The Impact of Changes in Depression on Cardiovascular Outcomes in Patients With Coronary Heart Disease

Background: Depression is associated with major adverse cardiovascular events (MACE). Whether longitudinal changes in depression affect MACE in patients with coronary heart disease (CHD) remains unknown.

Objectives: The authors evaluated the hypothesis that increasing or persistent depression predicts MACE in patients with CHD.

Methods: At baseline, 3,483 Emory Cardiovascular Biobank participants (median age 65.5 years, 31.6% female) completed the Patient Health Questionnaire 8 (PHQ8) for depression evaluation. At 1 year, 2,639 of these event-free participants repeated the questionnaire. Depression was defined as a PHQ8 score >9 and change in depressive symptoms ( $\Delta$ PHQ8) was year 1 score minus baseline PHQ8 scores. We categorized participants into never depression (both PHQ8 <10), new depression (baseline PHQ8 <10; 1-year PHQ8 >9), remitted depression (baseline PHQ8 >9; year 1 PHQ8 <10), and persistent depression (both PHQ8 >9) groups. Fine-Gray models with noncardiovascular death as the competing event and adjusted for demographics, CHD, and depression related factors evaluated how changes in depression affect MACE (cardiovascular death and MI).

Results: Overall, the incidence of MACE was 14%, with 8.7% of those with follow-up PHQ8 having MACE. 2.9% had persistent depression, 4.5% had new depression, 10.8% had remitted depression, and 81.8% never had depression. Increasing depressive symptoms independently predicted MACE ( $\Delta$ PHQ8 subdistribution HR: 1.06 [95% CI: 1.02-1.09], P < 0.001). Correspondingly, the incidence of MACE was higher in those with persistent (20.8%) or new depression (11.9%) than in those with remitted (9.4%) or never depression (8%) (P < 0.001). Compared to never depression, persistent depression independently predicted MACE (subdistribution HR: 2.78 [95% CI: 1.2-6.5], P = 0.017).

Conclusions: Increasing or persistent depression predicts MACE in individuals with CHD.