Internal and Emergency Medicine

, Volume 12, Issue 1, pp 31–43 | Cite as

Depressive symptoms, functional measures and long-term outcomes of high-risk ST-elevated myocardial infarction patients treated by primary angioplasty

  • Leonida CompostellaEmail author
  • Sonia Lorenzi
  • Nicola Russo
  • Tiziana Setzu
  • Caterina Compostella
  • Elia Vettore
  • Giambattista Isabella
  • Giuseppe Tarantini
  • Sabino Iliceto
  • Fabio Bellotto


The presence of major depressive symptoms is usually considered a negative long-term prognostic factor after an acute myocardial infarction (AMI); however, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention. The aims of this study are to evaluate if depression still retains long-term prognostic significance in our era of immediate coronary reperfusion, and to study possible correlations with clinical parameters of physical performance. In 184 patients with recent ST-elevated AMI (STEMI), treated by immediate reperfusion, moderate or severe depressive symptoms (evaluated by Beck Depression Inventory version I) were present in 10 % of cases. Physical performance was evaluated by two 6-min walk tests and by a symptom-limited cardiopulmonary exercise test: somatic/affective (but not cognitive/affective) symptoms of depression and perceived quality of life (evaluated by the EuroQoL questionnaire) are worse in patients with lower levels of physical performance. Follow-up was performed after a median of 29 months by means of telephone interviews; 32 major adverse cardiovascular events (MACE) occurred. The presence of three vessels disease and low left ventricle ejection fraction are correlated with a greater incidence of MACE; only somatic/affective (but not cognitive/affective) symptoms of depression correlate with long-term outcomes. In patients with recent STEMI treated by immediate reperfusion, somatic/affective but not cognitive/affective symptoms of depression show prognostic value on long-term MACE. Depression symptoms are not predictors “per se” of adverse prognosis, but seem to express an underlying worse cardiac efficiency, clinically reflected by poorer physical performance.


Depression Beck inventory Physical fitness Myocardial infarction Prognosis 



Percentage of expected peak oxygen uptake


6-min walk test


Angiotensin converting enzyme


Acute myocardial infarction


Angiotensin II receptor type 2


Beck Depression Inventory, version 1


Coronary artery bypass graft


Cardio-pulmonary exercise test


Cardiac rehabilitation




European QoL questionnaire 5D-3L


European QoL questionnaire Visual Scale


Major adverse cardiovascular events


Magnetic resonance imaging


Percutaneous coronary intervention


Peak oxygen uptake


Quality of life


ST-elevated myocardial infarction


Maximum sustained workload at CPET, in Watt


Compliance with ethical standards

Source of funding

This work was not supported by Grant.

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

The research was conducted in accordance with the ethical guidelines of the 1975 Declaration of Helsinki. This study is part of a larger follow-up study on AMI patients admitted to CR; approval of the Provincial Ethics Committee (Provincial Directorate of Health, Belluno, Italy) was obtained for the main research.

Informed consent

Informed consent was obtained by all participants involved in the study.


