Depression significantly increases mortality after aortic valve replacement

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Jonathan Afilalo

Data from the FRALITY-AVR (Frality aortic valve replacement) study suggest that the presence of depression in patients undergoing aortic valve replacement—either via surgery or transcatheter aortic valve implantation (TAVI)—is associated with a significantly increased risk of mortality at one month and at 12 months after the procedure.

Laura M Drudi (Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, Canada) and others report in JAMA Cardiology that previous studies have shown that depression is risk factor for adverse events after cardiac surgery (including valve replacement), but add that “little is known about the role of depression in older adults undergoing TAVI”. They note: “Thus, we sought to determine the prevalence of depression and its association with all-cause mortality in a large representative cohort of older adults undergoing TAVI and surgical aortic valve replacement.”

Reviewing data for 1,035 patients from FRALITY-AVR, they identified 326 patients who scored positively for depression but observed that “only 89 (8.6%) had a diagnosis of depression documented in their clinical record”. Patients with depression, the authors comment, were likely to be frail and be cognitively impaired.

At one month, according to a multivariate logistic regression, depression was the only patient-level variable prognostic factor of short-term mortality. At 12 months, again via a multivariate analysis, depression, cognitive impairment, and physical frailty were all patient-level prognostic factors for depression. Drudi et al say: “The association of depression with 12-month mortality was not significantly modified by the presence of concomitant frailty, cognitive impairment, or coronary artery disease. In addition, the association was not attenuated by adjusting for individual comorbidities associated with depression or by considering frailty as a continuous covariate.”

According to the authors, “persistent depression”—depression at baseline and at six months after the procedure—had the strongest association with subsequent mortality compared with no depression, resolved depression (depression at baseline only), and new depression (depression at six months after the procedure). They comment: “The extent to which this risk resulted from a persistent mood disorder or a marker of poor underlying health status may have varied among individual patients.”

Drudi et al report that their findings “support active screening for depression before and after aortic valve procedures to identify patients who may benefit from further psychiatric evaluation for the diagnosis and treatment of a depressive disorder.” They add that, given both new and persistent depression were associated with a greater risk of mortality, “clinicians should be vigilant to the evaluation of depression symptoms after surgery or TAVI.”

Coordinated care “involving cardiovascular and psychogeriatric specialists”, the authors conclude, is the optimal approach for managing patients with depression who are undergoing either TAVI or surgical valve replacement.

Study investigator Johnathan Afilalo (Geriatric Cardiology Fellowship Program, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital, Montreal, Canada) says: “I think it is important for clinicians to recognise that depression may be under-diagnosed in the electronic health record, and that it is worthwhile asking a few key questions to screen older adults for depressive symptoms. Given the well-documented overlap between certain symptoms of heart failure and those of depression, it is important—and often challenging—to confirm the diagnosis before instituting pharmacological or non-pharmacological antidepressant therapies. Depression and frailty often co-exist, and embody a family of geriatric domains that should be considered when evaluating vulnerable elderly patients before procedures such as aortic valve replacement.”

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