Depression Hurts Post-AVR Survival, So Screening, Treatment Urged

January 22, 2018

CHICAGO — Depression is common in patients undergoing surgical or transcatheter aortic valve replacement (AVR) and is independently associated with worsened survival a year after the procedure, especially when it persists, according to a new report based on a prospective observational study.[1]

Of its 1035 elderly patients slated for either procedure, 31.5% tested positive for depression on the Geriatric Depression Scale Short Form (GDS-SF). The rate was 27.5% in patients going to surgical aortic valve replacement (SAVR) and 33.8% of those getting the transcatheter procedure (TAVR).

Those numbers, which some observers question as unrealistically high, contrasted with an 8.6% prevalence of depression based on medical records of the patients, part of the Frailty Aortic Valve Replacement (FRAILTY-AVR) registry.

Still, testing positive for depression at baseline more than doubled the associated mortality risk 1 month after the procedure and raised 1-year mortality by 53% in adjusted analyses. The 1-year risk was most pronounced in such patients, who also tested positive at a 6-month re-evaluation, and was attenuated in those who were positive only at baseline.

Older patients scheduled for TAVR or SAVR should therefore be actively screened for depression before and after the procedures, so that those testing positive can get further psychiatric testing and possible treatment, conclude authors of the report, published January 17 in JAMA Cardiology with lead author Dr Laura M Drudi (Jewish General Hospital, Montreal, QC).

"It's a question of optimizing delivery of care to these patients for issues that are perhaps outside the aortic valve, looking beyond the aortic valve at the whole patient and see how we can improve their global outcome," senior author, Dr Jonathan Afilalo (Jewish General Hospital), told | Medscape Cardiology.

Testing for depression, he said, "should be used as a means of ensuring that patients derive the greatest benefit from this procedure, if it is clinically indicated."

Off by Half?

However, an editorial accompanying the published report raises doubts about the usefulness of routine screening for depression in such patients, contending that it "should only be embraced if clinical decision making is enhanced or clinical outcomes can be improved."[2]

The prevalence of depression in the report seems high, and it is "likely an artifact of using a questionnaire instrument for diagnosis compared with interviews by mental health professionals," write Drs Amisha Patel and Martin B Leon (Columbia University Medical Center, New York, NY).

Either way, identification of depressive symptoms "is unlikely to significantly affect AVR treatment decisions." Because elderly patients going to TAVR or SAVR usually also have coronary artery disease, "and the dominant symptom is usually heart failure, it is difficult to isolate depression caused by valvular disease from these other comorbidities," they write.

"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."

Dr Mary A Whooley (San Francisco Veterans Affairs Medical Center and University of California San Francisco), principal investigator of the Heart and Soul study, was also concerned about the choice of screening tool. For the group's diagnoses of depression, "they used a screening instrument that has very poor specificity, so probably half of the people that they called depressed actually were not," she said in an interview. "They should have called it depressive symptoms rather than depression."

Whooley, who isn't connected to the analysis, is co-developer of the Whooley Questions depression case-finding instrument.

Also, "screening for depression alone has no impact on patient outcomes. It's only when screening for depression is done in the context of a structured care program, with a nurse manager in place to follow up and make sure that the patient gets treated, goes to therapy, and takes their medications," she said.

"Patients should be screened for depression once a year by their primary care providers, but I don't think that depression screening should be done by surgeons or cardiologists." Those specialties aren't set up "to provide that kind of structured follow-up," according to Whooley.

"We Don't Necessarily Ask the Question"

The FRAILTY-AVR authors do state that "clinicians should be cautious not to rely solely on questionnaire instruments to diagnose depression." And Afilalo acknowledges that "the true prevalence of depression" in the cohort is probably "somewhere between" the rate they identified and the rate based on the patients' medical records.

"There is certainly an under-recognition of depression in the clinical record," he said. "We don't necessarily ask the question; we don't necessarily screen for depression systematically."

Because the study's screening tools could not reliably distinguish between clinical depression and depression-like symptoms caused by heart failure, "it's recommended to confirm the diagnosis with more in-depth psychological evaluation before beginning to consider antidepressant therapy, whether pharmacological or nonpharmacological," he agreed.

"That being said, the depression screening tool was predictive of outcomes irrespective of whether it was reflecting true depression or, say, a pseudo-depression. So I think it remains valid as a predictive tool."

Moreover, the authors note, the questionnaire screening "identified a vulnerable subset of patients in whom depressive symptoms did not improve but rather persisted or deteriorated and portended a higher risk." One-year mortality was tripled for the cohort's patients who tested positive at baseline as well as 6 months after the procedure.

That's consistent with expectations, Whooley said, because patients with depressive symptoms more due to heart failure, in contrast to those with true clinical depression, should have fewer symptoms at 6 months.

"So it doesn't make sense to screen until maybe a few weeks after procedure, after the patient feels better due to valve replacement."

Patients Testing Positive Were Sicker

The current analysis from FRAILTY-AVR included stable patients age 70 years or older (mean, 81.4 years), of whom 59% were women, slated for TAVR or SAVR from November 2011 to April 2016 at 14 centers in Canada, the United States, and France.

They were screened for depression by using the GDS-SF; for frailty with the Short Physical Performance Battery test and according to Fried criteria; and for cognitive ability using the Mini-Mental State Examination.

At baseline, patients with depression had been more likely than others to have diabetes, chronic kidney disease, hypertension, chronic obstructive pulmonary disease, and cerebrovascular disease and to test positive for frailty and cognitive impairment.

Such differences were at least partly considered in multivariate analyses that controlled for age, sex, physical frailty, cognitive impairment, Society of Thoracic Surgeons (STS) predicted risk, mortality, and whether the procedure was SAVR or TAVR, among other things.

With those adjustments, depression at baseline was a significant predictor of all-cause mortality at 1 month, with an odds ratio (OR) of 2.20 (95% CI, 1.18–4.10). That wasn't true for cognitive impairment or frailty, but at 1 year, depression remained a significant predictor; it was joined by cognitive impairment and frailty.

Table. Odds Ratio for Mortality 1 Year After AVR, by Screening Test Resultsa

Screening Test Result OR (95% CI)
Depression 1.53 (1.03–2.24)
Cognitive impairment 2.31 (1.53–3.49)
Physical frailty 2.37 (1.38–4.09)
aAdjustment included age, sex, physical frailty, cognitive impairment, STS risk score, mortality, and whether SAVR or TAVR was done.


Patients who tested positive for depression at both baseline and at the 6-month assessment, 11.3% of the cohort, showed a 12-month mortality risk at an OR of 2.98 (95% CI, 1.08–8.20).

The 18.4% of patients who tested positive at baseline but not at 6 months and the 11.1% testing positive for the first time at 6 months showed a much weaker mortality risk increase or no increase at all.

Afilalo said the group's conclusions probably would have been similar had patients younger than age 70 years not been excluded from the analysis. "At the time the study was conducted, TAVR was still only being performed for high- and extreme-risk patients. For the most part it predated the evidence to support TAVR in intermediate-risk patients. So it's very unlikely that even if we had included all ages, we would have captured a significant additional number of TAVR patients."

Afilalo, Drudi, Patel, and Leon have disclosed no relevant financial relationships. Disclosures for the other authors are in the report.

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