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      Depresión y su relación con el pronóstico en pacientes con insuficiencia cardíaca

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          Abstract

          Introducción. La depresión tiene un fuerte vínculo en pacientes con insuficiencia cardíaca, influyendo en su morbilidad, mortalidad y tratamiento. Objetivos. Describir las características clínicas, de laboratorio, electrocardiográficas, ecocardiográficas y factores de riesgo cardiovasculares de los pacientes con diagnóstico de insuficiencia cardíaca crónica (ICC) con y sin presencia de diagnóstico probable de depresión. Evaluar la asociación existente entre presencia de depresión y mal pronóstico en pacientes con insuficiencia cardíaca crónica sistólica y/o diastólica. Material y métodos. Se realizó un estudio de cohorte prospectivo en 80 pacientes con diagnóstico de ICC. La evaluación psicológica se realizó con el test de la Organización Mundial de la Salud (OMS) para determinar probabilidad de depresión. Se evaluaron parámetros de laboratorio, clínicos y electrocardiográficos. Se realizó ecocardiograma (modo M y bidimensional) al momento del ingreso al servicio y se consideró tanto la insuficiencia cardíaca sistólica y/o diastólica. Resultados. Se incluyeron 80 pacientes, 38 pacientes con diagnóstico probable de depresión y 42 sin diagnóstico probable de depresión con una edad promedio de 59,53 ± 12,34 vs 66,88 ± 15,67 años, respectivamente; el 49% de sexo femenino. La depresión se asoció significativamente con la edad (59,53 ± 12,34 años vs 66,88 ± 15,67 años; p=0,01), con la presión arterial diastólica (78,82 ± 11,36 mm Hg vs 80,00 ± 11,09 mm Hg; p=0,01), con la presión arterial sistólica (124,08 ± 18,74 mm Hg vs 127,50 ± 14,63 mm Hg; p=0,01), con la frecuencia cardíaca (71,74 ± 10,77 lpm vs 72,85 ± 13,49 lpm; p=0,01), con la creatininemia (11,01 ± 3,42 mg/dL vs 12,63 ± 4,47 mg/ dL; p=0,01), con la natremia (138,82 ± 3,76 mEq/L vs 136,58 ± 3,53 mEq/L; p=0,01), con la hemoglobinemia (13,76 ± 1,56 mg/dL vs 13,01 ± 1,79 mg/dL; p=0,01), con la fracción de eyección del ventrículo izquierdo (56,87 ± 12,69% vs 58,87 ± 12,61%; p=0,01) e infarto agudo de miocardio previo (80,62% vs 54,65%; p=0,01). No se encontró asociación estadísticamente significativa en tipo de IC, clase funcional (según New York Heart Association), en hospitalizaciones y en mortalidad de la población. Conclusión. Aunque la prevalencia de depresión en pacientes con insuficiencia cardíaca tanto sistólica como diastólica es alta, aun serán necesarias nuevas investigaciones y estudios randomizados para completar los conocimientos y detectar tempranamente esta comorbilidad cuyo efecto potencial es negativo en los pacientes con insuficiencia cardíaca.

          Translated abstract

          Depressão e sua relação com o prognóstico em pacientes com insuficiência cardíaca Introdução. A depressão tem um forte vínculo em pacientes com insuficiência cardíaca, influenciando sua morbidade, mortalidade e tratamento. Objetivos. Descrever os fatores de risco clínicos, laboratoriais, eletrocardiográficos, ecocardiográficos e cardiovasculares de pacientes com insuficiência cardíaca crônica (ICC) com e sem diagnóstico provável de depressão. Avaliar a associação entre a presença de depressão e mau prognóstico em pacientes com insuficiência cardíaca crônica sistólica e/ou diastólica. Material e métodos. Um estudo prospectivo de coorte foi realizado em 80 pacientes com diagnóstico de ICC. A avaliação psicológica foi realizada com o teste da Organização Mundial de Saúde (OMS) para determinar a probabilidade de depressão. Os parâmetros laboratoriais, clínicos e eletrocardiográficos foram avaliados. O ecocardiograma (modo M e bidimensional) foi realizado no momento da admissão e foi considerada a insuficiência cardíaca sistólica e/ou diastólica. Resultados. Foram incluídos 80 pacientes, 38 pacientes com provável diagnóstico de depressão e 42 sem diagnóstico provável de depressão com idade média de 59,53 ± 12,34 vs 66,88 ± 15,67 anos, respectivamente; 49% feminino. A depressão foi significativamente associada à idade (59,53 ± 12,34 anos vs 66,88 ± 15,67 anos; p=0,01), com pressão arterial diastólica (78,82 ± 11,36 mm Hg vs 80,00 ± 11,09 mm Hg; p=0,01), com pressão arterial sistólica (124,08 ± 18,74 mm Hg vs 127,50 ± 14,63 mm Hg; p=0,01), com frequência cardíaca (71,74 ± 10,77 bpm vs 72,85 ± 13,49 bpm; p=0,01), com creatininemia (11,01 ± 3,42 mg/dL vs 12,63 ± 4,47 mg/dL; p=0,01), com natremia (138,82 ± 3,76 mEq/L vs 136,58 ± 3,53 mEq/L; p=0,01), com hemoglobinemia (13,76 ± 1,56 mg/dL vs 13,01 ± 1,79 mg/dL; p=0,01), com a fração de ejeção do ventrículo esquerdo (56,87 ± 12,69% vs 58,87 ± 12,61%; p=0,01) e infarto agudo do miocárdio prévio (80,62% vs 54,65%; p=0,01). Não foi encontrada associação estatisticamente significativa no tipo de ICC, classe funcional (de acordo com a New York Heart Association), nas internações e na mortalidade da população. Conclusão. Embora a prevalência de depressão em pacientes com insuficiência cardíaca sistólica e diastólica seja alta, novas investigações e estudos randomizados serão necessários para completar o conhecimento e detectar precocemente esta comorbidade, cujo efeito potencial é negativo em pacientes com insuficiência cardíaca.