  1. 1.
    Lichtman JH, Froelicher ES, Blumenthal JA, Carney RM, Doering LV, Frasure-Smith N, Freedland KE, Jaffe AS, Leifheit-Limson EC, Sheps DS, Vaccarino V, Wulsin L, American Heart Association Statistics Committee of the Council on Epidemiology and Prevention and the Council on Cardiovascular and Stroke Nursing (2014) Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 129(12):1350–1369CrossRefPubMedGoogle Scholar
  2. 2.
    Kaufmann MW, Fitzgibbons JP, Sussman EJ, Reed JF 3rd, Einfalt JM, Rodgers JK, Fricchione GL (1999) Relation between myocardial infarction, depression, hostility, and death. Am Heart J 138(3 Pt 1):549–554CrossRefPubMedGoogle Scholar
  3. 3.
    Sørensen C, Brandes A, Hendricks O, Thrane J, Friis-Hasché E, Haghfelt T, Bech P (2006) Depression assessed over 1-year survival in patients with myocardial infarction. Acta Psychiatr Scand 113(4):290–297CrossRefPubMedGoogle Scholar
  4. 4.
    Beatty AL, Li S, Thomas L, Amsterdam EA, Alexander KP, Whooley MA (2014) Trends in referral to cardiac rehabilitation after myocardial infarction: data from the National Cardiovascular Data Registry 2007 to 2012. J Am Coll Cardiol 63(23):2582–2583CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Backshall J, Ford GA, Bawamia B, Quinn L, Trenell M, Kunadian V (2015) Physical activity in the management of patients with coronary artery disease: a review. Cardiol Rev 23(1):18–25CrossRefPubMedGoogle Scholar
  6. 6.
    Lavie CJ, Milani RV, O’Keefe JH, Lavie TJ (2011) Impact of exercise training on psychological risk factors. Progr Cardiovasc Dis 53(6):464–470CrossRefGoogle Scholar
  7. 7.
    Blumenthal JA, Sherwood A, Babyak MA, Watkins LL, Smith PJ, Hoffman BM, O’Hayer CV, Mabe S, Johnson J, Doraiswamy PM, Jiang W, Schocken DD, Hinderliter AL (2012) Exercise and pharmacological treatment of depressive symptoms in patients with coronary heart disease: results from the UPBEAT (Understanding the Prognostic Benefits of Exercise and Antidepressant Therapy) study. J Am Coll Cardiol 60(12):1053–1063CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE (2013) Exercise for depression. Cochrane Database Syst Rev 9:CD004366. doi: 10.1002/14651858.CD004366.pub6 Google Scholar
  9. 9.
    Milani RV, Lavie CJ (2007) Impact of cardiac rehabilitation on depression and its associated mortality. Am J Med 120(9):799–806CrossRefPubMedGoogle Scholar
  10. 10.
    Greco C, Cacciatore G, Gulizia M, Martinelli L, Oliva F, Olivari Z, Seccareccia F, Temporelli PL, Urbinati S, Associazione Nazionale Medici Cardiologi Ospedalieri, Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology, Gruppo Italiano di Cardiologia Riabilitativa (2011) Criteri per la selezione dei pazienti da inviare ai centri di cardiologia riabilitativa [Selection criteria for patient admission to cardiac rehabilitation centers]. G Ital Cardiol (Rome) 12(3):219–229Google Scholar
  11. 11.
    Beck AT, Steer RA, Brown GK (1987) Manual for the revised Beck Depression Inventory. Texas Psychological Corporation, San AntonioGoogle Scholar
  12. 12.
    The EuroQol Group (1990) EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16(3):199–208CrossRefGoogle Scholar
  13. 13.
    Mezzani A, Hamm LF, Jones AM, McBride PE, Moholdt T, Stone JA, Urhausen A, Williams MA, European Association for Cardiovascular Prevention and Rehabilitation, American Association of Cardiovascular and Pulmonary Rehabilitation, Canadian Association of Cardiac Rehabilitation (2012) Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 32(6):327–350CrossRefPubMedGoogle Scholar
  14. 14.
    American Thoracic Society Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories (2002) ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 166:111–117CrossRefGoogle Scholar
  15. 15.
    Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O’Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC, American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Committee to Update the 1997 Exercise Testing Guidelines (2002) ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 40(8):1531–1540CrossRefPubMedGoogle Scholar
  16. 16.
    Lane D, Carroll D, Ring C, Beevers DG, Lip GY (2002) The prevalence and persistence of depression and anxiety following myocardial infarction. Br J Health Psychol 7(Pt 1):11–21CrossRefPubMedGoogle Scholar
  17. 17.
    Drago S, Bergerone S, Anselmino M, Varalda PG, Cascio B, Palumbo L, Angelini G, Trevi PG (2007) Depression in patients with acute myocardial infarction: influence on autonomic nervous system and prognostic role. Results of a five-year follow-up study. Int J Cardiol 115(1):46–51CrossRefPubMedGoogle Scholar
  18. 18.
    Frasure-Smith N, Lespérance F, Talajic M (1995) Coronary heart disease/myocardial infarction: depression and 18-month prognosis after myocardial infarction. Circulation 91(4):999–1005CrossRefPubMedGoogle Scholar
