Smolderen Kim G, Spertus John A, Reid Kimberly J, Buchanan Donna M, Krumholz Harlan M, Denollet Johan, Vaccarino Viola, Chan Paul S
Center of Research on Psychology in Somatic Diseases, Department of Medical Psychology, Tilburg University, Tilburg, The Netherlands.
Circ Cardiovasc Qual Outcomes. 2009 Jul;2(4):328-37. doi: 10.1161/CIRCOUTCOMES.109.868588. Epub 2009 Apr 25.
Among patients with acute myocardial infarction (AMI), depression is both common and underrecognized. The association of different manifestations of depression, somatic and cognitive, with depression recognition and long-term prognosis is poorly understood.
Depression was confirmed in 481 AMI patients enrolled from 21 sites during their index hospitalization with a Patient Health Questionnaire (PHQ-9) score > or =10. Within the PHQ-9, separate somatic and cognitive symptom scores were derived, and the independent association between these domains and the clinical recognition of depression, as documented in the medical records, was evaluated. In a separate multisite AMI registry of 2347 patients, the association between somatic and cognitive depressive symptoms and 4-year all-cause mortality and 1-year all-cause rehospitalization was evaluated. Depression was clinically recognized in 29% (n=140) of patients. Cognitive depressive symptoms (relative risk per SD increase, 1.14; 95% CI, 1.03 to 1.26; P=0.01) were independently associated with depression recognition, whereas the association for somatic symptoms and recognition (relative risk, 1.04; 95% CI, 0.87 to 1.26; P=0.66) was not significant. However, unadjusted Cox regression analyses found that only somatic depressive symptoms were associated with 4-year mortality (hazard ratio [HR] per SD increase, 1.22; 95% CI, 1.08 to 1.39) or 1-year rehospitalization (HR, 1.22; 95% CI, 1.11 to 1.33), whereas cognitive manifestations were not (HR for mortality, 1.01; 95% CI, 0.89 to 1.14; HR for rehospitalization, 1.01; 95% CI, 0.93 to 1.11). After multivariable adjustment, the association between somatic symptoms and rehospitalization persisted (HR, 1.16; 95% CI, 1.06 to 1.27; P=0.01) but was attenuated for mortality (HR, 1.07; 95% CI, 0.94 to 1.21; P=0.30).
Depression after AMI was recognized in fewer than 1 in 3 patients. Although cognitive symptoms were associated with recognition of depression, somatic symptoms were associated with long-term outcomes. Comprehensive screening and treatment of both somatic and cognitive symptoms may be necessary to optimize depression recognition and treatment in AMI patients.
在急性心肌梗死（AMI）患者中，抑郁症很常见但未得到充分认识。抑郁症的不同表现形式，即躯体症状和认知症状，与抑郁症的识别及长期预后之间的关联尚不清楚。
对来自21个地点的481例AMI患者进行了抑郁症确认，这些患者在首次住院期间使用患者健康问卷（PHQ-9）评分≥10。在PHQ-9中，分别得出躯体症状和认知症状评分，并评估这些领域与病历中记录的抑郁症临床识别之间的独立关联。在另一个包含2347例患者的多地点AMI登记研究中，评估了躯体和认知抑郁症状与4年全因死亡率及1年全因再住院率之间的关联。29%（n = 140）的患者被临床诊断为抑郁症。认知抑郁症状（每标准差增加的相对风险，1.14；95%置信区间，1.03至1.26；P = 0.01）与抑郁症的识别独立相关，而躯体症状与识别之间的关联（相对风险，1.04；95%置信区间，0.87至1.26；P = 0.66）不显著。然而，未经调整的Cox回归分析发现，只有躯体抑郁症状与4年死亡率（每标准差增加的风险比[HR]，1.22；95%置信区间，1.08至1.39）或1年再住院率（HR，1.22；95%置信区间，1.11至1.33）相关，而认知表现则不然（死亡率的HR，1.01；95%置信区间，0.89至1.14；再住院率的HR，1.01；95%置信区间，0.93至1.11）。多变量调整后，躯体症状与再住院率之间的关联仍然存在（HR = 1.16；95%置信区间，1.06至1.27；P = 0.01），但与死亡率的关联减弱（HR = 1.07；95%置信区间，0.94至1.21；P = 0.30）。
AMI后抑郁症在不到三分之一的患者中得到识别。虽然认知症状与抑郁症的识别相关，但躯体症状与长期预后相关。可能需要对躯体和认知症状进行全面筛查和治疗，以优化AMI患者抑郁症的识别和治疗。
