REPORTS OF ORIGINAL INVESTIGATIONS

Untreated preoperative depression is not associatedwith postoperative arrhythmias in CABG patients

La depression preoperatoire non traitee n’est pas associee a desarythmies postoperatoires chez les patients subissant un PAC

Rita Katznelson, MD • W. Scott Beattie, MD, PhD • George N. Djaiani, MD •

Matthew Machina, MSc • Ronit Lavi, MD • Vivek Rao, MD, PhD •

Shahar Lavi, MD

Received: 23 July 2013 / Accepted: 7 October 2013 / Published online: 12 November 2013

� Canadian Anesthesiologists’ Society 2013

Abstract

Purpose The mechanism by which depression affects

postoperative outcome may involve arrhythmias. The

purpose of this study was to evaluate whether untreated

depression is associated with an increased incidence of

postoperative arrhythmias in patients undergoing coronary

artery bypass graft surgery (CABG).

Methods One hundred seven patients were assessed for

signs of depression with the Prime-MD Patient Health

Questionnaire (brief PHQ) one week before surgery and

subsequently underwent Holter monitoring for 48-72 hr

postoperatively. The incidences of atrial fibrillation (AF);

supraventricular tachycardia (SVT); ventricular

tachycardia (VT), defined as three or more consecutive

beats at a cycle length less than 600 msec; ventricular

fibrillation (VF); and average heart rate (HR) were

recorded in patients with and without signs of depression.

Results The incidence of preoperative untreated

depression was 27% (29/107). Twenty patients had mild

depression (brief PHQ score of 5-9), seven patients had

moderate depression (a score of 10-14), and two patients

had severe depression (a score of 20). The incidences of

postoperative AF, SVT, and non-sustained VT in depressed

and non-depressed patients were 37.9% vs 35.9%,

respectively (P = 0.50), 34.4% vs 52.5%, respectively

(P = 0.07), and 17.2% vs 37.1%, respectively (P = 0.04).

The average (SD) postoperative HR was similar in both

groups [95 (12) beats�min-1 in depressed patients and 92

(10) beats�min-1 in non-depressed patients, (P = 0.25)].

Multivariate regression analysis showed that older age, but

not depression, was a risk factor for postoperative

arrhythmia.

Conclusions Preoperative untreated depression is not

related to postoperative arrhythmia in the early

postoperative period in patients undergoing elective

CABG. This trial was registered at clinicaltrials.gov

(number: NCT00622024).

Resume

Objectif Le mecanisme par lequel la depression affecte

le pronostic postoperatoire pourrait impliquer des

arythmies. L’objectif de cette etude etait d’evaluer si une

depression non traitee etait associee a une incidence

accrue d’arythmies postoperatoires chez les patients

subissant un pontage aortocoronarien (PAC).

Author contributions Rita Katznelson, W. ScottBeattie, Vivec Rao,and Shahar Lavi contributed to the conception of the study. RitaKatznelson, W. Scott Beattie, George N. Djaiani, Vivec Rao, andShahar Lavi contributed to the study design. Rita Katznelson, RonitLavi, Vivec Rao, and Shahar Lavi contributed to the acquisition ofdata. Rita Katznelson, Matthew Mashina, Ronit Lavi, and ShaharLavi contributed to the analysis of data. Rita Katznelson, W. ScottBeattie, George N. Djaiani, Matthew Mashina, Ronit Lavi, VivecRao, and Shahar Lavi contributed to the interpretation of data. RitaKatznelson and Shahar Lavi participated in drafting the manuscript.W. Scott. Beattie, George N. Djaiani, Matthew Mashina, Ronit Lavi,and Vivec Rao contributed to manuscript revisions.