  19. 19.
    Lespérance F, Frasure-Smith N, Talajic M, Bourassa MG (2002) Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction. Circulation 105(9):1049–1053CrossRefPubMedGoogle Scholar
  20. 20.
    Lane D, Carroll D, Ring C, Beevers DG, Lip GY (2002) In-hospital symptoms of depression do not predict mortality 3 years after myocardial infarction. Int J Epidemiol 31(6):1179–1182CrossRefPubMedGoogle Scholar
  21. 21.
    Delisle VC, Arthurs E, Abbey SE, Grace SL, Stewart DE, Steele RJ, Ziegelstein RC, Thombs BD (2012) Symptom reporting on the Beck Depression Inventory among post-myocardial infarction patients: in-hospital versus follow-up assessments. J Psychosom Res 73(5):356–361CrossRefPubMedGoogle Scholar
  22. 22.
    Beck AT, Steer RA, Ball R, Ranieri W (1996) Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. J Pers Assess 67(3):588–597CrossRefPubMedGoogle Scholar
  23. 23.
    Lauzon C, Beck CA, Huynh T, Dion D, Racine N, Carignan S, Diodati JG, Charbonneau F, Dupuis R, Pilote L (2003) Depression and prognosis following hospital admission because of acute myocardial infarction. CMAJ 168(5):547–552PubMedPubMedCentralGoogle Scholar
  24. 24.
    Steeds RP, Bickerton D, Smith MJ, Muthusamy R (2004) Assessment of depression following acute myocardial infarction using the Beck Depression Inventory. Heart 90(2):217–218CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    de Jonge P, Ormel J, van den Brink RH, van Melle JP, Spijkerman TA, Kuijper A, van Veldhuisen DJ, van den Berg MP, Honig A, Crijns HJ, Schene AH (2006) Symptom dimensions of depression following myocardial infarction and their relationship with somatic health status and cardiovascular prognosis. Am J Psychiatry 163(1):138–144CrossRefPubMedGoogle Scholar
  26. 26.
    Linke SE, Rutledge T, Johnson BD, Vaccarino V, Bittner V, Cornell CE, Eteiba W, Sheps DS, Krantz DS, Parashar S, Bairey Merz CN (2009) Depressive symptom dimensions and cardiovascular prognosis among women with suspected myocardial ischemia: a report from the National Heart, Lung, and Blood Institute-sponsored women’s ischemia syndrome evaluation. Arch Gen Psychiatry 66(5):499–507CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Smolderen KG, Spertus JA, Reid KJ, Buchanan DM, Krumholz HM, Denollet J, Vaccarino V, Chan PS (2009) The association of cognitive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction. Circ Cardiovasc Qual Outcomes 2(4):328–337CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Martens EJ, Hoen PW, Mittelhaeuser M, de Jonge P, Denollet J (2010) Symptom dimensions of post-myocardial infarction depression, disease severity and cardiac prognosis. Psychol Med 40(5):807–814CrossRefPubMedGoogle Scholar
  29. 29.
    Roest AM, Thombs BD, Grace SL, Stewart DE, Abbey SE, de Jonge P (2011) Somatic/affective symptoms, but not cognitive/affective symptoms, of depression after acute coronary syndrome are associated with 12-month all-cause mortality. J Affect Disord 131(1–3):158–163CrossRefPubMedGoogle Scholar
  30. 30.
    Burns RJ, Gibbons RJ, Yi Q, Roberts RS, Miller TD, Schaer GL, Anderson JL, Yusuf S, CORE Study Investigators (2002) The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis. J Am Coll Cardiol 39(1):30–36CrossRefPubMedGoogle Scholar
  31. 31.
    Flachskampf FA, Schmid M, Rost C, Achenbach S, DeMaria AN, Daniel WG (2011) Cardiac imaging after myocardial infarction. Eur Heart J 32(3):272–283CrossRefPubMedGoogle Scholar
  32. 32.
    Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey KW, Valgimigli M, van’t Hof A, Widimsky P, Zahger D (2012) ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 33(20):2569–2619CrossRefGoogle Scholar
  33. 33.
    Lichtenberger CM, Martin Ginis KA, MacKenzie CL, McCartney N (2003) Body image and depressive symptoms as correlates of self-reported versus clinician-reported physiologic function. J Cardiopulm Rehabil 23(1):53–59CrossRefPubMedGoogle Scholar
  34. 34.
    Mostarda C, Rodrigues B, Vane M, Moreira ED, Rosa KT, Moraes-Silva IC, Lacchini S, Casarini DE, De Angelis K, Irigoyen MC (2010) Autonomic impairment after myocardial infarction: role in cardiac remodelling and mortality. Clin Exp Pharmacol Physiol 37(4):447–452CrossRefPubMedGoogle Scholar
  35. 35.
    Perkiömäki JS, Hämekoski S, Junttila MJ, Jokinen V, Tapanainen J, Huikuri HV (2010) Predictors of long-term risk for heart failure hospitalization after acute myocardial infarction. Ann noninvasive Electrocardiol 15(3):250–258CrossRefPubMedGoogle Scholar
  36. 36.
