Registered nurses' experiences of caring for patients with hypoactive delirium after cardiac surgery - A qualitative study.

OBJECTIVES: Delirium is a common post-cardiac surgery complication that presents as acute changes in mental abilities with confused thinking and a lack of awareness of the surroundings. Delirium symptoms present in hyperactive- and hypoactive forms. Hypoactive delirium is often overlooked. Although nursing interventions are important in preventing and treating hypoactive delirium, studies focusing on nurses' experiences of hypoactive delirium are scarce. This study describes registered nurses' experiences of caring for patients with hypoactive delirium after cardiac surgery. RESEARCH METHODOLOGY/DESIGN: This was a qualitative descriptive study with an inductive approach. Data was collected through focus group interviews with 12 registered nurses with experience in caring for cardiac surgery patients with hypoactive delirium. The study complied with the Consolidated Criteria for Reporting Qualitative Research. SETTING: A cardiac surgery department at a Swedish University Hospital. FINDINGS: The analysis resulted in one main category; "Navigating the complexities of care when caring for patients with hypoactive delirium" and three sub-categories: "Challenges, "Nursing interventions" and "Promoting a team approach". CONCLUSION: Delirium assessment and nursing interventions are perceived as essential yet demanding. when caring for patients with hypoactive delirium. Nursing interventions like maintaining the circadian rhythm and offering emotional support need to be prioritised by the nurses, in line with the autonomy of the registered nurse's profession. Moreover, the team around the patient is crucial for detecting and treating hypoactive delirium, and it is important to involve other professionals as well as the patient's relatives. Future research is needed to develop assessment instruments that more accurately capture hypoactive delirium in the postoperative setting. IMPLICATIONS FOR CLINICAL PRACTICE: Despite the use of screening tools, nurses still experience challenges in detecting the symptoms of hypoactive delirium, indicating a need for more clinically effective screening tools for hypoactive delirium. Nursing interventions are emphasised in the care of patients with hypoactive delirium.

Self-reported preoperative depressive symptoms and survival after cardiac surgery.

OBJECTIVES: Depression has been associated with increased cardiovascular morbidity and mortality. This study aimed to determine whether self-reported preoperative depressive symptoms were associated with worse long-term survival in patients undergoing cardiac surgery. METHODS: This population-based, observational cohort study included patients who had undergone cardiac surgery at Karolinska University Hospital between 2013 and 2016. Self-reported data about depressive symptoms were collected using the Patient Health Questionnaire (PHQ-9) and other patient data were collected from the institutional surgical database and medical charts. Depression was defined as a PHQ-9 score ≥10. Weighted flexible parametric survival models were used to estimate the association between self-reported preoperative depressive symptoms and all-cause mortality and to quantify absolute survival differences. RESULTS: Of the 1120 study patients, 162 (14.5%) had depressive symptoms before cardiac surgery. During a mean follow-up of 7.2 years (maximum, 9.2 years), there were 36 deaths in 1129 person-years (PYs) in the depressed group, compared to 160 deaths in 6889 PYs in the non-depressed group. In the adjusted analysis, self-reported depressive symptoms were associated with worse long-term survival (hazard ratio 1.66; 95% confidence interval 1.09-2.54) compared with no reported depressive symptoms. The absolute survival differences (% and 95% confidence interval) between the non-depressed and the depressed patients were -1.9 (-3.9 to 0.19), -5.7 (-11 to -0.01) and -9.7 (-19 to -0.4) after 1, 5 and 8 years, respectively. CONCLUSIONS: Self-reported preoperative depressive symptoms were associated with worse long-term survival following cardiac surgery and should be regarded as important as other classical risk factors.

Prevalence of abdominal aortic aneurysm (AAA) in first-degree relatives: detecting AAA in adult offspring of AAA patients.

