Depressive Symptoms, Poor Nutritional Intake and Event-Free Survival in Patients with Heart Failure: A Deadly Chain of Events

Introduction: Depressive symptoms and malnutrition have been associated with higher risk for hospitalization or death in patients with heart failure (HF). Although depressive symptoms may contribute to poor nutritional intake, the relationship among depressive symptoms, nutritional intake, and event-free survival has not been examined. Hypotheses: 1) Depressive symptoms are associated with poor nutritional intake; 2) Poor nutritional intake predicts event-free survival; 3) Co-existence of depressive symptoms and poor nutritional intake predicts the shortest event-free survival. Methods: A total of 190 patients with HF (age 61 ± 12 years, 67% male, 50% NYHA class III/IV, ejection fraction [EF] 34 ± 13%) completed the Beck Depression Inventory II (BDI-II). Nutritional intake was defined as the total number of micronutrient deficiencies (range 0 to 15) measured by detailed 4-day food diaries verified by a registered dietitian. Nutrition Data System software was used to determine intake of phosphate, calcium, magnesium, niacin, zinc, folate, selenium, vitamin B1, B2, B6, B12, C, D, E and K. Micronutrient deficiencies corrected for age and gender were defined using methods specified by the Institute of Medicine. Time to hospitalization or death was followed up for 1-year. Hypotheses were tested by hierarchical Cox hazard regression. Results: Worse depressive symptoms were correlated with higher number of micronutrient deficiencies (r = 0.20, p = .007). Severe depressive symptoms (hazard ratio [HR] = 1.05, 95% CI = 1.01-1.09) and higher number of micronutrient deficiencies (HR = 1.13, 95% CI = 1.02-1.26) independently predicted event-free survival after controlling for age, gender, BMI, etiology of HF, NYHA class, EF, and comorbidities. When stratified into 4 groups, patients with higher number of micronutrient deficiencies (> median split) and depressive symptoms (BDI-II >13) had the shortest event-free survival.

Conclusions: Depressive symptoms were associated with shorter event-free survival particularly when paired with poorer nutritional intake in patients with HF.