Features of the course and prognosis of chronic heart failure in elderly and senile patients with comorbid depressive symptomatology

The dissertation is devoted to the study of the features of the course and prognosis of chronic heart failure (CHF) in elderly and senile patients in the presence of comorbid depressive symptomatology. The study covers an assessment of the frequency of depressive states among hospitalized CHF patients depending on the severity of the disease, sex, age, and social factors, as well as an analysis of the influence of comorbid depression on the dynamics of clinical condition, quality of life, and exercise tolerance during inpatient treatment and over the subsequent one-year follow-up. Particular attention is paid to identifying the factors associated with depressive disorders in elderly CHF patients and to substantiating the need for screening diagnosis of depression in general medical practice.

Relevance of the problem

At present, chronic heart failure (CHF) is one of the main problems of public health, since the annual costs of treating patients are very high and mortality remains high (Mareev V.Yu., 1997; Chazov E.I., 2003). At least 15 million people suffer from heart failure, and more than 1 million new cases of CHF are diagnosed annually (Mareev V.Yu., 1997). As of today, the three-year survival of patients with CHF is less than 50%, the risk of sudden death is 5 times higher than in the general population, and the number of hospitalizations over the past 15 years has tripled, which requires enormous material investments (Kannel, 1994; Colse M., 1999). According to the Framingham study, the incidence of CHF increases with age, that is, CHF is more often a "companion" of elderly and senile people. CHF develops annually in 1-3% of persons over 60 years of age and in almost 10% of persons over 75 years of age (Belenkov Yu.N., 1999; Но К., 1993; Colse M., 1999). The increase in the proportion of elderly persons is considered one of the main reasons for the high prevalence of CHF in economically developed countries (Belenkov Yu.N., 1999; Vein A.M. et al., 2002; Lazebnik L.P., 2005).

The further increase in the proportion of elderly and senile persons in the population has led to an increase in the number of patients suffering from depressive disorders (Damulin I.V., 2002; Pogosova G.V., 2007). According to the results of the KOMPAS study, the prevalence of depression increases with age: the probability of having depression increases by 20% every 10 years. Depressive disorders in patients aged 61 to 70 years were detected in 54% of cases, and in patients over 70 years of age in 61.7%, with one third of patients showing clinically pronounced features (Oganov R.G. et al., 2005). Depression of aging is one of the global medical and social problems. If current demographic trends persist, according to WHO, by 2020 IHD and depression will occupy the 1st and 2nd places, respectively, among all diseases in terms of the number of years of full life lost due to disability (WHO, World Health Report, 2001). It is becoming obvious that depression has long gone beyond the confines of psychiatry and can be fully regarded as a general medical problem.

A number of studies have been devoted to the prevalence of depressive disorders among patients with cardiovascular pathology. The most well-known of these is the Russian KOMPAS program conducted in 2002. The study showed that the frequency of signs of depression in patients with CHF is 60.8% (Oganov R.G. et al., 2004). According to Koenig H. (1998), major depressive disorder was detected in 36.5% of patients over 60 years of age hospitalized for CHF. The prevalence of depressive states varies depending on the region of residence, diagnostic methods, patient's age, and other factors; however, average estimates indicate that 10-20% of patients in primary health care have depression (Smulevich A.B., 2003; Pogosova G.V., 2006). The interrelation between depression and CHF requires careful study, given that depressive disorders are widespread among elderly patients, as well as due to their chronic course and negative impact on the somatic state of the patient (Chazov E.I., 2003; Vasyuk Yu.A., 2004; Oganov R.G., 2005). It has been shown that individuals with depression have an increased risk of developing IHD, myocardial infarction, and cerebral stroke after adjustment for all other traditional risk factors (Barefoot J. et al., 1996; Ariyo A. et al., 2000). Thus, along with the classical risk factors of cardiovascular diseases, today depression can be considered as an independent risk factor for the development of cardiovascular pathology (Pogosova G.V., 2002; Chazov E.I., 2003). According to the international INTERHEART Study (2003), regardless of region, ethnic, racial, and social differences, the incidence of MI worldwide is determined by nine independent risk factors, among which depression and stress rank third in significance (Rosengren A. et al., 2004). Depression is one of the causes of low adherence of patients with cardiovascular diseases to treatment, fulfillment of non-pharmacological recommendations, rehabilitation, and secondary prevention (Pogosova G.V., 2002; Carney R. et al., 1995; McDermott M. et al., 1997).

All of the above indicates the high relevance of studying the features of the course and prognosis of CHF in elderly and senile patients with CHF and comorbid depressive states.

Aim of the study: to investigate the features of the course and prognosis of chronic heart failure in elderly and senile patients with comorbid depressive symptomatology under inpatient conditions.

Research objectives:

1. To assess the frequency of depressive states in elderly and senile patients depending on the severity of CHF, sex, age, social status, and concomitant diseases.

2. To study the relationship of comorbid depressive symptomatology with the dynamics of clinical condition, quality of life indicators, and exercise tolerance in elderly and senile patients with CHF during inpatient treatment.

3. To assess the dynamics of depressive states, as well as the course and prognosis of CHF in elderly and senile patients with CHF and comorbid depressive symptomatology over 12 months.

Scientific novelty. A high frequency of signs of depression (58.5%) was demonstrated among inpatients of elderly and senile age with CHF, and the main factors highly associated with depressive states in this category of patients were identified: elderly age (60-74 years), female sex, CHF functional class III, and the fact of living alone.

The interrelation between depressive states, quality of life parameters of elderly and senile patients, CHF functional class, sociodemographic factors, and concomitant somatic pathology has been proven.

The negative influence of comorbid depressive state on the dynamics of physical and emotional quality of life parameters during inpatient treatment, as well as on the dynamics of six-minute walk test indicators in elderly and senile patients with CHF, has been revealed.

During one-year follow-up after inpatient treatment, a higher frequency of cardiovascular complications, newly detected rhythm disorders, worsening of CHF functional class, and repeated hospitalizations was found in elderly and senile patients with CHF and comorbid depressive states compared with CHF patients without depressive states.

Practical significance of the study. The negative influence of depressive states on the course and prognosis of CHF in elderly and senile patients has been proven. The high frequency of signs of depression in elderly and senile patients with CHF and the negative influence of comorbid depressive states on the course and prognosis of CHF require their timely detection in the general medical health care network using screening methods for diagnosing depression, in particular, self-rating depression scales (CES-D and Zung). Particular attention in the process of identifying depressive states and determining the scope of psychoprophylactic measures should be given to elderly patients with CHF functional class III, in the age group of 60-74 years, female, living alone.

Main propositions for defense:

1. Chronic heart failure in elderly and senile patients is characterized by a high frequency of comorbid depressive states. The main factors associated with depressive states in elderly and senile patients with chronic heart failure are the severity of CHF, age, sex, and limitation of social contacts.

2. In elderly and senile patients with chronic heart failure, the presence of a comorbid depressive state worsens the quality of life and, during inpatient treatment, negatively affects the dynamics of physical and emotional quality of life indicators, as well as the dynamics of exercise tolerance.

3. Elderly and senile patients with CHF and a comorbid depressive state during the year after inpatient treatment are characterized by a higher frequency of cardiovascular complications, newly detected rhythm disorders, worsening of CHF functional class, and repeated hospitalizations.