1. College of Nursing ● University of Kentucky ● Lexington, KY
The Association of Persistent Symptoms of Depression and Anxiety with Recurrent Acute Coronary Syndrome Events: A Prospective Observational Study
Abdullah S. Alhurani, PhDc, MSN, RN, Gabrielle McKee, PhD,Sharon O’Donnell, PhD, RN, Frances O’Brien, PhD, RN, Mary Mooney, PhD, RN, Martha J. Biddle, PhD, RN , Basel Abdulqader, MSN, RN, CRRN, Terry A. Lennie, PhD, RN FAAN, Debra K. Moser, DNSc, RN, FAAN
College of Nursing ● University of Kentucky ● Lexington, KY
Background
Results
Depression is a mood disorder that affects patients’ ability to perform their basic life activities.
Although many investigators have shown a significant association between depressive symptoms and ACS morbidity and mortality rates, depression is usually only measured once and its co-occurrence with anxiety is rarely considered.
Anxiety can be defined as a negative emotional state that results from a patient perception of threat that interferes with ability to control the situation.
investigators have shown an association between anxiety and poor health outcomes among patients with ACS including morbidity and mortality. Yet, anxiety is rarely studied as a persistent state or in concert with depression.
Persistent depression only (HR 2.27; 95% CI: 1.35 – 3.81; p = ), and comorbid persistent depression and anxiety (HR 2.03; 95% CI: 1.03 – 3.98; p = 0.040) were the significant predictors of a second ACS event. Secondary education level compared to primary educational level (HR 0.63; 95% CI: – 0.93; p = 0.020) and college or more education level compared to primary educational level (HR 0.47; 95% CI: – 0.84; p = 0.011) were the only variables from the demographic and clinical variables that were also significant predictor of a second event., p = 0.002).
Cox Proportional hazard regression of variables associated with ACS second and anxiety and depression treated as categorical variables
Objective
Factor
(Exp) B
Confidence Intervals
P value
Block I
Age
1.00
0.617
Female gender
1.41
0.075
Secondary education compared to primary
College or more compared to Primary
0.60
0.44
0.40 – 0.88
0.25 – 0.78
0.009*
0.005*
Married/living with someone compared to single/separated/widowed/divorced
0.79
0.55 – 1.15
0.220
Block II
0.725
0.92
0.092
0.45
0.41 – 0.89
0.26 – 0.81
0.011*
0.007*
0.54 – 1.15
Smoking history
0.69 – 1.44
0.977
Hypertension history
1.20
0.81 – 1.75
0.362
Diabetes history
0.57 – 1.50
0.743
BMI
1.01
0.98 – 1.05
0.088
Block III (Final Model)
0.944
0.31
0.311
0.63
0.47
0.43 – 0.93
0.27 – 0.84
0.020*
0.81
0.56 – 1.18
0.278
0.96
0.66 – 1.39
0.821
1.19
0.388
0.87
0.53 – 1.41
0.560
0.470
Persistent depression only
2.27
1.35 – 3.81
0.002*
1.81
0.89 – 3.66
0.100
Comorbid Persistent anxiety and depression
2.03
1.03 – 3.98
0.040*
Overall Model (x2= 37.14, df.= 12; P<0.001)
To examine whether co-morbid and persistent symptoms of depression and anxiety are associated with a second ACS event among patient who were previously hospitalized with ACS.
Method
A total of 1162 patients (mean age ± 11.90, male 72.8%, married or living with someone 65.9%) participated from five hospitals in Dublin, Ireland.
Hierarchal Cox regression analyses were used to determine whether co-morbid persistent symptoms of depression and anxiety, independently, predicted a second ACS event among patients previously hospitalized with ACS.
Patients were divided into the following four groups:
patients who had neither persistent depression nor persistent anxiety (n=880).
patients who had persistent depression (n=74).
patients who had persistent anxiety (n=47).
patients who had comorbid persistent depression and anxiety (n=56).
Characteristic
N (%) or Mean ± SD
Age, years
63.45± 11.9
Anxiety (baseline)
10.29 ± 3.69
Anxiety (3 months)
7.97 ± 4.40
Depressive Symptoms (baseline)
18.70 ± 4.46
Depressive Symptoms (3 months)
16.13 ± 6.29
Anxiety and depression categories
No persistent anxiety or depression
Persistent depression only
Persistent anxiety only
Co-morbid persistent anxiety and depression
880 (83.3)
74 (7.0)
47 (4.4)
56(5.3)
Body mass index (BMI)
27.47 ± 4.84
ACS Attitudes
14.13 ± 2.89
Gender
Male
Female
846 (72.8)
316 (27.2)
Marital status
Single / separated/ widowed/ divorced
Married/ Living with someone
396 (34.1)
766 (65.9)
Education level
Little or primary level completed
Secondary level completed
College or higher
417 (35.9)
523 (45.0)
222(19.1)
Current smoker
575 (49.5)
Hypertension
682 (58.7)
Diabetes mellitus
190 (16.3)
Discussion
To improve health outcomes in patient with ACS, attention must be paid by healthcare providers to the assessment and management of persistent depression particularly when it is co-morbid with anxiety.
Results
Another hierarchal Cox regression was run with baseline depression and anxiety treated as categorical level variables and second ACS event as the outcome. None of the four depressions and anxiety variables was significant predictors of ACS second event in this analysis.