Depression, Cognitive Dysfunction and Increased Mortality in Patients With TAVR

Depression and cognitive dysfunction occur frequently in patients who have transcatheter aortic valve replacement (TAVR) and are independently associated with increased mortality, researchers reported in Circulation: Cardiovascular Interventions.

The prospective registry analysis included patients who received TAVR for native valve aortic stenosis between May 2014 and February 2017 from 11 centers in the United States. All participants (N=884) completed pre-TAVR assessments for depression or cognitive function.

Depression was measured with use of the 2-item Patient Health Questionnaire (PHQ-2), and cognitive function was measured with use of the Mini-Cog test.

Mortality was assessed at the last follow-up, and quality of life was evaluated at 30 days and 1 year. The Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) was used to assess disease-specific quality of life, and the EuroQol visual analogue scale (EQ-VAS) was used for generic quality of life.

Depression screening was positive in 171 of 873 (19.6%) patients, and cognitive dysfunction screening was positive in 273 of 859 (31.8%) participants. Overall, the mean age of participants was older than 80 years, and a majority were men. The median follow-up time was 2.88 (IQR, 1.2-3.7) years.

Baseline depression (hazard ratio [HR], 1.45; 95% CI, 1.13-1.86; P <.01) and cognitive dysfunction (HR, 1.27; 95%, 1.02-1.59; P =.04) were each independently associated with increased mortality in separate models and after adjustment. When depression and cognitive dysfunction were combined in 1 model, mortality was highest among participants with both depression and cognitive dysfunction (HR, 2.19; 95% CI, 1.55-3.10; P <.001) vs those without depression and cognitive dysfunction, which remained significant after adjustment (HR, 2.06; 95% CI, 1.44-2.96; P <.001).

In multivariable analyses, depression was associated with scores 6.6 (95% CI, 0.3-13.6; P =.01) points lower on the 1-year KCCQ-OS, and cognitive dysfunction was not associated with KCCQ-OS 1 year after TAVR. Depression and cognitive dysfunction were independently associated with worse generic quality of life per the EQ-VAS 1 year after TAVR (depression, 6.7 points lower [95% CI, 0.5-12.7; P =.01]; cognitive dysfunction, 5.5 points lower [95% CI, 0.9-9.7; P =.01]).

Among 207 patients who had follow-up PHQ-2 assessments at 1 year, 160 (77.3%) were negative for both evaluations, 24 (11.6%) had depression that resolved at 1 year, 13 (6.3%) had new depression, and 10 (4.8%) had persistent depression.

Limitations of the study include the reliance on screening questionnaires for depression and cognitive dysfunction. Aside from a chart diagnosis of dementia, previous diagnoses of mood and cognitive disorders, or medications used for them, were not accounted for. In addition, data on other post-TAVR endpoints and information on causes of death are not available, and the study is not powered to identify a relationship change in depression status at 1 year and subsequent mortality.

“Using simple, validated screening tools in a multicenter study, depression was identified in approximately 20% and CD [cognitive dysfunction] in one-third of patients undergoing TAVR,” wrote the researchers. “Recognition of depression and CD may improve preprocedural risk stratification and inform prognostic discussions.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.