© 2002 European Society of Cardiology
Heart failure and depression
University of Florida, College of Medicine 655 West 8th Street, Jacksonville, Florida, 32209, USA
The goals in the treatment of patients with heart failure have been more focused thanks to numerous clinical trials over the last two decades. Surrogate end points no longer carry as much weight as clinical outcomes. Basically, the treatment goals in heart failure are to decrease mortality and to improve patient symptoms. It is not acceptable to improve symptoms but increase mortality (flosequinon), but an increase in symptoms (transiently) with prolonged survival (beta blockers) is now an important strategy. The ‘quality of life’ in heart failure patients has been evaluated in trials but is not systematically analyzed in clinical practice.
Patients with chronic heart failure exhibit many symptoms. These are reviewed on a frequent basis as the patient presents to various medical settings including the outpatient clinic, emergency room and the inpatient facility. Most of the symptoms discussed involve classic problems associated with low output syndromes or abnormal hemodynamics. Predominant are patients’ feelings of fatigue, dyspnea, malaise and limitation of activity. Most heart failure specialists are not aware that these same symptoms can be manifested in patients with normal cardiac outputs and physiologic hemodynamics who are clinically depressed. It is also becoming evident that patients with chronic heart failure symptoms frequently manifest clinical depression [1,2]. This aspect of the illness is not routinely addressed diagnostically or therapeutically.
We are making great strides in identifying the abnormal molecular and cellular mechanisms, which lead to the progression of heart failure. We also assume that interventions to restore a more physiologic homeostasis to the cardiovascular system will lead to an improvement in clinically relevant outcomes such as survival. Measurement of quality of life does not adequately address the depressive state. The diagnosis of depression in ambulatory heart failure patients is not standardized, although use of conventional questionnaires may give an indication of depressive symptoms; a formal interview may more accurately ascertain the presence of clinical depression.
In addition to a potential cause and effect linking heart failure to depression, there may be a common pathophysiologic ground. The inflammatory cytokines appear to play a prominent role in the progression of heart failure. Several large-scale clinical trials have been developed using pharmacologic agents to reduce the toxic effects of cytokines on myocytes with the goal of improving clinical outcomes [3]. There are also data supporting the role of elevated cytokine levels leading to cognitive disturbances including depression [4].
Another promoting factor involves standard therapy for heart failure with beta-blockers, proven to positively alter clinical outcomes in heart failure patients. These agents can potentiate or trigger depression-particularly in the older patient.
There does not appear to be a clear relationship of the pathophysiology of depression and chronic heart failure. Some studies have failed to demonstrate a relationship between severity of heart failure and depression [2]. However, a recent retrospective analysis of patients with heart failure showed an increase in mortality and hospital re-admissions in those patients categorized as having major depression [5]. While the negative prognosis of depression has been noted in coronary artery disease particularly after myocardial infarction [6], this ‘linkage’ is not as consistent in chronic heart failure.
The resolution of this dilemma may be the development of clinical trials in collaboration with psychiatrists and psychologists in order to design protocols and obtain data that directly relate to accurately measuring and assessing the impact of depression in heart failure patients. Perhaps at that point, we will have an accurate assessment of true quality of life.
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[Abstract/Free Full Text] - Jiang W., Alexander J., Christopher E., et al. Relationship of depression to increased risk of mortality and rehospitilization in patients with congestive heart failure. Arch Int Med (2001) 161:1849–1856.
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