JCF：抑郁是心衰再入院的强预测因子

尽管在心力衰竭病理生理治疗等方面已经取得了多项进展，且持续有证据证实改善生活方式和药物治疗对心力衰竭有效，但因心衰所致再入院率仍居高不下。65岁以上患有心力衰竭的患者中，大约17%每年至少因心衰相关情况再入院一次，65%则因心衰相关或非相关症状再入院。心衰相关的非必要再入院费用昂贵，平均每次住院费用为9400美元。2004年心衰相关住院的总费用为104亿美元。很明显，有必要对除心衰严重程度及药物治疗以外，可能影响心衰患者再入院的因素进行研究，以理解为何心衰重复入院率如此之高。
相较于普通人群，心衰患者发生抑郁更为常见。在心衰人群中，抑郁被认为与临床预后差相关，包括冠心病发病率增高、服药依从性查和死亡率升高等。芝加哥Rush大学附属医院的 JOHNSON博士，进行了抑郁与心衰在入院率相关性方面的研究。
HART研究（心衰依从性和维持治疗研究）是一项随机行为研究，用以评估是否患者自我管理联合心衰教育能改善患者预后。在研究对象入选时，使用GDS（Geriatric抑郁量表）对患者进行基线评估。使用负二项回归模型对入院次数进行分析，分析因素包括不同随访持续时间患者发作间期。未经调整的平均年住院次数在抑郁组为0.4（GDS评分大于等于10），非抑郁组为0.33（GDS评分小于10）。调整医生对循证医学确认有效药物的处方、患者对心衰药物治疗依从性、疾病严重程度、心衰严重程度（6分钟步行距离小于620尺）以及社会经济学因素后，抑郁为再入院次数的强预测因子（事件率比1.45，P值等于0.006）.
就此，研究者得出结论抑郁是心衰患者重复住院的一项心理学预测隐私。即使医生处方循证有效药物、患者药物治疗依从性好、控制盐摄入，抑郁人群的再入院次数是非抑郁人群的1.45倍。研究结果提示，临床医生应在心力衰竭的治疗过程中注意进行抑郁筛查。
与心衰相关的拓展阅读：

• JACC：左室辅助装置改善终末心衰患者的抑郁和焦虑
• Diabetes Care：糖尿病与心衰患者心脏交感神经活性降低相关
• Circulation：睡眠呼吸障碍增加慢性心衰患者致死性室性心律失常的发生
• EHJ：铁调素水平降低与慢性心衰的不利结果独立显著相关
• Eur Heart J：失眠者发生心衰风险高
• Circulation：CRT对窄QRS心衰患者无效
更多信息请点击：有关心衰更多资讯

Depression predicts repeated heart failure hospitalizations.
OBJECTIVE
Management of depression, if it is independently associated with repeated hospitalizations for heart failure (HF), offers promise as a viable and cost-effective strategy to improve health outcomes and reduce health care costs for HF. The objective of this study was to assess the association between depression and the number of HF-related hospitalizations in patients with low-to-moderate systolic or diastolic dysfunction, after controlling for illness severity, socioeconomic factors, physician adherence to evidence-based medications, patient adherence to HF drug therapy, and patient adherence to salt restrictions.
METHODS AND RESULTS
The Heart Failure Adherence and Retention Trial (HART) was a randomized behavioral trial to evaluate whether patient self-management skills coupled with HF education improved patient outcomes. Depression was measured at baseline with the Geriatric Depression Scale (GDS). The number of hospitalizations was analyzed with a negative binomial regression model that included an offset term to account for the differential duration of follow-up for individual subjects. The average unadjusted number of hospitalizations per year was 0.40 in the depressed group (GDS ≥10) and 0.33 in the nondepressed group (GDS <10). Depression was a strong predictor (incident rate ratio 1.45; P = .006) after adjusting for physician adherence to evidence-based medication use, patient adherence to HF drug therapy, patient adherence to salt restriction, illness severity, HF severity (6-minute walk <620 feet), and socioeconomic factors.
CONCLUSIONS
Depression is a strong psychosocial predictor of repeated hospitalizations for HF. Compared with nondepressed individuals, those with depression were hospitalized for HF 1.45 times more often, even after controlling for physician adherence to evidence-based medications and patient adherence to HF drug therapy and salt restrictions. This finding suggests that clinicians should screen for depression early in the course of HF management.