Anxiety and depression as risk factors for mortality after coronary artery bypass surgery

doi:10.1016/j.jpsychores.2007.09.007

Journal of Psychosomatic Research

Volume 64, Issue 3, March 2008, Pages 285-290

https://doi.org/10.1016/j.jpsychores.2007.09.007 Get rights and content

Abstract

Objective

This retrospective study examined the association between symptoms of depression, anxiety, and mortality risk following coronary artery bypass graft (CABG) surgery.

Methods

We assessed 440 CABG surgery patients' scores on the Depression Anxiety and Stress Scale (DASS) and followed up mortality status for a median of 5 years, 10 months.

Results

There were 67 (15%) deaths overall during the follow-up period. Adjusted survival analysis showed that preoperative depressive symptoms were not associated with a significantly higher risk of mortality. Survival analysis with preoperative anxiety adjusted for covariates showed a significantly increased mortality risk [hazard ratio (HR)=1.88 (95% CI=1.12–3.17), P=.02].

Conclusion

Preoperative anxiety symptoms were significantly associated with increased mortality risk after adjustment for known mortality risk factors. Future research should further explore the simultaneous role of anxiety and depression on mortality following CABG.

Introduction

Unipolar depression is underrecognized in people with coronary artery disease (CAD) [1]. Among patients undergoing CABG surgery, the prevalence of clinical depression is consistently reported at around 20% [2], [3]. Subthreshold depressive symptoms in the absence of diagnostic interview is reportedly high, between 32% and 43% [4], [5]. Research further suggests that anxiety is frequently comorbid with depression among CAD outpatients [6], while self-reported anxiety symptoms correlate moderately with depression [7].

Unfortunately, despite treatment for the relief of CAD symptoms, CABG patients with depressive symptoms experience more cardiac morbidity and fatal cardiac events [2], [8]. In the largest study of depression among CABG patients, Blumenthal et al. [9] reported a significantly higher mortality risk for patients with depressive symptoms [hazard ratio (HR) 2.4 (95% CI 1.4–4.0), P=.001] independent of demographic and clinical risk factors. These recent findings highlight the importance of patient's mood state to cardiac surgery outcomes. However, the role of anxiety in long-term mortality has been neglected among CABG patients, despite recognition of its role in short-term morbidity [10].

The limitations of previous post-CABG mortality and depression studies include small sample size and wide confidence intervals [8], [11]. The studies reporting no differences in mortality between depressive and nondepressive patients have used assessments conducted after discharge [4] or have used generic health instruments [12]. Few studies have assessed anxiety in relation to post-CABG mortality despite apparent conceptual and diagnostic overlap with depression [13]. Given the high interrelation shared by anxiety and depression, it is requisite to assess the role of both negative affective states on mortality using a measure with adequate discrimination between their respective symptomatology.

We report findings from a retrospective cross-sectional study on the survival of patients undergoing open-heart surgery and the association with depressive and anxious symptoms using the Depression Anxiety and Stress Scale (DASS) [14]. As the DASS underwent unique psychometric development to maximally discriminate depressive and anxious symptoms, it may avoid the possible confounds of other measures with overlapping factor structures among cardiac patients [15], [16], [17]. The aim of the present study was to assess the association between self-reported depressive mood, anxiety, and mortality outcomes of patients following CABG with or without a concomitant valve procedure.

Section snippets

Patients

The patient sample for this retrospective study consisted of all 1686 consecutive patients undergoing a first-time CABG with or without a concomitant valve procedure using cardiopulmonary bypass (CPB) over a 10-year period—between January 16, 1996, and February 17, 2006. Patients were recruited into ongoing neuropsychological trials, and inclusion criteria were age >18 years, CABG procedure with CPB, and able and willing to provide informed consent. Patients were ineligible for the following

Results

The sample consisted predominantly of males (80%), with a mean age of 64 years, and 33 (8%) patients underwent a concomitant valve replacement (30 aortic, two mitral, 1 aortic and mitral) as shown in Table 1. The crude all-cause mortality was 15% (n=67) within the follow-up period, and 33% (n=22) of these were from cardiac causes, with 28% (n=19) noncardiac causes, while a further 37% (n=25) were unknown according to NDI classification. Comparison of the deceased and alive CABG patients at the

Discussion

This study adds to previous research by showing the postoperative mortality risk associated with depressive and anxious symptoms measured at the time of CABG surgery. In what we believe is the first study reporting both depression and anxiety measures to determine mortality risk after CABG, anxiety symptoms increased all-cause mortality risk. The results of the present study also show a trend towards significance for depression and mortality risk as previous studies have shown [8], [9], [11].

Acknowledgments

The authors acknowledge the assistance of research assistants Dr Marie Ludlow, Heather Soutar, Joclyne Ziatidis, Lisa Hallsworth, and Julia Kuring for their involvement in recruiting patients into the original studies. We thank Thomas Sullivan for his statistical advice.

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^☆: This study received support from the National Heart Foundation and Royal Australasian College of Surgeons.

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Original articleAnxiety and depression as risk factors for mortality after coronary artery bypass surgery☆

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgments

Lancet

Psychosomatics

J Psychosom Res

Lancet

Ann Thorac Surg

Psychiatry Res

Psychiatry Res

Behav Res Ther

Behav Res Ther

J Psychosom Res

J Am Coll Cardiol

Psychosomatics

J Psychosom Res

Am Heart J

J Psychosom Res

Prev Med

J Affect Disord

J Psychosom Res

J Psychosom Res

Depression in patients with coronary artery disease

Depression

Original article
Anxiety and depression as risk factors for mortality after coronary artery bypass surgery☆