Depression and long-term prognostic outcomes following peripheral endovascular interventions in the VA Healthcare System

Quality of life for patients with in-stent restenosis after interventional therapy of peripheral artery disease

OBJECTIVE

The aim of this study was to investigate the quality of life for patients with in-stent restenosis after interventional therapy of peripheral artery disease and the influencing factors.

METHODS

A total of 72 in-stent restenosis patients after interventional therapy of peripheral artery disease were enrolled, whose general data were obtained. SF-12 scale was used to evaluate the quality of life. Tilburg Frailty Scale was used to assess senile debilitation. Pittsburgh Quality Index Scale was used to evaluate sleep quality. Activity of Daily Living Scale was used to evaluate the self-care ability. The general data and in-stent restenosis-related indicators were compared between patients with low and high quality of life, respectively. Multivariate regression analysis was made on the factors affecting quality of life.

RESULTS

The average total quality of life score of 72 patients was 74.06±19.26 points. The gender, Fontaine stage and smoking, Activity of Daily Living Scale score, painless walking distance, senile debilitation score, sleep quality score, white blood cells, and C-reactive protein had significant differences between the two groups, respectively (p<0.05). Multivariate regression analysis showed that the female gender, low Fontaine stage (OR=0.186), low senile debilitation score (OR=0.492), and high sleep quality score (OR=0.633) were the protective factors for high quality of life (all p<0.05), and the low Activity of Daily Living score (OR=1.282) was the risk factor for high quality of life (p<0.05).

CONCLUSION

Quality of life of in-stent restenosis patients after interventional therapy of peripheral artery disease is low. Gender, Fontaine stage, senile debilitation, sleep quality, and Activity of Daily Living score are the influencing factors of quality of life for in-stent restenosis patients.

Preoperative Depression is Associated with Worse Outcomes after The Lower Extremity Revascularization

OBJECTIVE

This retrospective study sought to describe the association between preoperative diagnosis of depression and major adverse events after infrainguinal bypass surgery or peripheral vascular intervention (PVI).

METHODS

We retrospectively analyzed a consecutive series of all patients undergoing PVI and/or infrainguinal bypass surgery at a single tertiary institution between 2010 and 2019. Propensity matching and Cox regression analysis were conducted to examine the impact of comorbid depression on the incidence of major adverse events (MAEs), defined as re-intervention, major amputation, or death, within 2 years of surgery.

RESULTS

Of all patients (n = 512) undergoing intervention at our institution, 166 (32.4%) suffered an MAE and 169 (33.0%) patients had a preoperative diagnosis of depression. After propensity score matching, univariate (HR, 1.7; 95% CI, 1.1-2.7) and multivariable hazard analyses (aHR, 1.50; [1.1-2.2]) demonstrate that there is a statistically significant relationship between the diagnosis of depression and increased MAE.

CONCLUSION

Over one-third of our lower extremity revascularization patients were noted to have a preoperative diagnosis of depression. After intervention, these patients had worse outcomes compared to patients without depression; this finding was more evident in patients who underwent PVI mainly due to high overall mortality rate. Prospective studies are necessary to better understand this association and to ascertain if early intervention can improve post-procedure vascular outcomes.

Depression in Patients with Peripheral Artery Disease: An Underdiagnosis with Increased Mortality

BACKGROUND

Among patients with peripheral artery disease (PAD), depression is diagnosed in 17-25% and negatively impacts wound healing, quality of life, and survival. We hypothesized that depression is underdiagnosed in patients with PAD. Additionally, given the associations between depression and mortality in PAD patients, there is an increased need to investigate the strength of this relationship. The present analysis includes 2 studies to address the following aims: (1) Investigation of the prevalence of concomitant PAD and depression in a cohort from the Southeastern United States, and (2) Examination of the association between depression and all-cause mortality in a cohort of Canadian patients with PAD.

METHODS

STUDY 1: From June-August 2022, the Patient Health Questionnaire Module 9 (PHQ-9) was administered to all patients seeking PAD-related care including medical, wound/podiatric, or vascular interventional/surgical treatment, in the University of North Carolina-Chapel Hill Vascular, Wound, and Podiatry clinics. The PHQ-9 assesses symptoms over 2 weeks and is scored 0-27, with higher scores indicating increasingly severe depression. Demographics, primary diagnosis, depression history, and antidepressant prescription were determined through chart review. We compared the proportion of positive depression screenings (PHQ-9 ≥ 5) to known depression. Among those treated for depression, the PHQ-9 score severity was evaluated. T-tests and χ2 tests were used to compare means and proportions. STUDY 2: From July 2015 to October 2016, the Geriatric Depression Scale Short Form was administered to adult patients with PAD undergoing revascularization. The Geriatric Depression Scale Short Form is a self-report measure of depression with a score >5 consistent with depression. The prevalence of depression was determined; primary outcome was all-cause mortality at 6 months.

