Baseline depression linked to poorer outcomes in TAVR, SAVR

Symptoms of depression are widespread among elderly patients undergoing aortic valve replacement (AVR) surgery, and the condition is associated with as much as a threefold increase in mortality risk a year after the procedure, researchers reported in JAMA Cardiology this week.

No screening processes for depression currently exist prior to transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) operations, but they could be useful, lead author Jonathan Afilalo, MD, and colleagues wrote in their paper. While depression is increasingly recognized as a risk factor for adverse outcomes in heart disease, little research exists on the impact mental health can have on an AVR patient’s body.

“Previous studies have similarly shown that depression and anxiety are prevalent risk factors for adverse events after cardiac surgery, including SAVR procedures, which is not surprising given the pathophysiologic overlap between aortic valve stenosis and coronary artery disease,” Afilalo et al. wrote.

One study of 912 SAVR patients in 2015 found that self-reported depression and anxiety were linked to worse physical functioning post-op. Another prospective study of valve surgery patients connected pre-procedure depression with more negative outcomes six months after the operation.

Of these studies, none dealt with TAVR, Afilalo and co-authors said, nor did they utilize a validated depression scale or adjust results for cognitive function and physical frailty. Afilalo’s team achieved all three in their five-year review of 1,035 older adults.

Of the individuals enrolled in the Frailty Aortic Valve Replacement (FRAILTY-AVR) prospective cohort study, participants were an average 81 years old and majority women. Procedures took place between Nov. 15, 2011, and April 7, 2016.

Though just 8.6 percent of patients had depression documented in their clinical records pre-trial, 31.5 percent of the pool tested positive for depression at the study’s baseline. At both the beginning of the study and its endpoint, individuals were screened using the Geriatric Depression Scale Short Form, the authors wrote.

After adjusting for clinical and geriatric confounders, Afilalo and colleagues found that persistent depression, which was present at baseline and at least six months after the TAVR or SAVR procedure, was associated with the greatest increase in mortality risk at 12 months. Baseline depression was also tied to poorer mortality rates at 1 and 12 months.

“Our study suggests that depression is underdiagnosed and affects as many as one in three patients in this context,” the researchers wrote. “Beyond the disabling consequences on patient survival and quality of life, depression imparts a large economic, public health and caregiver burden, warranting careful consideration by healthcare clinicians and stakeholders. Clinicians should be vigilant to the evolution of depressive symptoms after surgery, because new or persistent symptoms herald a greater risk of mortality.”

Afilalo et al. suggested pre-SAVR and TAVR screenings for depression to face these risks head-on and intervene if possible. Following up on mental health status up to a year after the procedure could also be useful, they said.

In an accompanying JAMA editorial, Amisha Patel, MD, MS, and Martin B. Leon, MD, questioned the researchers’ work.

“Based on the aforementioned findings, should baseline depressive symptoms now be considered a new, common, and important mortality risk factor after TAVR?” they asked. “From our perspective, this may be a bridge too far.”

Patel and Leon cited several limitations to the study, including the fact that depression screenings were likely based on a questionnaire rather than an interview with a mental health professional. And, though Afilalo’s team attempted to adjust for comorbidities, it’s difficult to completely separate depression from a host of other risk factors that share similar symptoms and outcomes.

Also, the pair of doctors wrote, a current trend in TAVR is a minimalist approach to clinical care. Adding another pre-procedure test “is certainly counter to this simplicity approach.”

“Nevertheless, the findings presented are intriguing and cross the delicate interface of neuropsychiatric disorders and somatic disease,” Patel and Leon said. “The authors should be applauded for embarking on this novel research program and should be encouraged to probe further with additional studies to determine if intensive therapy of depressive symptoms in patients after AVR can improve subsequent outcomes.”