          Translated abstract

          Depression and its relation to prognosis in patients with heart failure Introduction. Depression has a strong link in patients with heart failure, influencing its morbidity, mortality and treatment. Objectives. To describe the clinical, laboratory, electrocardiographic, echocardiographic and cardiovascular risk factors of patients with chronic heart failure (CHF) with and without a probable diagnosis of depression. To evaluate the association between the presence of depression and poor prognosis in patients with chronic systolic and/or diastolic heart failure. Material and methods. A prospective cohort study was conducted in 80 patients with a diagnosis of CHF. The psychological evaluation was performed with the World Health Organization (WHO) test to determine probability of depression. Laboratory, clinical and electrocardiographic parameters were evaluated. Echocardiogram (M-mode and two-dimensional) was performed at the time of admission and both systolic and/or diastolic heart failure were considered. Results. We included 80 patients, 38 patients with probable diagnosis of depression and 42 without probable diagnosis of depression with an average age of 59.53 ± 12.34 vs 66.88 ± 15.67 years, respectively; 49% female. Depression was significantly associated with age (59.53 ± 12.34 years vs 66.88 ± 15.67 years, p=0.01), with diastolic blood pressure (78.82 ± 11.36 mm Hg vs 80.00 ± 11.09 mm Hg, p=0.01), with systolic blood pressure (124.08 ± 18.74 mm Hg vs 127.50 ± 14.63 mm Hg, p=0.01), with heart rate (71.74 ± 10.77 bpm vs 72.85 ± 13.49 bpm, p=0.01), with creatininemia (11.01 ± 3.42 mg/dL vs 12.63 ± 4,47 mg/dL; p=0.01), with natremia (138.82± 3.76 mEq/L vs 136.58 ± 3.53 mEq/L; p = 0.01), with hemoglobin levels (13.76 ± 1.56 mg/dL vs 13.01 ± 1.79 mg/dL, p=0.01), with the ejection fraction of the left ventricle (56.87 ± 12.69% vs 58.87 ± 12.61%, p=0.01) and previous acute myocardial infarction (80.62% vs 54.65%, p=0.01). No statistically significant association was found in type of HF, functional class (according to the New York Heart Association), in hospitalizations and mortality of the population. Conclusion. Although the prevalence of depression in patients with both systolic and diastolic heart failure is high, further investigations and randomized studies will be necessary to complete the knowledge and to detect this co-morbidity early, whose potential effect is negative in patients with heart failure.

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          Most cited references38

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          Depression in heart failure a meta-analytic review of prevalence, intervention effects, and associations with clinical outcomes.

          This article describes a meta-analysis of published associations between depression and heart failure (HF) in regard to 3 questions: 1) What is the prevalence of depression among patients with HF? 2) What is the magnitude of the relationship between depression and clinical outcomes in the HF population? 3) What is the evidence for treatment effectiveness in reducing depression in HF patients? Key word searches of the Medline and PsycInfo databases, as well as reference searches in published HF and depression articles, identified 36 publications meeting our criteria. Clinically significant depression was present in 21.5% of HF patients, and varied by the use of questionnaires versus diagnostic interview (33.6% and 19.3%, respectively) and New York Heart Association-defined HF severity (11% in class I vs. 42% in class IV), among other factors. Combined results suggested higher rates of death and secondary events (risk ratio = 2.1, 95% confidence interval 1.7 to 2.6), trends toward increased health care use, and higher rates of hospitalization and emergency room visits among depressed patients. Treatment studies generally relied on small samples, but also suggested depression symptom reductions from a variety of interventions. In sum, clinically significant depression is present in at least 1 in 5 patients with HF; however, depression rates can be much higher among patients screened with questionnaires or with more advanced HF. The relationship between depression and poorer HF outcomes is consistent and strong across multiple end points. These findings reinforce the importance of psychosocial research in HF populations and identify a number of areas for future study.
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            Depression and 18-month prognosis after myocardial infarction.

