Kathleen Louden

April 04, 2014

CHICAGO — Patients with anxiety or depression who are hospitalized for acute myocardial infarction (AMI) are less likely to receive cardiac catheterization and subsequent angioplasty or bypass surgery than their mentally well counterparts, a new cross-sectional study suggests.

"It's a concern that these patients with anxiety and depression are not getting what is considered the standard of care," study coauthor Jeffrey Bennett, MD, a psychiatrist at Southern Illinois University (SIU) School of Medicine, Springfield, told Medscape Medical News.

In another surprising finding, the investigators reportedly found lower mortality rates after AMI in patients with anxiety and depressive disorders compared with the general population.

Lead author Trinadha Pilla, MD, a resident in psychiatry and internal medicine at SIU, presented the findings here at the Anxiety and Depression Association of America (ADAA) Conference 2014.

Nationally Representative Sample

Using the Nationwide Inpatient Sample database, the investigators analyzed trends in incidence, treatment, and mortality among adults who had an ST-segment elevation myocardial infarction (STEMI) or non-STEMI between 2002 and 2011.

They tracked outcomes in patients with a diagnostic code for anxiety disorders (n = 50,981) or depressive disorders (n = 106,790) at discharge but no other psychiatric disorder, including bipolar disorder and schizophrenia.

These outcomes were compared with those in a random sample of adults who had no mental illness (more than 1.7 million control individuals). In logistic regression analyses, the researchers adjusted for possible confounders, including demographic variables, medical risk factors, hospital location (rural vs urban) and teaching status, and complications.

They found that during the study period, AMI rates decreased in control patients (by 5%) but not in the other 2 groups.

"There has been a dramatic rise in AMI in anxiety and depressive patients over the last 10 years across the whole country," Dr. Pilla said.

This surge was most pronounced for STEMIs, the data showed. The researchers found that patients with depression had 4437 STEMIs in 2002 vs 12,478 in 2011, a 200% increase. Patients with anxiety disorders reportedly experienced a 150% increase in STEMIs during that period: from 2124 in 2002 to 6111 in 2011.

Patients with depressive disorder had a 30% reduced likelihood of undergoing cardiac catheterization during AMI and a 35% decreased likelihood of receiving revascularization with percutaneous transluminal coronary angioplasty (PTCA) compared with control patients who had no coexisting psychiatric disorder, Dr. Pilla reported.

Anxiety disorders were associated with a 10% and 20% decreased likelihood for catheterization and revascularization, respectively.

However, when the investigators compared catheterization rates by type of AMI, patients with anxiety in the STEMI group had a higher rate than control patients did (45.7% vs 41.6%; P < .0001).

Practice guidelines from the American College of Cardiology and the American Heart Association released early in the study period ( Circulation. 2004;110:588-636) recommend that "all STEMI patients should undergo rapid evaluation for reperfusion therapy and have a reperfusion strategy implemented promptly."

The researchers also found differences in the rates of coronary artery bypass grafting (CABG) for the non-STEMI group. They reported that 7.8% of patients with anxiety disorders and 5.5% of those with depression received CABG compared with nearly 8% of the control patients (P < .0001).

For the STEMI group, only patients with depression (5.5%) received CABG significantly less often than the control patients (7.6%; P < .0001). Individuals with anxiety were reportedly more likely to undergo the procedure (7.9%; P < .0001).

Lower Inpatient Mortality

Despite the fact that patients with anxiety and depressive disorders had increased rates of AMI, they were less likely to die in the hospital than their counterparts with no anxiety or depression, the authors noted.

Table. In-hospital Mortality Rates (percent)

Type of Acute Myocardial Infarction Anxiety (n = 50,981) Depression (n = 106,790) Control Patients (n = 1,711,162) P -value
ST segment elevation 4.45 5.48 8.33 < .0001
Non-ST segment elevation 7.48 10.98 13.62 < .0001


Dr. Bennett said that the population with anxiety and depressive disorders may have had a lower inpatient mortality because, compared with the control patients, they had a lower incidence of congestive heart failure and other complications.

Regarding the tendency for patients with anxiety and depression to receive interventional procedures less often, Dr. Pilla speculated that this might be due to patients' difficulties in obtaining or keeping health insurance coverage at that time or to noncompliance with treatment recommendations. Also, hospitals may not have had catheterization, PTCA, and CABG facilities, he added.

On the other hand, he said it may be that physicians are wary of recommending cardiac procedures in this population because of concerns that any existing cognitive and behavioral problems could complicate aftercare.

More research is needed to determine the reasons for treatment discrepancies, said Dr. Bennett, so there are no treatment implications at the moment.

Some Findings Questionable

Asked by Medscape Medical News to comment on the study, Leo Pozuelo, MD, a psychiatrist with Cleveland Clinic's Cardiovascular and Behavioral Health Clinic, in Ohio, said he could not explain the reasons for differences in treatment of AMI in those with anxiety or depressive disorders.

"In clinical practice, these disorders don't preclude us from doing interventions," said Dr. Pozuelo, who did not participate in the study.

He questioned the finding of a lower mortality rate in patients with either of these psychiatric disorders. "There may be a flaw in how the authors looked at this," he suggested.

"For decades, studies have shown that patients with heart disease and concomitant depression have increased morbidity and mortality," Dr. Pozuelo, an expert in depression and heart disease, continued. "We also know that anxiety increases morbidity in heart disease."

The finding that the incidence of AMI is increasing in patients with depression and anxiety makes sense, he said. "We know that depression is a risk factor for heart disease and can make it worse, and that anxiety is also cardiotoxic."

The message for mental health professionals from these study findings, according to Dr. Pozuelo, is that "we should partner with our cardiology colleagues in screening and treating depression and anxiety along with heart disease."

Dr. Pilla and Dr. Bennett report no relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2014. Poster 39. Presented March 28, 2014.


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