disorders were associated with a more than twofold increase in MACE risk (OR = 2.66, 95%CI: 1.11-6.41, P = 0.028), independent of age, diabetes, renal function, cardiac function, and medication adherence. Poor adherence (8-item Morisky Medication Adherence Scale < 6) also independently predicted MACE (OR = 2.77, 95%CI: 1.17-6.56, P = 0.021); B: Kaplan-Meier curves for MACE-free survival, comparing patients with psychological disorders (n = 56, 17 events) vs those without (n = 89, 9 events). Psychological morbidity was associated with significantly reduced MACE-free survival over the 2-year follow-up period (HR = 2.68, 95%CI: 1.25-5.73; Log-rank P = 0.008). Vertical dashed line in A represents the null effect (OR = 1). MMAS-8: 8-item Morisky Medication Adherence Scale; PCI: Percutaneous coronary intervention; MACE: Major adverse cardiovascular event; LVEF: Left ventricular ejection fraction; eGFR: Estimated glomerular filtration rate.