Coronary Artery Disease
Depressive Symptoms, Cardiac Disease Severity, and Functional Status in Patients With Coronary Artery Disease (from the Heart and Soul Study)

https://doi.org/10.1016/j.amjcard.2016.07.062Get rights and content

Patient-reported health status is highly valued as a key measure of health care quality, yet little is known about the extent to which it is determined by subjective perception compared with objective measures of disease severity. We sought to compare the associations of depressive symptoms and objective measures of cardiac disease severity with perceived functional status in patients with stable coronary artery disease. We assessed depressive symptoms, severity of cardiovascular disease, and perceived functional status in a cross-sectional study of 1,023 patients with stable coronary artery disease. We compared the extent to which patient-reported functional status was influenced by depressive symptoms versus objective measures of disease severity. We then evaluated perceived functional status as a predictor of subsequent cardiovascular hospitalizations during 8.8 years of follow-up. Patients with depressive symptoms were more likely to report poor functional status than those without depressive symptoms (44% vs 17%; p <0.001). After adjustment for traditional risk factors and co-morbid conditions, independent predictors of poor functional status were depressive symptoms (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.89 to 3.79), poor exercise capacity (OR 2.30, 95% CI 1.65 to 3.19), and history of heart failure (OR 1.61, 95% CI 1.12 to 2.29). Compared with patients who had class I functional status, those with class II functional status had a 96% greater rate (hazard ratio 1.96, 95% CI 1.15 to 3.34) and those with class III or IV functional status had a 104% greater rate (hazard ratio 2.04, 95% CI 1.12 to 3.73) of hospitalization for HF, adjusted for baseline demographic characteristics, co-morbidities, cardiac disease severity, and depressive symptoms. In conclusion, depressive symptoms and cardiac disease severity were independently associated with patient-reported functional status. This suggests that perceived functional status may be as strongly influenced by depressive symptoms as it is by cardiovascular disease severity.

Section snippets

Methods

The Heart and Soul Study is a prospective cohort study that was originally designed to investigate the effects of psychosocial factors on health outcomes in patients with stable CAD. Methods have been previously described.10 Patients were eligible if they had at least one of the following: history of myocardial infarction (MI), angiographic evidence of ≥50% stenosis in ≥1 coronary vessels, evidence of exercise-induced ischemia by treadmill electrocardiogram or stress nuclear perfusion imaging,

Results

At baseline, among 1,023 participants, 199 (19.4%) had depressive symptoms (PHQ-9 score ≥10). Compared with nondepressed participants, those who were depressed were younger and less likely to be male or married (Table 1). Patients with depression had lower income and were more likely to smoke than those without depression. They were also more likely to have a history of diabetes, myocardial infarction, heart failure, and/or increased body mass index. Participants with depressive symptoms had

Discussion

In a cohort of 1,023 older adults with stable CAD, we found that perceived functional status was as strongly associated with depressive symptoms as objective measures of cardiac disease severity. Subjects with depression were more likely to report worse cardiac symptom burden compared with those without depression. Also, we found those with worse symptoms were more likely to be hospitalized over a long-term follow-up period. These findings suggest that (a) depressive symptoms should be

Disclosures

The authors have no conflicts of interest to disclose.

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    Dr. Schopfer is supported by the National Center for Advancing Translational Sciences, Bethesda, Maryland of the National Institutes of Health, Bethesda, Maryland under award number KL2TR000143. The Heart and Soul Study was supported by grants from the Department of Veterans Affairs, Washington, DC (Epidemiology Merit Review Program), the National Heart, Lung, and Blood Institute, Bethesda, Maryland (R01 HL079235), the Robert Wood Johnson Foundation, Princeton, New Jersey (Generalist Physician Faculty Scholars Program), the American Federation for Aging Research, New York, New York (Paul Beeson Faculty Scholars in Aging Research Program), the Ischemia Research and Education Foundation, South San Francisco, California, and Nancy Kirwan Heart Research Fund, San Francisco, California.

    The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the report, and its final contents. None of these funding sources had any role in the collection of data, interpretation of results, or preparation of this report.

    See page 1291 for disclosure information.

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