    Coviello I, Pinnacchio G, Laurito M, Stazi A, Battipaglia I, Barone L, Mollo R, Russo G, Villano A, Sestito A, Lanza GA, Crea F (2013) Prognostic role of heart rate variability in patients with ST-segment elevation acute myocardial infarction treated by primary angioplasty. Cardiology 124(1):63–70CrossRefPubMedGoogle Scholar
  37. 37.
    Carney RM, Blumenthal JA, Freedland KE, Stein PK, Howells WB, Berkman LF, Watkins LL, Czajkowski SM, Hayano J, Domitrovich PP, Jaffe AS (2005) Low heart rate variability and the effect of depression on post-myocardial infarction mortality. Arch Intern Med 165(13):1486–1491CrossRefPubMedGoogle Scholar
  38. 38.
    Shi S, Liang J, Liu T, Yuan X, Ruan B, Sun L, Tang Y, Yang B, Hu D, Huang C (2014) Depression increases sympathetic activity and exacerbates myocardial remodeling after myocardial infarction: evidence from an animal experiment. PLoS One 9(7):e101734CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Dunlay SM, Pack QR, Thomas RJ, Killian JM, Roger VL (2014) Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am J Med 127(6):538–546CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Ståhle A, Nordlander R, Bergfeldt L (1999) Aerobic group training improves exercise capacity and heart rate variability in elderly patients with a recent coronary event. A randomized controlled study. Eur Heart J 20(22):1638–1646CrossRefPubMedGoogle Scholar
  41. 41.
    Routledge FS, Campbell TS, McFetridge-Durdle JA, Bacon SL (2010) Improvements in heart rate variability with exercise therapy. Can J Cardiol 26(6):303–312CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Oliveira NL, Ribeiro F, Teixeira M, Campos L, Alves AJ, Silva G, Oliveira J (2014) Effect of 8-week exercise-based cardiac rehabilitation on cardiac autonomic function: A randomized controlled trial in myocardial infarction patients. Am Heart J 167(5):753.e3–761.e3CrossRefGoogle Scholar
  43. 43.
    Elderon L, Whooley MA (2013) Depression and cardiovascular disease. Prog Cardiovasc Dis 55(6):511–523CrossRefPubMedGoogle Scholar
  44. 44.
    Malfatto G, Blengino S, Annoni L, Branzi G, Bizzi C, Facchini M (2005) Primary coronary angioplasty and subsequent cardiovascular rehabilitation are linked to a favorable sympathovagal balance after a first anterior myocardial infarction. Ital Heart J 6(1):21–27PubMedGoogle Scholar
  45. 45.
    Ndrepepa G (2015) Improving myocardial injury, infarct size, and myocardial salvage in the era of primary PCI for STEMI. Coron Artery Dis 26(4):341–355CrossRefPubMedGoogle Scholar
  46. 46.
    Pedersen F, Butrymovich V, Kelbæk H, Wachtell K, Helqvist S, Kastrup J, Holmvang L, Clemmensen P, Engstrøm T, Grande P, Saunamäki K, Jørgensen E (2014) Short- and long-term cause of death in patients treated with primary PCI for STEMI. J Am Coll Cardiol 64(20):2101–2108CrossRefPubMedGoogle Scholar
  47. 47.
    Mendes De Leon CF (1999) Depression and social support in recovery from myocardial infarction: confounding and confusion. Psychosom Med 61(6):738–739CrossRefPubMedGoogle Scholar
  48. 48.
    Zuidersma M, Conradi HJ, van Melle JP, Ormel J, de Jonge P (2013) Depression treatment after myocardial infarction and long-term risk of subsequent cardiovascular events and mortality: a randomized controlled trial. J Psychosom Res 74(1):25–30CrossRefPubMedGoogle Scholar
  49. 49.
    Shapiro PA (2015) Management of depression after myocardial infarction. Curr Cardiol Rep 17(10):634CrossRefGoogle Scholar
  50. 50.
    Berkman LF, Blumenthal J, Burg M, Carney RM, Catellier D, Cowan MJ, Czajkowski SM, DeBusk R, Hosking J, Jaffe A, Kaufmann PG, Mitchell P, Norman J, Powell LH, Raczynski JM, Schneiderman N, Enhancing Recovery in Coronary Heart Disease Patients Investigators (ENRICHD) (2003) Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) randomized trial. JAMA 289(23):3106–3116CrossRefPubMedGoogle Scholar
  51. 51.
    Scalco AZ, Rondon MU, Trombetta IC, Laterza MC, Azul JB, Pullenayegum EM, Scalco MZ, Kuniyoshi FH, Wajngarten M, Negrão CE, Lotufo-Neto F (2009) Muscle sympathetic nervous activity in depressed patients before and after treatment with sertraline. J Hypertens 27(12):2429–2436CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2016

Authors and Affiliations

  • Leonida Compostella
    • 1
    • 2
    Email author
  • Sonia Lorenzi
    • 1
  • Nicola Russo
    • 1
    • 2
  • Tiziana Setzu
    • 1
  • Caterina Compostella
    • 3
  • Elia Vettore
    • 2
  • Giambattista Isabella
    • 2
  • Giuseppe Tarantini
    • 2
  • Sabino Iliceto
    • 2
  • Fabio Bellotto
    • 1
    • 2
  1. 1.Preventive Cardiology and RehabilitationInst. Codivilla-PuttiCortina d’AmpezzoItaly
  2. 2.Department of Cardiac, Thoracic and Vascular SciencesUniversity of PaduaPadovaItaly
  3. 3.Department of Medicine, School of Emergency MedicineUniversity of PaduaPadovaItaly

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