R. Katznelson, MD (&) � W. Scott Beattie, MD, PhD �G. N. Djaiani, MD � M. Machina, MSc

Department of Anesthesia and Pain Management, Toronto

General Hospital, Toronto, ON, Canada

e-mail: rita.katznelson@uhn.ca

R. Lavi, MD

Department of Anesthesia and Perioperative Medicine,

University of Western Ontario, London, ON, Canada

V. Rao, MD, PhD

Department of Cardiac Surgery, Toronto General Hospital,

Toronto, ON, Canada

S. Lavi, MD

Division of Cardiology, Department of Medicine, University of

Western Ontario, London, ON, Canada

123

Can J Anesth/J Can Anesth (2014) 61:12–18

DOI 10.1007/s12630-013-0051-3

Methode Cent sept patients ont ete evalues pour

determiner s’ils presentaient des signes de depression a

l’aide du Questionnaire Prime-MD Patient Health (le PHQ

court) une semaine avant leur chirurgie, puis ils ont ete

monitores avec un Holter cardiaque durant 48 a 72 h apres

leur operation. Les incidences de fibrillation auriculaire

(FA); de tachycardie supraventriculaire (TSV); de

tachycardie ventriculaire (TV), definie en tant que trois

battements consecutifs ou plus a une duree de cycle

inferieure a 600 msec; de fibrillation ventriculaire (FV) et

la frequence cardiaque (FC) moyenne ont ete enregistrees

chez les patients avec et sans signes de depression.

Resultats L’incidence de depression preoperatoire non

traitee etait de 27 % (29/107). Vingt patients souffraient de

depression legere (score sur le PHQ court de 5-9), sept

patients de depression moderee (score de 10-14), et deux

de depression grave (score de 20). Les incidences de FA,

de TSV et de TV non soutenue chez les patients deprimes et

non deprimes etaient de 37,9 % vs. 35,9 %, respectivement

(P = 0,50), 34,4 % vs. 52,5 %, respectivement (P = 0,07),

et 17,2 % vs. 37,1 %, respectivement (P = 0,04). La FC

postoperatoire moyenne (ET) etait semblable dans les deux

groupes [95 (12) battements�min-1 chez les patients

deprimes et 92 (10) battements�min-1 chez les patients

non deprimes, (P = 0,25)]. L’analyse de regression

multivariee a montre qu’un age avance, et non la

depression, etait un facteur de risque d’arythmie

postoperatoire.

Conclusion La depression preoperatoire non traitee

n’est pas liee a l’arythmie postoperatoire en debut de

periode postoperatoire chez les patients subissant un PAC

non urgent. Cette etude a ete enregistree au numero

ClinicalTrials.gov NCT00622024.

Preoperative depression is common among patients

undergoing heart surgery1–3 and is an independent risk

factor for short- and long-term mortality after valve4 or

coronary artery bypass graft (CABG) surgeries.1,5,6

Patients with preoperative depression have longer

hospital length of stay, higher rates of readmission, and

increased need for repeat procedures.1,6–9

The mechanism by which depression affects outcome

following cardiac surgery is not completely understood but

may involve arrhythmias.10,11

Atrial and ventricular arrhythmias usually occur within

three to four days after the surgery. The prevalence of

postoperative supraventricular arrhythmias, particularly

atrial fibrillation (AF), ranges from 25-60%.12 Malignant

ventricular arrhythmias are less common and occur in 0.4-

11% of patients.13 Postoperative arrhythmia is one of the

most frequent early postoperative complications after

CABG surgery and is associated with increased

morbidity and mortality.14–17

Arrhythmia occurs frequently in patients with depression,

irrespective of the presence of coronary artery disease.18–23

One of the plausible mechanisms explaining the relationship

between depression and arrhythmia is autonomic dysfunction.

Patients with depression have altered secretion of

norepinephrine, a higher resting heart rate, low heart rate

variability, and reduced baroreflex sensitivity,23–29 resulting

in resting sinus tachycardia.25,26

There are numerous facts indicating a possible link

between depression, arrhythmia, and outcome. Patients

with coronary artery disease who are affected by

depression have a higher prevalence of ventricular

tachycardia (VT) and atrial fibrillation.18,23 Depression is

associated with higher mortality rates after myocardial

infarction, likely due to arrhythmias.30 Arrhythmias, such

as premature ventricular contractions after myocardial

infarction were associated with increased risk of sudden

cardiac death in patients with depression.31 Symptoms of

depression were associated with sudden death among

placebo-treated patients but not among amiodorone-treated

patients.31 Finally, depression predicted rates of

defibrillation for VT/ventricular fibrillation (VF) among

patients with implanted cardioverter-defibrillators.22

Despite the growing body of evidence that preoperative

depression can increase the incidence of postoperative

arrhythmia, two recently published reports in CABG

patients did not support this hypothesis.32,33 Both studies

used self-administered questionnaires to screen for

preoperative depression and did not address whether the

patients were treated for their depression symptoms.

