合併與未合併憂鬱之冠心病患者在自主神經反應與臨床事件之追蹤研究

目的：憂鬱為影響冠狀動脈心臟病(coronary artery disease, CAD)預後之重要心理社會危險因子，有20%~40%的心臟病患者符合重度憂鬱的診斷或曾經經歷憂鬱症狀，過去研究已證實CAD患者合併憂鬱會導致自主神經(autonomic nervous system, ANS)功能失調、增加心血管疾病復發率。然而國內目前尚無研究針對合併與未合併憂鬱之CAD患者的憂鬱、ANS功能、預後臨床事件發生率進行長期追蹤。因此本研究將探討合併與未合併憂鬱之CAD患者在一年追蹤期間憂鬱與ANS功能的變化，以及兩年追蹤期間臨床事件發生率的差異，並進一步探討CAD患者的憂鬱與臨床事件發生率的關聯。方法：本研究以貝克憂鬱量表第二版(Beck depression inventory, BDI-II)得分14分作為切截分數，將204名CAD患者區分為160名單純CAD患者(BDI-II總分 < 14)以及44名合併憂鬱的CAD患者(BDI-II總分 ≧ 14)，兩組均接受前測、後測、一年追蹤三個時間點的憂鬱程度與ANS功能評估，研究者在兩年追蹤期間以病歷回朔的方式調查CAD患者兩年期間內的臨床事件，包括心血管、非心血管原因與所有原因住院率、急診率。結果：在憂鬱的部分，合併憂鬱的CAD患者相較於單純CAD患者在前測、後測、一年追蹤皆有顯著較高的BDI-II總分、身體型憂鬱、認知型憂鬱。在ANS指標的部分，合併憂鬱的CAD患者相較於單純CAD患者在前測時有顯著較低的正常心跳間期的標準差(standard deviation of NN intervals, SDNN)、極低頻(very low frequency, VLF)、低頻波(low frequency, LF)、高頻波(high frequency, HF)、總功率(total power, TP)，在一年追蹤時有顯著較低的VLF、LF、TP。在臨床事件發生率的部分，合併憂鬱的CAD患者相較於單純CAD患者在兩年追蹤期間有顯著較高的心血管原因住院率、所有原因住院率、非心血管原因急診率、所有原因急診率。在憂鬱與兩年臨床事件發生率關聯的部分，BDI-II總分與心血管原因住院次數、非心血管原因急診次數、所有原因急診次數達顯著正相關；身體型憂鬱與心血管原因住院次數、所有原因住院次數、非心血管原因急診次數、所有原因急診次數達顯著正相關；認知型憂鬱與心血管原因住院次數、非心血管原因急診次數、所有原因急診次數達顯著正相關。身體型憂鬱可預測CAD患者心血管疾病住院次數；認知型憂鬱可預測CAD患者心血管疾病住院次數、所有原因住院次數、非心血管原因急診次數、所有原因急診次數。結論：合併憂鬱的CAD患者相較於單純CAD患者有長期較嚴重的憂鬱程度與較差的ANS功能，預後也有較高的臨床事件發生率。CAD患者的憂鬱與臨床事件發生率有關，可預測臨床事件發生率。因此未來篩檢CAD患者是否有憂鬱症狀，予以早期介入並持續追蹤，將為心臟復健當務之急。

關鍵字

冠狀動脈心臟病；憂鬱；自主神經；心血管預後

並列摘要

Objective: Depression is an important psychosocial risk factor affecting the prognosis among the patients with coronary artery disease (CAD). It is estimated that about 20~40% of the CAD patients have been diagnosed with major depressive disorder or have experienced depressive symptoms. However, there is a lack of research targeting to the long-term follow-up of the incidence of depressive symptoms, autonomic nervous system(ANS) activation and prognostic of cardiovascular clinical events among CAD patients with/without depressive symptoms in Taiwan so far. Therefore, the aim of this study is to examine the 1-year long-term parameters on the depressive symptoms and ANS activation, and 2-year long-term prognostic of clinical events among patients with/without depressive symptoms in CAD, and examine the correlation of depressive symptoms and 2-year long-term prognostic of clinical events among patients in CAD. Methods: Total 204 CAD patients were screened for depression using Beck Depression Inventory II (BDI-II). Based on the cut-off score 14, participants were divided into two group with 160 CAD patients without depression and 44 CAD patients with depression. Both groups received measurement of cardiac autonomic activation and BDI-II at pre-intervention, post-intervention and 1-year follow-up. The cardiovascular prognostic markers including hospital readmissions, and emergency revisits were obtained from medical records at 2-year follow-up. Results: The with depression group showed significantly higher scores of total BDI-II, somatic symptoms of depression, cognitive symptoms of depression at pre-intervention, post-intervention, and 1-year follow-up compared to the without depression group. Moreover, the results of HRV indices showed that the with depression group had significantly lower standard deviation of NN intervals (SDNN), very low frequency (VLF), low frequency (LF), high frequency (HF), and total power (TP) at pre-intervention, as well as VLF, LF, and TP at 1-year follow-up compared to the without depression group. At 2-year follow-up, there were higher recurrence of cardiovascular causes readmission, all-cause readmission, non-cardiovascular causes emergency visits, and all-cause emergency visits in the with depression group compared to the without depression group. Pearson’s correlation analysis revealed the BDI-II at pre-intervention was related to the cardiovascular causes readmission, non-cardiovascular causes emergency visits, and all-cause emergency visits at 2-year follow-up, somatic symptoms of depression at pre-intervention was related to the cardiovascular causes readmission, all-cause readmission, non-cardiovascular causes emergency visits, and all-cause emergency visits at 2-year follow-up, cognitive symptoms of depression at pre-intervention was related to the cardiovascular causesreadmission, non-cardiovascular causes emergency visits, and all-cause emergency visits at 2-year follow-up. Regression analysis revealed the somatic symptoms of depression at pre-intervention can predicted cardiovascular causes readmission at 2-year follow-up in CAD patients, cognitive symptoms of depression at pre-intervention can predicted cardiovascular causes readmission, all causes readmission, non-cardiovascular causes emergency visits, and all-cause emergency visits at 2-year follow-up in CAD patients. Conclusion: CAD patients with depressive symptoms showed significantly more severe depression, poor autonomic activation, and higher clinical events. The depressive symptoms was related to the prognostic of clinical events in CAD patients. Therefore, examining the depressive symptoms for CAD patients, offering early interventions, and continuous following-up will be the priority of cardiac rehabilitation for CAD patients in the future.