Commentary concerning treatment of depression in patients with heart failure according to 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice.
Commentary concerning treatment of depression in patients with heart failure according to 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice.
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根据 2021 年 ESC 临床实践心血管疾病预防指南治疗心力衰竭患者抑郁症的评论。
DOI：
10.1093/eurjpc/zwac077
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发表时间：
2022
影响因子：
8.3
通讯作者：
W. Cubała
中科院分区：
文献类型：
--
作者：
A. Wilkowska;M. Bohdan;W. Cubała
我们饶有兴趣地阅读了ESC在临床实践中预防心血管疾病的指南，其中包括不使用SSRI、SNRI和TCA(III类，B级)的新建议。1该指南参考最近的荟萃分析2，包括8项研究，其中包括2个随机对照试验(RCT)3、4和6个观察性研究。两个随机对照试验3、4显示舍曲林(尽管这项研究不是为了评估死亡率)和艾司匹兰的安全性，但没有观察到比安慰剂有任何益处。荟萃分析结果提供的证据表明，心力衰竭(HF)患者使用抗抑郁药与全原因死亡的风险增加有关，无论他们是否患有临床抑郁症或他们使用的抗抑郁药的类型。3这样的建议应该谨慎对待，因为来自随机研究的证据是有限的，而且必须考虑到心力衰竭患者未经治疗的抑郁症的临床后果。重度抑郁障碍(MDD)是一种慢性反复发作的疾病，与物质使用、代谢紊乱和认知障碍的严重共病有关，这些因素都导致心力衰竭的负面预后。MDD的病理生理机制包括下丘脑-垂体-肾上腺轴调节失调、自主系统过度驱动和低度全身炎症。20%-30%的心力衰竭患者出现抑郁，导致死亡率和发病率增加。5有必要进行面对面的随机研究，调查抑郁症状严重程度的变化和抗抑郁药物的使用。荟萃分析6中的一项研究是基于丹麦国家队列中的抗抑郁药物处方，不包括关于临床诊断和抑郁症状严重程度的数据，这是方法论上的考虑。测量抑郁的严重程度是必要的，以回答抗抑郁药物是否有害，因为治疗无效的抑郁可能会增加死亡率，而不是使用的抗抑郁药物。在这项荟萃分析的另一项研究中，7只有在氟西汀的情况下才观察到与更高的死亡风险相关，而与其他抗抑郁药没有相关性，而且氟西汀具有特定的代谢，比其他SSRI能引起更多的相互作用。此外，2021年ESC急慢性心力衰竭诊断和治疗指南8指出，应提供足够的常规抑郁症治疗，对于心力衰竭患者的最佳治疗仍未达成共识。如果不推荐药物治疗，可能会降低这种合并症在临床实践中的重要性。如果治疗是有害的，为什么还要费心诊断呢？指南应该放在心力衰竭患者的治疗依从性和康复的背景下。欧洲预防心脏病协会工作组最近发布了关于心理健康相关风险因素和干预措施的建议。9这项关于心力衰竭患者抑郁的最新研究的全面综述构成了关于可在该患者群体中实施的药物治疗和非药物策略的有价值的临床指南。作者强调，需要考虑未经治疗的抑郁症的风险，以及抗抑郁药物治疗的风险。他们强调需要对患有心力衰竭的抑郁患者进行个性化管理，考虑到治疗的有效性和耐受性问题。除了SSRIs，作者还指出了伏替西汀的用途，
We read with interest ESC guidelines on cardiovascular disease prevention in clinical practice including a new recommendation for not using SSRI, SNRI, and TCA (Class III, Level B). 1 The guideline refers to recent metanalysis 2 including eight studies, among which there were two randomized controlled trials (RCTs) 3, 4 and six observational studies. The two analyzed RCTs 3, 4 have shown safety of sertraline (although this study was not designed to evaluate mortality) and escitalopram, but no benefit over placebo was observed. The metanalytic outcome provides evidence that the use of antidepressants in patients with heart failure (HF) is associated with an increased risk of all-cause death, regardless of whether they had clinical depression or the type of antidepressants they used. 3 Such recommendation should be treated with caution as the evidence from randomized studies is limited and the clinical consequences of untreated depression in patients with HF must be taken into consideration. Major depression disorder (MDD) is a chronic and recurrent condition associated with substantial comorbidity of substance use, metabolic disorders, and cognitive impairment which all contribute to the negative prognosis in HF. The pathophysiology of MDD includes dysregulation in hypothalamic–pituitary–adrenal axis, autonomous system overdrive, and low-grade systemic inflammation. Depression appears in 20–30% of HF cases and results in increased mortality and morbidity. 5 There is a need for head-to-head randomized studies investigating both, the change in depressive symptom severity and the use of antidepressant. One study in the metanalysis 6 was based on the prescription of antidepressants in a National Danish Cohort and did not include data on the clinical diagnosis and the severity of depressive symptoms which is a methodological consideration. Measuring of the severity of depression is necessary to answer if antidepressants are harmful because it is possible that ineffectively treated depression increases mortality and not the antidepressants used. In another study from this metanalysis, 7 the correlation with higher mortality risk was observed only in case of fluoxetine, but not with other antidepressants and fluoxetine has specific metabolism and can cause more interactions than other SSRIs. Moreover, 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic HF guideline 8 state that adequate conventional treatment of depression should be offered and that there is still no consensus on the best therapy for patients with HF. If it does not recommend pharmacological treatment it can lead to diminishing the significance of this comorbidity in clinical practice. Why bother with diagnosis if the treatment is harmful? The guideline should be placed in context of treatment adherence and rehabilitation of patients with HF. The European Association of Preventive Cardiology task force has recently published recommendations on mental health-related risk factors and interventions. 9 This comprehensive overview of recent studies concerning depression in HF patients constitutes a valuable clinical guideline on the pharmacotherapy and non-pharmacological strategies that can be implemented in this patient population. The authors underline the need to consider the risk of untreated depression, as well as the risk of antidepressant pharmacotherapy. They emphasize the need for individualized management of depressed patients with HF, concerning the effectiveness of treatment and tolerability issues. Apart from SSRIs, the authors point out the utility of vortioxetine,