Therapeutic options for depression include antidepressant

medications, electroconvulsive therapy (ECT), transcranial

magnetic stimulation, vagus nerve stimulation, deep brain

stimulation, and psychotherapy.34 Each option or their

combination can potentially affect the incidence of

arrhythmia in rather unpredictable ways. Antidepressants,

ECT, and vagus nerve stimulation have possible

arrhythmogenic effects,35–40 yet, psychotherapy, such as

biofeedback41 and cognitive behaviour therapy,42 can

decrease the incidence of arrhythmia in cardiac patients.

The purpose of the current study was to evaluate

whether untreated depression symptoms are associated

with an increased incidence of postoperative arrhythmias in

patients undergoing CABG.

Methods

This prospective observational study included patients under-

going elective CABG surgery. The study was approved by The

University Health Network Research Ethics Board.

No link between depression and arrhythmia 13

123

The study took place from August 2008 until August

2011 and included 120 consecutive patients. All

participants provided informed consent. Inclusion criteria

were patients undergoing elective CABG and aged

18-75 yr. Exclusion criteria were history of arrhythmias

(AF, supraventricular tachycardia [SVT], VT, VF, perma-

nent pacemaker, and/or defibrillator), history of psychiatric

disorders (schizophrenia, mania, psychosis), treatment for

depression in the last six months prior to surgery,

pulmonary hypertension, and left ventricular ejection

fraction \ 40%.

One week before surgery, a trained research assistant

assessed patients in the anesthesia preoperative clinic for

signs of depression using the brief version of Prime-MD

Patient Health Questionnaire (brief PHQ). The depression

module of the brief PHQ scores each of the nine DSM-IV

depression criteria as ‘‘0’’ (not at all) to ‘‘3’’ (nearly every

day). Scores of 5, 10, 15, and 20 represent mild, moderate,

moderately-severe, and severe depression, respectively.43

The brief PHQ is a screening tool for depression symptoms

recommended by the American Heart Association to

identify depression in cardiac patients.44 Patients with a

PHQ score C 10 were referred to psychiatry consult

postoperatively.

Starting immediately after surgery, Holter monitoring

was applied for 48-72 hr. Holter electrocardiogram (ECG)

recordings were scanned by a MARS�8000 Arrhythmia

Review Station (Wipro GE Healthcare) and interpreted by

a Holter technician and a cardiologist who were blinded to

the results of the depression assessment.

The primary outcome was the proportion of patients with

postoperative ventricular or supraventricular arrhythmias.

The following arrhythmias were recorded: number and

frequency of episodes of AF, SVT, VT (defined as three or

more consecutive beats at a cycle length less than 600

msec), and VF, and average heart rate.

Based on the psychiatric assessment, all patients were

divided into two groups: patients with signs of depression

(depression score C 5) and patients without signs of

depression (depression score \ 5). The incidence of

postoperative arrhythmias was compared between the

groups.

Sample size calculation

Our sample size was based on an incidence of post CABG

atrial fibrillation of 40% in patients with no depression.12

Although the incidence of depression in patients with

coronary artery disease before CABG may be 40%,45 we

made a conservative assumption that only 25% of our

patients would have preoperative depression.

A sample size of 108 patients (unequal n in the two

groups, 25% of patients having untreated depression) has

80% power to detect a relative risk of 1.77 with a

significance level of 0.05.

We estimated an attrition rate of 10%; therefore, the

final sample size was 120 patients.

Statistical analysis

A simple 2 x 2 contingency table was constructed to

evaluate the presence of ventricular and /or supraventricular

arrhythmias (dichotomous outcome) based on the Holter

monitor assessment after surgery in patients with and

without untreated depression.

Single predictor and multivariable logistic regression

models were used to calculate the effect of preoperative

untreated depression on postoperative arrhythmia. Untreated

depression and other variables shown to have marginal

association (P\0.20) in the single predictor analysis were

included in the multivariable model. The following variables

were included in the multivariable model: age, sex,

preoperative use of beta- and calcium channel blockers,

cardiopulmonary bypass time, postoperative use of inotropic

agents, and depression scores. Stata� ver. 12.1 (StataCorp

LP, College Station, TX, USA) was used to analyze the data.