BACKGROUND: First-degree relatives of patients with abdominal aortic aneurysm (AAA) may have an increased risk of developing the disease. The primary aim was to report the prevalence of AAA in adult male and female offspring of patients with AAA. The secondary aim was to explore the efficiency of a registry-based detection route, and the third aim was to report contemporary prevalence in the population. METHODS: Adult offspring of individuals with AAA and matched controls were identified through national registries. The examination included questionnaires and ultrasound examinations of the infrarenal aorta. Aortic pathology was defined as an aortic diameter ≥25 mm, AAA ≥30 mm. RESULTS: The participation rate among male and female adult offspring was 64% (350/543) and 69% (402/583), respectively. A lower participation rate was found in male and female controls (51% and 52%). No difference in prevalence of AAA was observed between male adult offspring and controls (0.9%, c.i. 0.2 to 2.3%) or in the female population (prevalence of 0.2% in adult offspring and controls). Aortic pathology and previously diagnosed AAA were detected in 5.3% (c.i. 3.3 to 8.0%) of male adult offspring and 2.3% (c.i. 1.1 to 4.2%) in controls. Aortic pathology was more prevalent among adult offspring of females with AAA. CONCLUSION: The prevalence of AAA in the general population is low, but aortic pathology is notably higher among male first-degree relatives. Increased awareness should be directed towards individuals with a possible hereditary predisposition, particularly offspring of females with AAA and older smokers. Risk factor-based targeted screening of adult offspring of patients with AAA after registry-based detection should be further explored. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT4623268.

Suffering in silence - Cardiac surgery patients recalling hypoactive delirium a qualitative descriptive study.

OBJECTIVES: Postoperative delirium affects up to 50% of patients undergoing cardiac surgery. Delirium phenotypes are commonly divided into hyperactive and hypoactive, with hypoactive symptoms (reduced motor activity and withdrawal) often being overlooked due to their discreet character. Although the consequences of hypoactive delirium are severe, studies focusing on patients' experiences of hypoactive delirium are scarce. The aim of the study was to describe cardiac surgery patients' experiences of hypoactive delirium. RESEARCH METHODOLOGY/DESIGN: We used qualitative descriptive semi-structured interviews with an inductive, latent approach. Twelve patients with hypoactive symptoms of delirium after cardiac surgery were purposefully selected. Interview data were analysed by qualitative content analysis. FINDINGS: Two themes based on eight sub-themes emerged. "Dream or reality in parallel worlds" included disturbing experiences of existing in parallel realities with cognitive effects, residual nightmares, and illusions that occasionally persisted after hospital discharge. "Managing the state of hypoactive delirium" included experiences of intellectually dealing with hypoactive delirium with assumptions of causes and cures, and through interactions like communicating with others. CONCLUSION: Participants experienced hypoactive delirium as extensive and long-lasting with perceptions of existing in parallel realities. The findings emphasize the need for healthcare professionals to have expertise in hypoactive delirium and its fluctuating course, as the delirium of many patients may be undetected and undiagnosed. Improving the use of screening tools for clinical practice is essential for the detection of hypoactive delirium, and a person-centred approach is needed to properly care for this group of patients. IMPLICATIONS FOR CLINICAL PRACTICE: The challenges in the recognition of hypoactive delirium need to be emphasized because the syndrome is still overlooked. The use of screening tools in clinical practice is essential. A person-centred approach supports relationships between delirious patients and healthcare professionals.

Women with large intact abdominal aortic aneurysms remain untreated.

OBJECTIVE: A lower elective repair rate among women with abdominal aortic aneurysms (AAAs) has been a consistent finding. Reasons behind this gender gap have not been thoroughly outlined. METHODS: This was a retrospective multicenter cohort study (ClinicalTrials.gov: NCT05346289) at three European vascular centers in Sweden, Austria and Norway. Patients in surveillance with AAAs were consecutively identified starting from January 1, 2014, until reaching a total sample size of 200 women and 200 men. All individuals were followed for 7 years through medical records. Final treatment distributions and the proportion of "truly untreated" (surgically untreated despite reaching guideline-directed thresholds: 50 mm for women and 55 mm for men) were determined. In a complementary analysis, a universal 55-mm threshold was used. Gender-specific primary reasons behind untreated statuses were clarified. Eligibility for endovascular repair among the truly untreated was assessed in a structured computed tomography analysis. RESULTS: Women and men had similar median diameters at inclusion (46 mm; P = .54) and at treatment decisions (55 mm; P = .36). After 7 years, the repair rate was lower among women (47% vs 57%). More women were truly untreated (26% vs 8%; P < .001) despite similar mean ages as for male counterparts (79.3 years; P = .16). With the 55-mm threshold, 16% women still classified as truly untreated. Similar reasons for nonintervention were captured for women and men (50% due to comorbidities alone, 36% morphology and comorbidity). The endovascular repair imaging analysis revealed no gender differences. Among truly untreated women, ruptures were common (18%), and mortality was high (86%). CONCLUSIONS: Surgical AAA management differed between women and men. Women could be underserved in terms of elective repairs: one in every four women was untreated with over-the-threshold AAAs. The lack of obvious gender differences in eligibility analyses could imply unmeasured discrepancies (eg, in disease extent or patient frailty).

