Comorbid Depression and Heart Failure: A Community Cohort Study

Objective
To examine the association between depression and clinical outcomes in heart failure (HF) in a community cohort.
Patients and Methods
HF patients in Minnesota, United States completed depression screening using the 9-item Patient Health Questionnaire (PHQ-9) between 1st Oct 2007 and 1st Dec 2011; patients with PHQ-9≥5 were labelled “depressed”. We calculated the risk of death and first hospitalization within 2 years using Cox regression. Results were adjusted for 10 commonly used prognostic factors (age, sex, systolic blood pressure, estimated glomerular filtration rate, serum sodium, ejection fraction, blood urea nitrogen, brain natriuretic peptide, presence of diabetes and ischaemic aetiology). Area under the curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) compared depression as a predictor against the aforementioned factors.
Results
425 patients (mean age 74, 57.6% males) were included in the study; 179 (42.1%) had PHQ-9≥5. The adjusted hazard ratio of death was 2.02 (95% CI 1.34–3.04) and of hospitalization was 1.42 (95% CI 1.13–1.80) for those with compared to those without depression. Adding depression to the models did not appreciably change the AUC but led to statistically significant improvements in both the IDI (p = 0.001 and p = 0.005 for death and hospitalization, respectively) and NRI (for death and hospitalization, 35% (p = 0.002) and 27% (p = 0.007) were reclassified correctly, respectively).
Conclusion
Depression is frequent among community patients with HF and associated with increased risk of hospitalizations and death. Risk prediction for death and hospitalizations in HF patients can be improved by considering depression.

研究目的 本研究旨在探讨社区队列中心力衰竭（Heart Failure, HF）患者的抑郁状态与临床结局之间的关联。
患者与方法 2007年10月1日至2011年12月1日期间，美国明尼苏达州的心力衰竭患者采用9条目患者健康问卷（9-item Patient Health Questionnaire, PHQ-9）完成抑郁筛查；PHQ-9评分≥5分者被归类为「抑郁状态」。本研究采用Cox回归模型计算2年内的死亡与首次住院风险，并针对10项常用预后因素（年龄、性别、收缩压、估算肾小球滤过率、血清钠、射血分数、血尿素氮、脑钠肽、糖尿病患病情况及缺血性病因）进行校正。采用受试者工作特征曲线下面积（Area Under the Curve, AUC）、综合判别改善指数（Integrated Discrimination Improvement, IDI）以及净重新分类指数（Net Reclassification Improvement, NRI），将抑郁作为预测因子与上述10项预后因素进行对比分析。
研究结果 本研究共纳入425例患者（平均年龄74岁，男性占比57.6%），其中179例（42.1%）患者PHQ-9评分≥5分。与无抑郁状态的患者相比，抑郁患者的校正后死亡风险比为2.02（95%置信区间：1.34~3.04），住院风险比为1.42（95%置信区间：1.13~1.80）。将抑郁状态纳入预测模型后，AUC未出现显著变化，但IDI与NRI均获得统计学显著改善：针对死亡结局，IDI的P值为0.001，NRI的正确重新分类比例为35%（P=0.002）；针对住院结局，IDI的P值为0.005，NRI的正确重新分类比例为27%（P=0.007）。
研究结论 社区心力衰竭患者中抑郁状态较为常见，且与住院及死亡风险升高显著相关。将抑郁状态纳入考量后，可改善心力衰竭患者死亡与住院风险的预测效能。