Results

One hundred seven patients completed the study (Figure).

The incidence of preoperative untreated depression was

27% (29/107). Twenty patients were found to have mild

depression (brief PHQ score of 5-9), seven patients had

moderate depression (a score of 10-14), and two patients

had severe depression (a score of 20).

The depression group included more females, and the

patients in this group had lower hemoglobin and creatinine

levels. Patients without signs of depression had a higher

preoperative heart rate and a higher incidence of

preoperative myocardial infarction (Table 1). There was

no difference between groups in surgical characteristics or

in the incidence of intraoperative use of inotropes and

vasoactive drugs (Table 2).

None of the patients developed sustained VT or VF. The

incidence of non-sustained VT was 31.8%, and the

incidence of postoperative atrial fibrillation was 36.4%.

Overall, there were more arrhythmias in the no

depression group. There was no difference between

groups in the incidence of postoperative atrial fibrillation

and supraventricular arrhythmias (Table 3). None of the

patients developed sustained VT or VF, but the incidence

of non-sustained VT was higher in the patients without

depression. Multivariate logistic regression analysis

showed that preoperative depression is not associated

14 R. Katznelson et al.

123

with postoperative arrhythmia. The only risk factor for

postoperative arrhythmia was older age (Table 4). The c

statistic, estimate of the area under the receiver operating

characteristic curve, was equal to 0.8.

Discussion

The results of the present study show that untreated

preoperative depression symptoms and postoperative

arrhythmia are frequent conditions in patients undergoing

elective CABG. Preoperative untreated depression was not

a predictor of postoperative arrhythmias in this patient

cohort.

In fact, we found that patients without depression had a

slightly higher incidence of postoperative arrhythmia

compared with patients with signs of depression.

Furthermore, the resting preoperative heart rate (a

marker of autonomic dysfunction) was slightly higher in

patients without preoperative depression. There was no

significant difference between the two groups in the need

for inotropes and vasopressors intra- and postoperatively.

Although the incidence of preoperative depression in our

study was in the same range as previously reported,9 only

Figure Protocol flow diagram

No link between depression and arrhythmia 15

123

nine patients fulfilled the criteria for moderate-severe

depression. Therefore, the majority of patients in our

cohort with mild depression symptoms simply did not

reach the trigger threshold for autonomic dysfunction and

neurotransmitter imbalance contributing to postoperative

arrhythmia.

We excluded patients who were at high risk for

postoperative arrhythmia. These included patients with a

history of arrhythmia prior to surgery, poor left ventricular

function, and pulmonary hypertension. The incidence of

postoperative arrhythmia (AF and non-sustained VT) in the

current cohort was similar to that in previous reports.13,17,46

Table 1 Baseline characteristics

Suspected

depression*

No

depression

P value

(n = 29) (n = 78)

Age (yr) 63.0 (9.6) 64.6 (9.4) 0.45

Sex (female) 8 (27.5%) 2 (2.5%) 0.004

BMI (kg�m-2) 27.7 (4.4) 28.5 (5.6) 0.5

Preoperative heart rate

(beats�min-1)

63 (10) 68 (15) 0.03

Preoperative pulse Pressure

(mmHg)

54 (13) 57 (18) 0.27

Hypertension 23 (79.3%) 54 (69.2%) 0.3

Diabetes 8 (27.5%) 35 (44.8%) 0.12

PVD 4 (13.8%) 9 (11.5%) 0.7

Previous MI 4 (13.8%) 28 (35.9%) 0.03

Stroke 1 (3.4%) 7 (8.9%) 0.4

COPD 1 (3.4%) 4 (5.1%) 1.0

Alcohol use C 2 drinks/day 29 (6.9%) 4 (5.1%) 0.6

Beta blockers 21 (72.4%) 47 (60.2%) 0.27

Ca channel blockers 4 (13.8%) 14 (17.9%) 0.7

Preoperative Hb (g�dL-1) 138 (13) 144 (12) 0.05

Preoperative creatinine (lM) 73 (38) 88 (22) 0.01

Preoperative potassium

(mEq�L-1)