Risk of depression after coronary artery bypass grafting: a SWEDEHEART population-based cohort study.

Aims: A diagnosis of depression in patients with coronary heart disease is associated with worse outcomes. This study examined the long-term risk for new onset of depression after coronary artery bypass grafting (CABG) compared to an age- and sex-matched control group from the general population. Methods and results: In total, 125 418 primary isolated CABG patients and 495 371 matched controls were included from 1992 to 2017. The SWEDEHEART registry and three other national registers were used to acquire information about baseline characteristics and depression. The adjusted risk of depression was estimated by using Cox regression models adjusted for patient characteristics, and socioeconomic variables, described by hazard ratios (HR) and 95% confidence intervals (CI). In total, 6202 (4.9%) CABG patients and 17 854 (3.6%) controls developed depression. The cumulative incidence of depression was higher in CABG patients than in the control population [6.1%, 95% CI 6.0-6.3 vs. 4.7% (4.7-4.8), P < 0.0001]. Overall, the CABG group had a marginally increased adjusted risk of depression compared to controls [adjusted HR (aHR): 1.05 (1.01-1.09), P = 0.0091]. In age-specific analyses, the increased risk compared to controls was only present in patients <65 years [aHR: 1.19 (1.11-1.27), P <0.0001] and was only evident during the first 5 years after surgery. Conclusion: Patients who underwent CABG had a higher risk of new onset of depression compared to sex- and age-matched controls in the general population. The risk of depression was especially pronounced in younger patients during the first 5 years after surgery.

Depression is associated with delirium after cardiac surgery-a population-based cohort study.

OBJECTIVES: Depression is common in patients with cardiac disease, and preoperative depression is associated with worse outcomes after cardiac surgery. Depression is also correlated with postoperative delirium (POD) after major surgery. However, the association between preoperative depression and POD after cardiac surgery is sparsely studied. The aim of this study was to investigate depression as a predictor for POD in cardiac surgery patients. METHODS: This population-based cohort study included 1133 cardiac surgery patients in Stockholm 2013-2016. Depression was defined by the Patient Health Questionnaire-9, and POD was evaluated by assessing medical records for symptoms of POD according to Diagnostic and Statistical Manual of Mental Disorders criteria. The association between depression and POD was determined through multivariable logistic regression analysis. RESULTS: A total of 162 (14%) individuals reported depressive symptoms preoperatively. The incidence of POD was 26% and highest among elderly patients. Among patients with depression, 34% developed POD. In the group of non-depressed patients, 24% developed POD. The overall adjusted odds of delirium were 2.19 times higher in individuals with depressive symptoms compared to controls (95% confidence interval 1.43-3.34). The onset of delirium was most common on Days 0-2 after surgery. CONCLUSIONS: This unique population-based study in patients undergoing cardiac surgery shows that preoperative depression is associated with POD in a large proportion of treated patients. The findings support the need for improved preoperative screening for depression, especially in younger patients, and enhanced clinical surveillance in the early postoperative period for all patients.

Prognostic impact of depressive symptoms on all-cause mortality in individuals with abdominal aortic aneurysm and in the general population: a population-based prospective HUNT study in Norway.

BACKGROUND: Abdominal aortic aneurysm (AAA) is a potentially life-threatening disease but the high mortality rate is linked to high age and comorbidity pattern. Depression is associated with increased mortality in the general population and individuals with cardiovascular diseases, but this is sparsely studied for AAA. The aim was to examine the prognostic impact of depressive symptoms on all-cause mortality in individuals with AAA and compare with findings in a general population of the same age and risk profile. METHODS: Population-based prospective study including 36 616 participants (52.1% women) from the Trøndelag Health Study in Norway. A total of 9428 individuals died during a median follow-up of 10 years at ages 60-90 years. Depressive symptoms were defined by a Hospital Anxiety and Depression Scale-Depression score ≥8. Data on AAA diagnoses and death were obtained from medical records and national registers. HRs from Cox proportional hazard regression models are reported. RESULTS: A total of 4832 (13.2%) individuals reported depressive symptoms, whereas 583 (1.6%) AAAs were identified. The adjusted hazard of death was 2.66 times higher in persons with AAA compared with the general population (95% CI 2.39 to 2.97). Overall, there was no significant adverse effect of depressive symptoms in individuals with AAA (HR 1.15;95% CI 0.88 to 1.51), whereas an increased risk was seen in the general population (HR 1.23;95% CI 1.17 to 1.30). CONCLUSION: The overall risk of death was considerably higher in individuals with AAA compared with a general population of the same age and risk profile. Depressive symptoms did not significantly influence the risk of death in the AAA group.

