Fosbøl Emil Loldrup, Gislason Gunnar H, Poulsen Henrik Enghusen, Hansen Morten Lock, Folke Fredrik, Schramm Tina Ken, Olesen Jonas Bjerring, Bretler Ditte-Marie, Abildstrøm Steen Z, Sørensen Rikke, Hvelplund Anders, Køber Lars, Torp-Pedersen Christian
Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark.
Circ Heart Fail. 2009 Nov;2(6):582-90. doi: 10.1161/CIRCHEARTFAILURE.109.851246. Epub 2009 Sep 22.
Depression worsens the prognosis in patients with cardiac disease, and treatment with antidepressants may improve survival. Guidelines recommend use of selective serotonin reuptake inhibitors (SSRIs), but knowledge of the prognostic effect of different classes of antidepressants is sparse.
We studied 99 335 patients surviving first hospitalization for heart failure (HF) from 1997 to 2005. Use of HF medication and antidepressants (divided into tricyclic antidepressants [TCA] and SSRI) was determined by prescription claims. Risk of overall and cardiovascular death associated with antidepressants, HF medication, and coadministration of these 2 drug classes was estimated by Cox proportional hazard analyses. Propensity adjusted models were performed as sensitivity analysis. During the study period, there were 53 988 deaths, of which 83.0% were due to cardiovascular causes (median follow-up, 1.9 years; 5, 95% fractiles, 0.04 to 7.06 years). Use of beta-blockers was associated with decreased risk of cardiovascular death (hazard ratio [HR], 0.77; 95% CI, 0.75 to 0.79). Antidepressants were prescribed to 19 411 patients, and both TCA and SSRI were associated with increased risk of overall and cardiovascular death (TCA: HR, 1.33; CI, 1.26 to 1.40; and HR, 1.25; CI, 1.17 to 1.32; SSRI: HR, 1.37; CI, 1.34 to 1.40; and HR, 1.34; CI, 1.30 to 1.38, respectively). Coadministration of SSRI and beta-blockers was associated with a higher risk of overall and cardiovascular death compared with coadministration of beta-blockers and TCA (P for interaction <0.01).
Use of antidepressants in patients with HF was associated with worse prognosis. Coadministration of SSRIs and beta-blockers was associated with increased risk of overall death and cardiovascular death compared with coadministration of TCAs and beta-blockers. To further clarify this, clinical trials testing the optimal antidepressant strategy in patients with HF are warranted.
抑郁症会使心脏病患者的预后恶化，而使用抗抑郁药可能会提高生存率。指南推荐使用选择性5-羟色胺再摄取抑制剂（SSRI），但对于不同种类抗抑郁药的预后效果了解甚少。
我们研究了1997年至2005年首次因心力衰竭（HF）住院后存活的99335例患者。通过处方记录确定HF药物和抗抑郁药（分为三环类抗抑郁药[TCA]和SSRI）的使用情况。通过Cox比例风险分析评估与抗抑郁药、HF药物以及这两类药物联合使用相关的全因死亡和心血管死亡风险。进行倾向调整模型作为敏感性分析。在研究期间，有53988例死亡，其中83.0%是由心血管原因导致的（中位随访时间为1.9年；第5和第95百分位数分别为0.04至7.06年）。使用β受体阻滞剂与心血管死亡风险降低相关（风险比[HR]为0.77；95%置信区间为0.75至0.79）。19411例患者使用了抗抑郁药，TCA和SSRI均与全因死亡和心血管死亡风险增加相关（TCA：HR为1.33；置信区间为1.26至1.40；HR为1.25；置信区间为1.17至1.32；SSRI：HR分别为1.37；置信区间为1.34至1.40；HR为1.34；置信区间为1.30至1.38）。与β受体阻滞剂和TCA联合使用相比，SSRI和β受体阻滞剂联合使用与全因死亡和心血管死亡风险更高相关（交互作用P<0.01）。
HF患者使用抗抑郁药与更差的预后相关。与TCA和β受体阻滞剂联合使用相比，SSRI和β受体阻滞剂联合使用与全因死亡和心血管死亡风险增加相关。为进一步阐明这一点，有必要进行临床试验来测试HF患者的最佳抗抑郁策略。