4.2 (0.3) 4.1 (0.4) 0.2

Data are expressed as mean (SD) or number (%). BMI = body mass

index; Hb = hemoglobin; PVD = peripheral vascular disease;

MI = myocardial infarction; COPD = chronic obstructive

pulmonary disease. *Prime-MD Patient Health Questionnaire score C 5

Table 2 Intraoperative data

Suspected

Depression*

No

depression

P value

(n = 29) (n = 78)

Number of coronary artery

grafts, median (min; max)

3 (1;4) 3 (1;4) 0.9

CPB time (min) 78 (28) 79 (23) 0.8

Aortic cross clamp time (min) 63 (27) 61 (19) 0.7

Intraoperative dopamine 12 (41.3%) 18 (23%) 0.06

Intraoperative epinephrine 1 (3.4%) 7 (8.9%) 0.3

Intraoperative norepinephrine 5 (17.2%) 17 (21.8%) 0.6

Intraoperative vasopressin 1 (3.4%) 4 (5.1%) 0.6

Intraoperative milrinone 0 2 (2.5%) 0.5

Data are expressed as mean (SD) or number (%) unless otherwise

indicated. CPB = cardiopulmonary bypass. *Prime-MD Patient

Health Questionnaire score C 5

Table 3 Postoperative arrhythmia

Suspected

depression*

No

depression

P value

(n = 29) (n = 78)

Heart rate (average)

(beats�min-1)

95 (12) 92 (10) 0.25

AF 11 (37.9%) 28 (35.9%) 0.5

AF time [ 3 min 8 (27.5%) 13 (16.7%) 0.27

SVT 10 (34.4%) 41 (52.5%) 0.07

VT 5 (17.2%) 29 (37.1%) 0.04

All arrhythmias 20 (68.9%) 69 (88.4%) 0.02

Postoperative amiodarone 9 (31%) 26 (33.3%) 0.2

Postoperative beta blockers 21 (72.4%) 48 (61.5%) 0.12

Postoperative Ca channel

blockers

1 (3.4%) 2 (2.5%) 0.6

Cardioversion 0 2 (2.5%) 0.5

Postoperative norepinephrine 10 (34.4%) 25 (32.0%) 0.49

Postoperative epinephrine 1 (3.4%) 6 (7.7%) 0.39

Postoperative dopamine 13 (33.3%) 37 (47.4%) 0.03

Postoperative vasopressin 2 (6.9%) 9 (11.5%) 0.38

Postoperative milrinone 0 2 (2.6%) 0.5

Data are expressed as mean (SD) or number (%). AF = atrial

fibrillation; SVT = supraventricular tachycardia; VT = ventricular

tachycardia. *Prime-MD Patient Health Questionnaire score C 5

Table 4 Multivariate logistic regression for postoperative

arrhythmias (ventricular and supraventricular)

Odds

Ratio

Standard

Error

z score P value Confidence

intervals

Suspected

Depression*

0.27 0.23 -1.48 0.1 0.05 (1.5)

Age 1.13 0.05 2.63 0.008 1.03 (1.24)

Female sex 1.9 2.8 0.47 0.5 0.12 (32.6)

CPB time [ 90 min 1.8 1.6 0.6 0.5 0.27 (1.6)

Preoperative Ca

channel blockers

3.1 4.5 0.93 0.3 0.25 (45)

Preoperative beta

blockers

0.8 0.8 -0.2 0.8 0.1 (6.0)

Postoperative

dopamine

1.7 1.6 0.59 0.6 0.27 (10.7)

CPB = cardiopulmonary bypass. *Prime-MD Patient Health

Questionnaire score C 5

16 R. Katznelson et al.

123

One of the mechanisms explaining the association

between depression and arrhythmia is the arrhythmogenic

effect of antidepressant medications. Both tricyclic

antidepressants and selective serotonin reuptake inhibitors

may prolong the QT interval, affect heart rate variability,

and cause arrhythmias.35–38 In addition, non-

pharmacological modalities, such as ECT and vagus

nerve stimulation, can trigger arrhythmias by affecting

the QT interval or causing heart block.39,40 To avoid this

confounding factor, patients who were treated for

depression were excluded from our study. Similar to

previous studies, we confirmed that older age is an

independent risk factor for postoperative arrhythmia and

that there was no positive association between depression

and arrhythmia in patients with coronary artery disease.