Depression as a predictor of postoperative delirium after cardiac surgery: a systematic review and meta-analysis.

OBJECTIVES: Depression is common in patients with cardiac disease. The importance of preoperative depression for development of postoperative delirium (POD) following cardiac surgery is not well known. The aim is to provide a summary estimate of depression as a predictor of POD following cardiac surgery. METHODS: Systematic search of MEDLINE, EMBASE, Cochrane Library, Web of Science Core Collection and Psycinfo (Ovid) was performed from inception to October 2019, including cohort studies reporting odds ratios (ORs) and 95% confidence intervals (CIs) for POD following cardiac surgery in patients with preoperative depression compared to patients without depression. ORs and 95% CIs for POD were calculated using random-effects meta-analyses. Subgroup and sensitivity analyses were performed. RESULTS: Seven studies were included with a combined study population of 2066 patients. The pooled prevalence of POD in the combined study population was 26% and preoperative depression was present in ∼9% of the total study population. All studies showed a positive association between preoperative depression and POD; and in 5 studies, the association was statistically significant. Patients with depression had a pooled OR of 2.31 (95% CI 1.37-3.90) for POD. CONCLUSIONS: This systematic review and meta-analysis confirm the findings that the previous association between preoperative depression and increased risk for developing POD reported for other patient groups is found also in cardiac surgery. Depression screening prior to cardiac surgery may be effective in identifying patients at higher risk for POD.

Sex Differences in Rupture Risk and Mortality in Untreated Patients With Intact Abdominal Aortic Aneurysms.

Background Studies on intact abdominal aortic aneurysms mainly focus on treated patients, and data on untreated patients are sparse. The objective was to investigate sex differences among untreated patients regarding rupture and mortality rates and to determine predictors for these events. Sex-specific causes of death were evaluated. Methods and Results All patients ≥40 years diagnosed from 2001 to 2015 (n=32 393) with intact abdominal aortic aneurysms were identified in national registries; 60% (n=19 569) were untreated. Comorbid loads, crude rupture, and mortality rates were assessed. Predictors of 5-year rupture and mortality were analyzed in Cox models (sex, age, comorbidities, income, and marital status). The proportion of men and women with multiple comorbidities was similar. Within 5 years, 798 ruptures occurred (9.7% women versus 6.9% men, P<0.001). Ruptures were independently predicted by female sex (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; P=0.004), chronic obstructive pulmonary disease (HR, 1.36; 95% CI, 1.15-1.62; P<0.001), age (HR, 11.49; 95% CI, 5.68-23.25 for ≥80 years; P<0.001), and income (HR, 0.63; 95% CI, 0.53-0.75 for highest tertile; P<0.001). After 5 years, 56.5% women and 50.4% men were deceased. Mortality was not independently predicted by female sex. Rupture was the third most common cause of death (11.9% women versus 8.7% men; P<0.001). The median time-to-events was 2.8 years. Conclusions A considerable proportion of patients with intact abdominal aortic aneurysms in surveillance remain untreated. Despite surveillance algorithms, the healthcare system fails to prevent a high number of ruptures, especially among women. The time-to-event data highlight the urgency to develop more individualized surveillance.

Depressive and/or anxiety scoring instruments used as screening tools for predicting postoperative delirium after cardiac surgery: A pilot study.

BACKGROUND: Depression is common in patients with cardiac disease. Depression is a risk factor for developing postoperative delirium, a common and serious complication to cardiac surgery. OBJECTIVES: The aim was to evaluate if screening tools for depression can be used to predict postoperative delirium after cardiac surgery. METHODS: This was a prospective population-based pilot study including 26 patients between 23 and 80 years of age undergoing cardiac surgery in Sweden during 2018. The day before surgery the participants filled out the depression screening instruments Hospital Anxiety and Depression Scale and Patient Health Questionnaire. After discharge the patient charts were examined for documentation of symptoms of delirium. RESULTS: Five (20%) patients screened positive regarding depression using the Hospital Anxiety and Depression Scale and 7 patients (27%) screened positive using The Patient Health Questionnaire. Four (22%) patients showed symptoms of postoperative delirium, none of them screened positive for depression prior to surgery. CONCLUSION: We found no difference between the questionnaires PHQ-9 and HADS regarding identifying depressive symptoms. Moreover, we found that post-operative delirium, to a certain extent, can be detected by reading the patient́s charts postoperatively. However, this pilot study showed that screening tools for delirium need to be better implemented.