            We previously reported that major depression in patients in the hospital after a myocardial infarction (MI) substantially increases the risk of mortality during the first 6 months. We examined the impact of depression over 18 months and present additional evidence concerning potential mechanisms linking depression and mortality. Two-hundred twenty-two patients responded to a modified version of the National Institute of Mental Health Diagnostic Interview Schedule (DIS) for a major depressive episode at approximately 7 days after MI. The Beck Depression Inventory (BDI), which measures depressive symptomatology, was also completed by 218 of the patients. All patients and/or families were contacted at 18 months to determine survival status. Thirty-five patients met the modified DIS criteria for major in-hospital depression after the MI. Sixty-eight had BDI scores > or = 10, indicative of mild to moderate symptoms of depression. There were 21 deaths during the follow-up period, including 19 from cardiac causes. Seven of these deaths occurred among patients who met DIS criteria for depression, and 12 occurred among patients with elevated BDI scores. Multiple logistic regression analyses showed that both the DIS (odds ratio, 3.64; 95% confidence interval [CI], 1.32 to 10.05; P = .012) and elevated BDI scores (odds ratio, 7.82; 95% CI, 2.42 to 25.26; P = .0002) were significantly related to 18-month cardiac mortality. After we controlled for the other significant multivariate predictors of mortality in the data set (previous MI, Killip class, premature ventricular contractions [PVCs] of > or = 10 per hour), the impact of the BDI score remained significant (adjusted odds ratio, 6.64; 95% CI, 1.76 to 25.09; P = .0026). In addition, the interaction of PVCs and BDI score marginally improved the model (P = .094). The interaction showed that deaths were concentrated among depressed patients with PVCs of > or = 10 per hour (odds ratio, 29.1; 95% CI, 6.97 to 122.07; P or = 10 PVCs per hour. This result is compatible with the literature suggesting an arrhythmic mechanism as the link between psychological factors and sudden cardiac death and underscores the importance of developing screening and treatment programs for post-MI depression.
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              Depression and immunity: a meta-analytic review.

              A meta-analysis indicated that clinical depression was associated with several large alterations in cellular immunity. Analyzing only methodologically sound studies, reliable immune alterations included lowered proliferative response of lymphocytes to mitogens (effect size rs = .24-.45), lowered natural killer cell activity (r = .28), and alterations in numbers of several white blood cell populations (rs = .11-.77). Immune alterations were greater in both older and hospitalized samples. There was also evidence of a linear relation between intensity of depressive affect and indicators of cellular immunity. Estimates of sample sizes needed to detect reliable effects for each immune outcome are provided. How neuroendocrine mechanisms or health practices might link depression to immunity is discussed, and design features needed to better understand these pathways are specified.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                ic
                Insuficiencia cardíaca
                Insuf. card.
                Comité Insuficiencia Cardíaca (Ciudad Autónoma de Buenos Aires, , Argentina )
                1852-3862
                December 2017
                : 12
                : 4
                : 160-167
                Affiliations
                [05] orgnameComité de Insuficiencia Cardíaca de la Federación Argentina de Cardiología.
                [02] Philadelphia. orgnameDrexel Neuroscience Institute. orgdiv1Drexel University Estados Unidos de Norteamérica.
                [04] San Miguel de Tucumán. Tucumán. orgnameCentro Médico Galbermed. República Argentina.
                [01] Buenos Aires. orgnameServicio de cardiología. orgdiv1Hospital Alemán. República Argentina.
                [03] San Miguel de Tucumán. Tucumán orgnameDiagnóstico cardiovascular. República Argentina.
                Article
                S1852-38622017000400004
                70e2e2b5-565a-44ff-b697-b79972b9fe27

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 04 June 2017
                : 18 September 2017
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 42, Pages: 8
                Product

                SciELO Argentina


                Depresión,Insuficiencia cardíaca,Prevalencia,Diagnóstico,Depressão,Insuficiência cardíaca,Prevalência,Depression,Heart failure,Prevalence,Diagnosis

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