A recent report by Turagam et al.47 showed that patients

who survived sudden cardiac death and have a history of

depression are not at higher risk of recurrent arrhythmia

and death than those with no history of depression.

In a study by Beresnevaite et al.,32 109 male patients

undergoing CABG were evaluated for preoperative

depression and postoperative complications. They did not

find any association between preoperative depression and

early postoperative complications, including arrhythmia.

The authors did not elaborate on their definition of

postoperative arrhythmia or on the diagnostic criteria

they used. In a study by Tully et al.,33 222 patients

undergoing cardiac surgery were assessed for preoperative

depression and anxiety. The primary outcome in this study

was atrial fibrillation. The diagnosis was done with Holter

monitoring applied for the first three postoperative days

and thereafter with daily electrocardiograms until

discharge. They found that anxiety, but not preoperative

depression, had an association with postoperative atrial

fibrillation. The authors did not comment on ventricular

arrhythmias in their patient cohort. As previously

mentioned, there was no discussion in any of these

studies regarding the presence or absence of preoperative

antidepressant therapy in the studied patients.

The results of our study extend the prior observations.

Ours is a novel study using Holter monitoring specifically

to diagnose the incidence of both supraventricular and

ventricular postoperative arrhythmia in patients screened

preoperatively for untreated depression. Therefore, we

consider our results to be robust enough to conclude that

untreated preoperative depression symptoms are not

associated with postoperative arrhythmias.

The definition of depression was based on the results of

a brief PHQ, which is a screening tool to identify patients

with high risk for depression. Although high scores of the

brief PHQ have high specificity and sensitivity for major

depression, it cannot substitute psychiatric assessment for

clinical diagnosis of depression. We did not perform a

formal psychiatric examination in our patients and,

therefore, our findings should be limited to only those

patients defined as high risk for depression. The Holter

monitor was applied for only 48-72 hr, and thus, there may

have been arrhythmias after this period. Nevertheless, the

incidence within the first 48-72 hr was high enough to

confirm our findings. We included all types of arrhythmias

in our study, some with a very short duration; therefore,

some of the recorded arrhythmias are less likely to be

clinically significant.

The results of our study cannot be applied to patients

with a known history of arrhythmia and those who were

treated with antidepressant medications or other

therapeutic modalities in the perioperative period.

Although preoperative depression is a known independent

risk factor for postoperative morbidity and mortality, it is

unlikely that the negative effect of untreated depression

symptoms on postoperative outcomes is related to arrhythmia

in the early postoperative period.

Funding Dean’s Fund, University of Toronto, Canada.

Competing interests None declared.

References

1. Burg MM, Benedetto MC, Rosenberg R, Soufer R. Presurgical

depression predicts medical morbidity 6 months after coronary

artery bypass graft surgery. Psychosom Med 2003; 65: 111-8.

2. Blumenthal JA, Lett HS. Depression and cardiac risk.

J Cardiopulm Rehabil 2005; 25: 78-9.

3. Phillips-Bute B, Mathew JP, Blumenthal JA, et al. Relationship

of genetic variability and depressive symptoms to adverse events

after coronary artery bypass graft surgery. Psychosom Med 2008;

70: 953-9.

4. Ho PM, Masoudi FA, Spertus JA, et al. Depression predicts

mortality following cardiac valve surgery. Ann Thorac Surg

2005; 79: 1255-9.

5. Pignay-Demaria V, Lesperance F, Demaria RG, Frasure-Smith

N, Perrault LP. Depression and anxiety and outcomes of

coronary artery bypass surgery. Ann Thorac Surg 2003; 75:

314-21.

6. Connerney I, Shapiro PA, McLaughlin JS, Bagiella E, Sloan RP.

Relation between depression after coronary artery bypass surgery

and 12-month outcome: a prospective study. Lancet 2001; 358:

1766-71.

7. Baker RA, Andrew MJ, Schrader G, Knight JL. Preoperative

depression and mortality in coronary artery bypass surgery:

preliminary findings. ANZ J Surg 2001; 71: 139-42.

8. Tully PJ, Baker RA, Turnbull D, Winefield H. The role of

depression and anxiety symptoms in hospital readmissions after

cardiac surgery. J Behav Med 2008; 31: 281-90.

