Older adults who are depressed may be at particularly high risk of death after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), researchers said.
Baseline depression, as determined by the Geriatric Depression Scale Short Form, was associated with all-cause mortality at 1 month (7.4% versus 3.0% for non-depressed peers, adjusted OR 2.20, 95% CI 1.18-4.10) and 12 months (19.0% versus 11.7%, adjusted OR 1.532, 95% CI 1.03-2.24) after aortic valve intervention.
The association held strong whether the patient had TAVR or SAVR, Jonathan Afilalo, MD, MSc, of Jewish General Hospital in Montreal, and colleagues reported online in JAMA Cardiology. Depression persisting to 6 months post-procedure was linked to an especially high risk of mortality at 12 months (OR 2.98, 95% CI 1.08-8.20).
“The clinical implications of our 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. This two-tiered approach is in line with the American Heart Association recommendation to screen for depression with a brief questionnaire and, when the finding is positive, to confirm the diagnosis with a comprehensive expert evaluation,” the authors said.
“Although previous studies focusing on quality of life after TAVR and SAVR reported that mental health, on aggregate, improved in the ensuing months after the procedure, our study identified a vulnerable subset of patients in whom depressive symptoms did not improve but rather persisted or deteriorated and portended a higher risk of death.”
A total of 1,035 participants were included in this analysis of the Frailty Aortic Valve Replacement prospective cohort study, which enrolled participants age 70 years or older who were being treated for symptomatic aortic stenosis across 14 centers.
Just 8.6% had depression documented in their medical record, but 31.5% screened positive for depression in the study. Depression aside, other predictors of death at 1 year were cognitive impairment (adjusted OR 2.31, 95% CI 1.53-3.49) and physical frailty (adjusted OR 2.37, 95% CI 1.38-4.09).
“Our study suggests that depression is underdiagnosed and affects as many as one in three patients in this context,” Afilalo’s group said. The depressed suffered a heavier burden of comorbidities, were more frail, and had at higher risk of mortality to begin with, compared with non-depressed peers.
The investigators admitted that they did not systematically have patients get a formal psychiatric evaluation, so there is some possible misclassification of depression status. Additionally, it was not known who took antidepressants or who was referred to psychiatric specialists after TAVR or SAVR.
“Based on the aforementioned findings, should baseline depressive symptoms now be considered a new, common, and important mortality risk factor after TAVR? From our perspective, this may be a bridge too far,” according to an invited commentary from Amisha Patel, MD, MS, and Martin Leon, MD, both of Columbia University Medical Center in New York City.
They also saw the study’s reliance on a depression questionnaire and possible confounding by other comorbidities and geriatric syndromes as major limitations.
Moreover, the findings from Afilalo’s group do little to guide clinical practice — at least for now, Patel and Leon said: “The identification of depressive symptoms either by questionnaire or by mental health professionals is unlikely to significantly affect aortic valve replacement treatment decisions. The association with mortality is present for both surgery and TAVR, which discourages favoring either therapy in patients with depression. Perhaps the one clinical scenario of relevance is the rare patient with multiple comorbidities and depressive symptoms that are acute and severe, tilting the management in the direction of favoring palliative care.”
“Finally, to our knowledge, there is no evidence that short-term treatment of depressive symptoms in this population by any means, including pharmacotherapy, will either resolve symptoms or affect mortality,” the editorialists continued, adding that additional routine serial screening tests for depression run counter to the goals of minimalist care pathway in TAVR.
These tests “should only be embraced if clinical decision-making is enhanced or clinical outcomes can be improved,” they urged.
Afilalo, Patel, and Leon listed no relevant conflicts of interest.
Study co-authors reported several relationships with industry.
F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner