CLINICAL RESEARCH: HEART RHYTHM DISORDERS
Depression as a predictor for appropriate shocks among patients with implantable cardioverter-defibrillators
Results from the Triggers of Ventricular Arrhythmias (TOVA) study
William Whang, MD, MS*,*,
Christine M. Albert, MD, MPH*, ,
Samuel F. Sears, Jr, PhD ,
Rachel Lampert, MD ,
Jamie B. Conti, MD,
Paul J. Wang, MD||,
Jagmeet P. Singh, MD, DPhil*,
Jeremy N. Ruskin, MD*,
James E. Muller, MD*,
Murray A. Mittleman, MD, DrPH¶ TOVA Study Investigators
* Cardiovascular Division, Massachusetts General Hospital, Boston, Massachusetts
Division of Preventive Medicine, Brigham and Women's Hospital, Boston, Massachusetts
University of Florida Health Science Center, Gainesville, Florida
Yale-New Haven Medical Center, New Haven, Connecticut
|| Stanford University Medical Center, Stanford, California
¶ Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Manuscript received September 1, 2004;
revised manuscript received November 22, 2004,
accepted December 14, 2004.
* Reprint requests and correspondence: Dr. William Whang, Cardiology Division, Mailstop GRB 109, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114 (Email: wwhang{at}partners.org).
OBJECTIVES: We sought to examine the relationship between symptoms of depression and shock-treated ventricular arrhythmias among implantable cardioverter-defibrillator (ICD) patients.
BACKGROUND: Depression predicts mortality in patients with coronary artery disease (CAD), but whether this is via an increased risk of fatal ventricular arrhythmias is unclear.
METHODS: We prospectively analyzed data on symptoms of depression and risk of ventricular arrhythmia (ventricular tachycardia/ventricular fibrillation [VT/VF]) resulting in ICD discharge in the Triggers of Ventricular Arrhythmias (TOVA) study. Symptoms were assessed by the Center for Epidemiologic Studies-Depression (CES-D) scale. Scores of 16 to 26 and  27 represented mild and moderate/severe depression, respectively. The Cox and Anderson-Gill proportional hazards models were used to test for associations among all patients and patients with CAD.
RESULTS: Among 645 patients with baseline assessments, 90 (14%) were mildly depressed and 25 (3.9%) were moderately to severely depressed. Moderate/severe depression was associated with time to first shock for VT/VF (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.1 to 9.9) and all shocks for VT/VF including recurrent episodes (HR 3.2, 95% CI 1.2 to 8.6). Among the 476 CAD patients, the association with time to first shock (HR 6.4, 95% CI 1.9 to 21.1) and all shocks (HR 8.3, 95% CI 2.9 to 23.3) remained. The risk of shock for VT/VF was associated with depression severity in the total population (p for trend = 0.02) and among patients with CAD (p < 0.01), even after controlling for multiple confounders.
CONCLUSIONS: More severe symptoms of depression predict shocks for VT/VF among ICD patients. The elevated risk of VT/VF among patients with CAD and depression suggests that arrhythmia may contribute significantly to total mortality in this subgroup.
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Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | ARB = angiotensin receptor blocker | | CES-D = Centers for Epidemiologic Studies-Depression | | HRV = heart rate variability | | ICD = implantable cardioverter-defibrillator | | SSRI = selective serotonin reuptake inhibitor | | VT/VF = ventricular tachycardia/ventricular fibrillation |
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