RESULTS

STUDY 1: In 104 PAD patients (mean age 66.6 ± 11.3 years, 37% female), 37% of respondents scored ≥5 on the PHQ-9 survey, indicating at least mild depression. Only 18% of PAD patients had a history of depression, demonstrating a significant difference between the PHQ-9 findings and documented medical history. While depression was underdiagnosed in both men and women, men were more likely to have unrecognized depression (chi-squared statistic = 35.117, df = 1, P < 0.001). Among those with a history of depression, 74% had a current prescription for antidepressant medication, but 57% still had an elevated PHQ-9 score indicating possible undertreatment. STUDY 2: In 148 patients (mean age 70.3 ± 11.0 years, 39% female) the prevalence of screened depression was 28.4%, but only 3.3% had a documented history of depression suggesting significant underdiagnosis. Patients with depression were significantly more likely to die within 6 months of revascularization (9.5% vs. 0.9%; odds ratio 1.48, 95% confidence interval: 1.08 to 2.29). There was no association between depression and risk of length of stay, reintervention, or readmission.

CONCLUSIONS

Depression is underdiagnosed and undertreated among patients with PAD, which has grave consequences as it is associated with 1.5 times the odds of mortality within 6 months of revascularization. There is a critical need for more robust screenings and comprehensive mental health treatment for patients with concomitant depression and PAD.

Longitudinal Pathways Between Physical Activity, Depression, and Perceived Stress in Peripheral Artery Disease

BACKGROUND

One-fifth of the patients with peripheral artery disease (PAD) experience depression and stress. Depression and stress may impact patients' abilities to be physically active, a key recommendation for supporting overall PAD management to improve symptoms and reduce the risk of cardiovascular events. We aimed to study interrelationships between 1-year longitudinal trajectories of depression, stress, and physical activity following a PAD diagnosis.

METHODS

Patients with new or worsening PAD symptoms enrolled at 10 US PORTRAIT study (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) vascular specialty clinics (CT, LA, MI, MO, NC, OH, and RI) were assessed at baseline, 3, 6, and 12 months between June 2, 2011 and December 3, 2015. Depressive symptoms were measured with the 8-item Patient Health Questionnaire, perceived stress with the 4-item Perceived Stress Scale and physical activity with items from the INTERHEART study. Path analysis was used to examine the longitudinal relationship between depression and physical activity and perceived stress and physical activity.

RESULTS

A total of 766 patients were included (mean age of 68.2 [±9.4] years; 57.7% male). Overall, 17.8% reported significant depressive symptoms, 36.0% experienced increased perceived stress, and 44.1% were sedentary upon PAD diagnosis. A decrease in physical activity preceded a rise in subsequent depressive symptoms (β ranges -0.45 [95% CI, -0.80 to -0.09]; -0.81 [95% CI, -1.19 to 0.42]) over the course of 1 year. Low physical activity scores at the initial presentation were followed by high perceived stress at 3 months (β=-0.44 [95% CI, -0.80 to -0.07]).

CONCLUSIONS

In symptomatic PAD, a decrease in physical activity was followed by an increased risk of depressive symptoms and perceived stress at subsequent intervals over the course of 1 year following PAD diagnosis and treatment. Integrated behavioral health approaches for PAD, addressing physical activity and managing depression or distress, are indicated as collective PAD treatment goals.

Association of depression and anxiety disorders with outcomes after revascularization in chronic limb-threatening ischemia hospitalizations nationwide

OBJECTIVE

Patients with chronic limb-threatening ischemia (CLTI), the end stage of peripheral artery disease, often present with comorbid depression and anxiety disorders. The prevalence of these comorbidities in the inpatient context over time, and their association with outcomes after revascularization and resource usage is unknown.

METHODS

Using the 2011 to 2017 National Inpatient Sample, two cohorts were created-CLTI hospitalizations with endovascular revascularization and CLTI hospitalizations with surgical revascularization. Within each cohort, the annual prevalence of depression and anxiety disorder diagnoses was determined, and temporal trends were evaluated using the Cochran-Mantel-Haenszel test. Hierarchical multivariable logistic and linear regression analyses were used to examine the association of depression and anxiety disorder diagnoses with inpatient major amputation, mortality, length of stay (LOS), and cost, adjusting for illness severity, comorbidities, and potential bias in the documentation of depression and anxiety disorder diagnoses stratified by patient sociodemographic data.