Symptoms of Depression and Risk of Abdominal Aortic Aneurysm: A HUNT Study.

Background Depression is associated with cardiovascular diseases, but the evidence is scarce regarding depression and risk of abdominal aortic aneurysms (AAA). The aim was to determine whether individuals with depressive symptoms have increased risk of AAA. Methods and Results This population-based prospective study included 59 136 participants (52.4% women) aged 50 to 106 years from the HUNT (Norwegian Nord-Trøndelag Health Study). Symptoms of depression were assessed using the depression subscale of the Hospital Anxiety and Depression Scale (HADS). During a median follow-up of 13 years, there were 742 incident cases of AAA (201 women). A total of 6401 individuals (12.3%) reported depressive symptoms (defined as HADS depression scale [HADS-D]) ≥8) (52.5% women). The annual incidence rate of AAA was 1.0 per 1000 individuals. At all ages, the estimated proportion of individuals diagnosed with AAA was higher among those with depressive symptoms (log-rank test, P<0.001). People with HADS-D ≥8 were older than those with HADS-D<8 (median 57.8 versus 52.3 years, P<0.001) and a statistically significantly higher proportion of them (P<0.001) were smokers, overweight or obese, and reported a history of coronary heart disease, diabetes mellitus, and hypertension. In a Cox proportional hazard regression model adjusted for these factors, individuals with depressive symptoms had a ≈30% higher risk of AAA than those without (hazard ratio, 1.32, 95% CI 1.08-1.61, P=0.007). Conclusions This study shows that individuals with depressive symptoms have significantly higher risk of incident AAA, after adjustments for established risk factors.

Longitudinal changes in depression screening results in cardiac surgery patients.

BACKGROUND: The aim was to investigate longitudinal changes in depression screening results by sex up to one year following cardiac surgery. METHODS: We introduced a depression screening project using the Patient Health Questionnaire (PHQ-9) including patients between 2013-2016. Patients received the PHQ-9 prior to surgery, and at follow-up one year after surgery. We analyzed changes in PHQ-9 scores and screening status from baseline to 1-year follow-up. RESULTS: Screening results were obtained in 1,133 patients prior to surgery, and after one year, 1,084 patients were alive and of those 897 (83%) patients completed the follow-up PHQ-9 questionnaire. A positive depression screen at baseline was twice as common in women compared to men. A total of 547 (92%) men and 173 (91%) women who were screening negative at baseline were still screening negative at 1-year follow-up. There was no difference between men and women. A lower proportion of men compared with women (44% vs. 61%) improved from screening positive at baseline to screening negative at 1-year follow-up (P=0.069). The total PHQ-9 score difference between baseline and one year had increased with 0.23 points among men and decreased with 0.68 points in women. CONCLUSIONS: We found that twice as many women as men had a positive depression screen at baseline, and that almost 10% of all who were screening negative at baseline, were screening positive after one year. An improvement in depressive symptoms (transition from a screening positive state to a negative screening state) was more common among women than men after one year of follow up.

Depression Screening in Cardiac Surgery Patients.

BACKGROUND: Depression is common in patients with ischaemic heart disease and preoperative depression is a risk factor following coronary artery bypass grafting. The American Heart Association recommends depression screening in all patients with heart disease. Our aim was to assess the feasibility and results of a depression screening program in cardiac surgery patients. METHODS: We introduced a depression screening project at the cardiac surgery department at Karolinska University Hospital and included patients between 2013 and 2016. Patients scheduled for elective surgery recieved the Patient Health Questionnaire (PHQ-9), a depression screening instrument, by mail approximately 2weeks before surgery. Urgent patients recieved the PHQ-9 on the ward. Baseline characteristics, medical history, and medications were collected from patient charts, and entered into a study database together with the results from the PHQ-9 questionaires. RESULTS: During the study period, 2,512 patients underwent cardiac sugery; 1,133 (45%) completed PHQ-9. The response-rate in patients scheduled for elective surgery was 64%, and 15% in urgent patients. Fifteen per cent (15%) had a PHQ-9 score ≥10 suggestive of major depression. Reporting a PHQ-9 score ≥10 was twice as common in women as in men (23% vs 12%). CONCLUSIONS: Systematic depression screening using PHQ-9 in cardiac surgery patients was feasible and not very resource-intensive. The project showed a satisfactory response-rate in elective patients, but adjustments to increase the response-rate in urgent patients are needed. Future studies should investigate if and how patients with symptoms of depression would benefit from depression management.