9. Tully PJ, Baker RA. Depression, anxiety, and cardiac morbidity

outcomes after coronary artery bypass surgery: a contemporary

and practical review. J Geriatr Cardiol 2012; 9: 197-208.

10. Tully PJ. Psychological depression and cardiac surgery: a

comprehensive review. J Extra Corpor Technol 2012; 44: 224-32.

11. Sher Y, Lolak S, Maldonado JR. The impact of depression in heart

disease. Curr Psychiatry Rep 2010; 12: 255-64.

No link between depression and arrhythmia 17

123

12. Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after

cardiac surgery. Ann Intern Med 2001; 135: 1061-73.

13. Knotzer H, Dunser MW, Mayr AJ, Hasibeder WR. Postbypass

arrhythmias: pathophysiology, prevention, and therapy. Curr

Opin Crit Care 2004; 10: 330-5.

14. Jongnarangsin K, Oral H. Postoperative atrial fibrillation.

Cardiol Clin 2009; 27: 69-78.

15. Mayr A, Knotzer H, Pajk W, et al. Risk factors associated with

new onset tachyarrhythmias after cardiac surgery–a retrospective

analysis. Acta Anaesthesiol Scand 2001; 45: 543-9.

16. Sapin PM, Woelfel AK, Foster JR. Unexpected ventricular

tachyarrhythmias soon after cardiac surgery. Am J Cardiol

1991; 68: 1099-100.

17. Almassi GH, Schowalter T, Nicolosi AC, et al. Atrial fibrillation

after cardiac surgery: a major morbid event? Ann Surg 1997; 226:

501-11.

18. Carney RM, Freedland KE, Rich MW, Smith LJ, Jaffe AS.

Ventricular tachycardia and psychiatric depression in patients

with coronary artery disease. Am J Med 1993; 95: 23-8.

19. Lange HW, Herrmann-Lingen C. Depressive symptoms predict

recurrence of atrial fibrillation after cardioversion. J Psychosom

Res 2007; 63: 509-13.

20. Lown B, DeSilva RA. Roles of psychologic stress and autonomic

nervous system changes in provocation of ventricular premature

complexes. Am J Cardiol 1978; 41: 979-85.

21. Mallik S, Krumholz HM, Lin ZQ, et al. Patients with depressive

symptoms have lower health status benefits after coronary artery

bypass surgery. Circulation 2005; 111: 271-7.

22. Whang W, Albert CM, Sears SF Jr, et al. Depression as a predictor for

appropriate shocks among patients with implantable cardioverter-defibrillators: results from the Triggers of Ventricular Arrhythmias

(TOVA) study. J Am Coll Cardiol 2005; 45: 1090-5.

23. Catipovic-Veselica K, Galic A, Jelic K, et al. Relation between

major and minor depression and heart rate, heart-rate variability,

and clinical characteristics of patients with acute coronary

syndrome. Psychol Rep 2007; 100: 1245-54.

24. Louis WJ, Doyle AE, Anavekar SN. Plasma noradrenaline

concentration and blood pressure in essential hypertension,

phaeochromocytoma and depression. Clin Sci Mol Med Suppl

1975; 2: 239S-42S.

25. Lechin F, van der Dijs B, Orozco B, et al. Plasma

neurotransmitters, blood pressure, and heart rate during supine-

resting, orthostasis, and moderate exercise conditions in major

depressed patients. Biol Psychiatry 1995; 38: 166-73.

26. Carney RM, Rich MW, teVelde A, Saini J, Clark K, Freedland

KE. The relationship between heart rate, heart rate variability and

depression in patients with coronary artery disease. J Psychosom

Res 1988; 32: 159-64.

27. Johansson M, Ehnvall A, Friberg P, Myredal A. Arterial

baroreflex dysfunction in major depressive disorder. Clin Auton

Res 2010; 20: 235-40.

28. Francis JL, Weinstein AA, Krantz DS, et al. Association between

symptoms of depression and anxiety with heart rate variability in

patients with implantable cardioverter defibrillators. Psychosom

Med 2009; 71: 821-7.

29. Watkins LL, Grossman P. Association of depressive symptoms

with reduced baroreflex cardiac control in coronary artery

disease. Am Heart J 1999; 137: 453-7.

