Depression Is Associated with More Severe Angina and Dyspnea in Patients with Chronic Total Occlusion

A study led by Dr. Robert Yeh that was published in JACC: Cardiovascular Interventions showed that in the setting of chronic total occlusion (CTO), patients with depression had more significant angina before percutaneous coronary intervention (PCI). However, these patients also had a greater improvement in health status after PCI.

Depression is commonly encountered in patients with ischemic heart disease and has been linked to refractory angina, especially in patients with recurrent cardiovascular events. However, the prevalence of depression in patients with CTO who undergo PCI is not known. Additionally, whether depression influences symptom improvement after PCI in these patients also remains to be uncertain. The OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) is a registry that enrolled 1,000 patients with CTO who underwent PCI. Using the data from the registry, Dr. Yeh and his team aimed to determine the prevalence of depression in their cohort, assess the association between symptom severity and depression before PCI, and see if the change in symptom severity by 1 year differed in patients with and without depression. Patients were considered depressed if they had a score of 10 points or higher in the Personal Health Questionnaire Depression Scale (PHQ-8). Symptom severity was assessed using the Rose Dyspnea Scale and three domains of the Seattle Angina Questionnaire (Physical limitation, quality of life and angina frequency).

Of the 811 patients included in the study, 190 (23%) had depression at baseline. Patients with depression were more likely younger, female, and have a higher rate of comorbidities including diabetes, congestive heart failure, and chronic kidney disease. Patients with depression at baseline had significantly greater angina (p <0.001) and dyspnea (p< 0.001) than those without depression.  Additionally, patients with depression experienced a significantly greater improvement in their angina than patients without depression (p<0.001). However, there was no difference in dyspnea improvement between patients with and without depression. Although patients with depression had a greater degree of improvement in their angina, both their angina and dyspnea after PCI were more severe than patients without depression. In the 190 patients with depression at baseline, 157 (82.6%) were considered no longer depressed at one year. Of the patients without depression at baseline, 19 out of the 621 patients (2.3%) became depressed by 1 year.

Dr. Yeh offered multiple explanations for the association between depression and worse symptoms. It could be that patients with chronic pain may end up manifesting adverse psychological effects due to recurrent angina, ultimately leading to higher rates of depression. Alternatively, depression could decrease a person’s ability to adapt to chronic pain, which would manifest with more severe symptoms of angina and dyspnea. It has also been shown that patients with depression had lower rates of physical activity and medication compliance which could contribute to the worsening symptoms at baseline. When discussing the significance of the study, Dr. Yeh noted, “This study may provide additional motivation to screen for depression in patients who have a CTO, because untreated depression is associated with poorer health outcomes including reduced quality of life, recurrent events, and death. Furthermore, depression screening and treatment is likely to be of greater impact in CTO patients not that CTO patients should be a target for more concerted depression screening and treatment along with interventional treatment to optimize their care and help them achieve greater symptom benefit.”

In an editorial published with the article, Dr. Stéphane Rinfret emphasized the importance of Dr. Yeh’s findings. He wrote, “This study should be of paramount importance to all physicians, including general practitioners, and noninvasive or interventional cardiologists, dealing with CTO patients. With almost a quarter of patients being depressed, and the majority untreated, it highlights the heartbreaking nature, so to say, of the disease. Reassuring the patient about the “safety” of the chronic condition, in the absence of evidence of increased longevity with successful CTO PCI, is unlikely to help reduce their distress, and can indeed be more upsetting. Many patients would rather sacrifice several years of longevity for a life with improved daily functioning and reduced symptoms.” However, Dr. Rinfret pointed out a limitation in using the Seattle Angina Questionnaire to assess for angina and that is patients with chronic pain would typically refrain from physical activity to avoid having symptoms. These patients would provide negative answers to questions about the presence, severity, and frequency of angina. Dr. Rinfret said that these answers might “reflect [the] absence of angina but are in fact masking a state of poor functional status and impaired QOL caused by the disease.” Finally, Dr. Rinfret stated that “CTO PCI provides hope for patients to recover from a depressive health state, a goal that all of us should strive to achieve for this patient population”.