RESULTS

Across the study period were a total of 245,507 CLTI-related hospitalizations with endovascular revascularization and 138,922 with surgical revascularization. Hospitalizations with a depression or anxiety disorder diagnosis increased from 10.8% in 2011 to 15.3% in 2017 in the endovascular revascularization cohort and from 11.7% in 2011 to 14.4% in 2017 in the surgical revascularization cohort (P_trend < .001). In the endovascular revascularization cohort, depression was associated with higher odds of major amputation (odds ratio, 1.15; 95% confidence interval, 1.03-1.30). In addition, depression (9 vs 8 days [P < .001]; $105,754 vs $102,481 [P = .018]) and anxiety disorder (9 vs 8 days [P < .001]; $109,496 vs $102,324 [P < .001]) diagnoses were associated with a longer median LOS and higher median costs. In the surgical revascularization cohort, depression was associated with a higher odds of major amputation (odds ratio, 1.33; 95% confidence interval, 1.13-1.58) and a longer LOS (median, 9 vs 9 days; P = .004).

CONCLUSIONS

Depression and anxiety disorder diagnoses have become increasingly prevalent among CLTI hospitalizations including revascularizations. When present, these psychiatric comorbidities are associated with an increased risk of amputation and greater resource usage.

Comparison of the incidence of depression before and after endovascular treatment in patients with lower limb peripheral artery disease

Depression is a chronic illness that affects mood, physical health, and overall vitality and quality of life. Depression has been associated with an increased risk of all-cause and cardiovascular mortality among patients with peripheral arterial disease (PAD). Therefore, this study aimed to compare the incidence of depression before and after endovascular treatment in patients with lower limb PAD. This is an important clinical issue considering the worldwide increase in PAD with the aging population and the known negative impact of depression on recovery. This was a retrospective sub-analysis of data from the Tokyo Peripheral Vascular Intervention Study using the TOMA-CODE registry. The presence and extent of depressive symptoms were evaluated using the patient health questionnaire (PHQ-9), with a depressive tendency score of ≥ 5. The PHQ-9 score was evaluated before endovascular treatment (EVT) and at 4 (± 1) weeks after EVT. The study population consisted of 87 patients who completed the PHQ-9 before EVT, with 76 completing the post-EVT PHQ-9. Of these 76, 19 had a pre-EVT score ≥ 5. Overall, there was no difference in the pre- and post-EVT scores (P = 0.091). There was no significant change in the 19 patients with a pre-EVT score ≥ 5 (mean 9.2 ± 4.4); however, there was a tendency to improve in the pre- to post-EVT score (mean, 6.9 ± 5.2; P = 0.059). Diabetes was a significant negative factor for pre- to post-EVT score improvement (P = 0.023). Overall, symptoms of depression showed the tendency to improve at 30 days post-EVT. However, diabetes was associated with lower improvement in symptoms.

The association of depression with mortality and major adverse limb event outcomes in patients with peripheral artery disease: A systematic review and meta-analysis

BACKGROUND

Peripheral artery disease (PAD) is highly prevalent and associated with poor outcomes. Depression is a risk factor for adverse outcomes in patients with coronary artery disease. Despite evidence showing that depression is common in patients with PAD, less is known about its association with adverse prognostic outcomes. To address this, we conducted a systematic review and meta-analysis to summarize the association between depression and outcomes in patients with PAD.

METHODS

We performed a systematic search of eight databases to January 2022 including studies that reported a risk estimate for the association of depression or depressive symptoms with all-cause mortality or major adverse limb events (MALE) in patients with PAD and pooled results in a meta-analysis. Risk of bias was assessed using ROBINS-I.

RESULTS

Of the 7048 articles screened, 5 observational studies with 119,123 patients were included. A total of 16.2 % had depression or depressive symptoms. Depression was associated with a statistically significant increased risk of all-cause mortality (HR 1.24, confidence interval 1.07-1.25, p = .005). The association between depression and MALE was not significant but trended toward a positive association.

LIMITATIONS

Due to lack of data, results were limited by a single study with a large sample size, overrepresentation of men, and lack of information of depression severity or treatment status.

CONCLUSION

Depression or depressive symptoms are associated with a 24 % increased risk of all-cause mortality in patients with PAD. Future work should explore the mechanisms and directionality of this association and identify depression as an important comorbidity to address for patients with PAD.

REGISTRATION

PROSPERO CRD 42021223694.

Comorbid Depression is Associated with Increased Major Adverse Limb Events in Peripheral Arterial Disease: A systematic review and meta-analysis

OBJECTIVE

Depression is a significant risk factor for mortality in coronary artery disease. On the contrary, the research surrounding depression and peripheral arterial disease is limited. This review aims to systematically evaluate the available literature on the impact of comorbid depression on adverse outcomes in peripheral arterial disease.