30. Carney RM, Blumenthal JA, Catellier D, et al. Depression as a

risk factor for mortality after acute myocardial infarction. Am J

Cardiol 2003; 92: 1277-81.

31. Irvine J, Basinski A, Baker B, et al. Depression and risk of sudden

cardiac death after acute myocardial infarction: testing for the

confounding effects of fatigue. Psychosom Med 1999; 61:

729-37.

32. Beresnevaite M, Benetis R, Taylor GJ, Jureniene K, Kinduris S,

Barauskiene V. Depression predicts perioperative outcomes

following coronary artery bypass graft surgery. Scand

Cardiovasc J 2010; 44: 289-94.

33. Tully PJ, Bennetts JS, Baker RA, McGavigan AD, Turnbull DA,

Winefield HR. Anxiety, depression, and stress as risk factors for

atrial fibrillation after cardiac surgery. Heart Lung 2011; 40: 4-11.

34. Mavrides N, Nemeroff C. Treatment of depression in

cardiovascular disease. Depress Anxiety 2013; 30: 328-41.

35. Vieweg WV, Wood MA, Fernandez A, Beatty-Brooks M, Hasnain

M, Pandurangi AK. Proarrhythmic risk with antipsychotic and

antidepressant drugs: implications in the elderly. Drugs Aging

2009; 26: 997-1012.

36. Deshmukh A, Ulveling K, Alla V, Abuissa H, Airey K. Prolonged

QTc interval and torsades de pointes induced by citalopram. Tex

Heart Inst J 2012; 39: 68-70.

37. Johnson EM, Whyte E, Mulsant BH, et al. Cardiovascular

changes associated with venlafaxine in the treatment of late-life

depression. Am J Geriatr Psychiatry 2006; 14: 796-802.

38. Licht CM, de Geus EJ, van Dyck R, Penninx BW. Longitudinal

evidence for unfavorable effects of antidepressants on heart rate

variability. Biol Psychiatry 2010; 68: 861-8.

39. Yamaguchi S, Nagao M, Ikeda T, et al. QT dispersion and rate-

corrected QT dispersion during electroconvulsive therapy in

elderly patients. J ECT 2011; 27: 183-8.

40. Singleton AH, Rosenquist PB, Kimball J, McCall WV. Cardiac

rhythm disturbance in a depressed patient after implantation with

a vagus nerve stimulator. J ECT 2009; 25: 195-7.

41. Patron E, Messerotti Benvenuti S, Favretto G, et al. Biofeedback

assisted control of respiratory sinus arrhythmia as a biobehavioral

intervention for depressive symptoms in patients after cardiac

surgery: a preliminary study. Appl Psychophysiol Biofeedback

2013; 38: 1-9.

42. Chevalier P, Cottraux J, Mollard E, et al. Prevention of

implantable defibrillator shocks by cognitive behavioral

therapy: a pilot trial. Am Heart J 2006; 151: 191.

43. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a

brief depression severity measure. J Gen Intern Med 2001; 16:

606-13.

44. Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and

coronary heart disease: recommendations for screening, referral,

and treatment: a science advisory from the American Heart

Association Prevention Committee of the Council on

Cardiovascular Nursing, Council on Clinical Cardiology,

Council on Epidemiology and Prevention, and Interdisciplinary

Council on Quality of Care and Outcomes Research: endorsed by

the American Psychiatric Association. Circulation 2008; 118:

1768-75.

45. Pirraglia PA, Peterson JC, Williams-Russo P, Gorkin L,

Charlson ME. Depressive symptomatology in coronary artery

bypass graft surgery patients. Int J Geriatr Psychiatry 1999; 14:

668-80.

46. Magyar-Russell G, Thombs BD, Cai JX, et al. The prevalence of

anxiety and depression in adults with implantable cardioverter

defibrillators: a systematic review. J Psychosom Res 2011; 71:

223-31.

47. Turagam MK, Velagapudi P, Szabo A, Visotcky A, Kocheril AG.

Survivors of sudden cardiac death with history of depression are

not at significantly greater risk of recurrent arrhythmias and

death. Int J Cardiol 2012; 157: 445-6.

18 R. Katznelson et al.

123