Association between preoperative depression and long-term survival following coronary artery bypass surgery - A systematic review and meta-analysis.

BACKGROUND: Depression is common in patients with cardiovascular disease. The importance of preoperative depression for long-term survival following coronary artery bypass grafting (CABG) is not well known. The aim was to provide a summary estimate of the association between preoperative depression and long-term survival in adults who underwent CABG. METHODS: We did a systematic search of MEDLINE, EMBASE, Cochrane Library, PsycINFO, Web of Science, and PubMed from inception to November, 2015, including cohort studies with at least one month of follow-up that reported hazard ratios (HR) and 95% confidence intervals (CI) for long-term all-cause mortality following CABG in patients with preoperative depression compared to non-depressed patients. Two reviewers independently extracted data on populations, exposure, outcome, risk of bias, and quality of evidence. We calculated HR and 95% CIs for all-cause mortality using random-effects meta-analyses and performed subgroup and sensitivity analyses. RESULTS: Seven studies were included with a combined study population of 89,490 patients (4002 depressed/85,488 non-depressed). All studies observed a positive association between preoperative depression and all-cause mortality, and in 4 studies the association was statistically significant. Patients with depression had a pooled hazard ratio of 1.46 (95% CI: 1.23-1.73, p<0.0001) for all-cause mortality with moderate heterogeneity (I(2)=50.1%, p=0.061). CONCLUSIONS: This systematic review and meta-analysis indicates that patients with preoperative depression are at increased risk for long-term, all-cause mortality following CABG compared with those without depression. Systematic screening for depression prior to cardiac surgery could identify those at higher risk.

Do socioeconomic factors modify the association between preoperative antidepressant use and survival following coronary artery bypass surgery?

BACKGROUND: The impact of socioeconomic factors on mortality in patients with depression and cardiovascular disease is unknown. The aim was to study if socioeconomic factors modified the association between preoperative depression and survival following CABG. METHODS: In a nationwide population-based cohort study, 22,930 patients who underwent CABG in Sweden between 2006 and 2013 were included from the SWEDEHEART register. The national Prescribed Drug Register was used to ascertain preoperative antidepressant use which was utilized as a proxy for depression. Educational level, income, and civil status were extracted from the Longitudinal integration database for health insurance and labor market studies. The primary outcome measure was all-cause mortality and was ascertained from the Cause of Death register. Cox regression and propensity score methods were used to estimate the risk for death while controlling for differences in baseline characteristics. RESULTS: During a mean follow-up of 4.1 years, 340 (11%) patients died in the antidepressant group and 1923 (9.7%) patients died in the control group. The adjusted risk for death was higher in patients with preoperative antidepressant use (HR 1.27; 95% CI 1.13-1.43), and was practically unchanged after the addition of educational level, family disposable income, and civil status (HR 1.25; 95% CI 1.11-1.41). The results were confirmed in a propensity-score matched cohort, and in selected subgroup analyses. CONCLUSIONS: Among patients who underwent CABG in Sweden, preoperative antidepressant use was associated with worse survival even after controlling for socioeconomic factors. The clinical implication is that the impact of depression on mortality was not influenced by socioeconomic factors.

Relation of major depression to survival after coronary artery bypass grafting.

The primary aim was to study the association between preoperative depression and long-term survival after coronary artery bypass grafting (CABG). Our secondary objective was to analyze the association between depression and cardiovascular events or all-cause mortality. In a nationwide, population-based, cohort study, all patients who underwent CABG in Sweden from 1997 to 2008 were included from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Individual-level data were cross-linked from other national Swedish registers. Depression status and outcomes were obtained from the National Patient Register. The study population was 56,064 patients who underwent primary, isolated, nonemergent CABG. We identified 324 patients (0.6%) with depression before CABG. During a mean follow-up of 7.5 years, 114 patients (35%) with depression died, compared with 13,767 patients (25%) in the control group. Depression was significantly associated with increased mortality and the combined end point of death or rehospitalization for myocardial infarction, heart failure, or stroke (multivariate-adjusted hazard ratios [95% confidence intervals] 1.65 [1.37 to 1.99] and 1.61 [1.38 to 1.89], respectively). In conclusion, we found a strong and significant association between depression and long-term survival in patients with established ischemic heart disease who underwent CABG. Depression was also associated with an increased risk for a combination of death or rehospitalization for heart failure, myocardial infarction, or stroke.