DATA SOURCES

A systematic review and meta-analysis were performed using the following databases: MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Library from inception until July 2021.

REVIEW METHODS

Included studies compared depressed and non-depressed patients with peripheral arterial disease. The outcomes included mortality, major adverse cardiovascular events, and major adverse limb events.

RESULTS

A total of 9 297 articles were searched. Of these, seven studies were identified. Depressed patients were more likely to be women, be diabetic, have a history of smoking, and have chronic limb threatening ischemia, despite being younger than non-depressed patients. There was a 20% increase in major adverse limb events in depressed patients [RR 1.20, 95% CI (1.11 - 1.31), z =3.9, p<.001, GRADE strength: very low] but no increased risk of mortality [RR 1.03, 95% CI (0.72-1.40), z =0.06, p =.95. GRADE strength: very low] or major adverse cardiovascular events [RR 1.16, 95% CI (0.67 - 2.01), z =0.54, p =.59, GRADE strength: very low]. A follow-up meta-regression of various comorbidities and demographic variables did not demonstrate a significant contribution to the observed risk ratio for major adverse limb events.

CONCLUSION

Depression was reported in 13% of peripheral arterial disease patients, associated with more medical comorbidity, and a 20% increased risk of major adverse limb events. Although the strength of this evidence is very low, the current state of the literature is still limited. Future studies should prospectively assess the impact of depression and its relationship with medical comorbidities and high risk health behaviors.

Physical and psychological functioning of patients with chronic limb ischemia during a 1-year period after endovascular revascularization

OBJECTIVE

Symptoms of peripheral artery disease (PAD) and patients' physical and psychological status are related in a vicious circle. The aim of this study was to determine the relationships between improvement in parameters of PAD after endovascular procedures and changes in patients' physical and psychological status.

METHODS

We studied 140 consecutive PAD patients: 50 patients with chronic limb-threatening ischemia (CLTI), 50 patients with intermittent claudication (IC) undergoing an endovascular procedure, and 40 IC patients who were not qualified for leg revascularization. All participating patients were assessed at the beginning of the study and at 3 and 12 months of follow-up; scores taken included: ankle-brachial index, 6-minute walking test distance, Barthel index, activities of daily living (ADL) index, instrumental activities of daily living (IADL) index, Mini-Mental State Examination (MMSE), and Hospital Anxiety and Depression Scale (HADS).

RESULTS

After 12 months of follow-up, an improvement in PAD-related symptoms following leg revascularization had been maintained in 56% of the patients with CLTI and in 68% of those with IC. Twelve months after endovascular leg revascularization, the scores in respect of ADL, IADL, and MMSE had increased, and scores for HADS had decreased in both CLTI and IC patients. A higher baseline score in the IADL index was associated with a reduction in the 1-year cardiovascular event risk (OR; 95% CI: 0.70; 0.54-0.91; P < .01).

CONCLUSIONS

In PAD patients, endovascular procedures not only improved PAD-related symptoms, but also ameliorated patients' physical state, improved cognitive function, and reduced depression.

Relationship Between Depressive Symptoms and Health Status in Peripheral Artery Disease: Role of Sex Differences

Background

The association of depressive symptoms with health status in peripheral artery disease (PAD) is understudied. No reports of differential impact on women have been described.

Methods and Results

The PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Artery Disease Investigating Trajectories) registry enrolled 1243 patients from vascular specialty clinics with new or worsening PAD symptoms. Depressive symptoms were assessed at baseline and 3 months using the 8‐Item Patient Health Questionnaire (score ≥10 indicating clinically relevant depressive symptoms). Disease‐specific and generic health status were measured by Peripheral Artery Questionnaire and EQ‐5D Visual Analogue Scale at baseline and 3, 6, and 12 months. An adjusted general linear model for repeated measures was constructed for baseline and 3‐, 6‐, and 12‐month health status outcomes by depressive symptoms at baseline. Differences by sex were tested with interaction effects. The mean age was 67.6±9.4 years with 38% (n=470) women. More women than men (21.1% versus 12.9%; P<0.001) presented with severe depressive symptoms. In the adjusted model, patients with depressive symptoms had worse health status at each time point (all P<0.0001). Results were similar for EQ‐5D Visual Analogue Scale scores. The magnitude in 1‐year change in health status scores did not differ by sex. Depressive symptoms explained 19% of the association between sex differences in 1‐year Peripheral Artery Questionnaire summary scores.

Conclusions

Women with PAD have a high burden of depressive symptoms. Depressive symptoms were associated with a strikingly worse disease‐specific health status recovery path over the year following PAD diagnosis in men and women. Developing and testing interventions to address depressive symptoms in PAD are urgently needed.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01419080.