S. Lee1, A. Khakharia1, Z. O. Binney1, G. Zahner2, M. S. Grenon2, S. Arya1,3 1Emory University School Of Medicine,Vascular Surgery,Atlanta, GA, USA 2University Of California – San Francisco,Vascular Surgery,San Francisco, CA, USA 3Atlanta VA Medical Center,Surgery Service,Decatur, GA, USA
Introduction: As a multi-system illness, peripheral arterial disease (PAD) affects many areas of patients’ lives, including their mental health. Recent studies have associated depression with increased risk of PAD. The link between PAD outcomes and depression has however yet to be fully defined. In this study, we examined the effects of comorbid depression on amputation rate and mortality in the Veteran Affairs (VA) population.
Methods: Patients with PAD in the VA database were identified (2003-2014) using a validated algorithm. The diagnosis of depression was defined using 2 outpatient diagnosis codes for depression within 14 months or one inpatient primary diagnosis code of depression (ICD-9 codes 296.2, 296.3, 300.4 and 311). Outcomes were amputation risk and overall mortality at 1, 3, and 5 years. Kaplan-Meier analysis was used to assess time to amputation. A Cox proportional hazards model was used to assess the effect of depression on amputation and mortality adjust for covariates, including age, gender, race, social economic status, comorbidities, cholesterol levels, creatinine, and medications.
Results: In 208,194 patients with PAD, depression was present in 15.2% of the cohort, with occurrence of 14,981 major amputations and 99,870 deaths [Median follow up 5.2 yrs]. Bivariate comparisons showed increased risk of amputation at 1, 3 and 5 years for patients with depression (4.6% vs 3%, 7.3% vs 5.1% and 10.3% vs 7.3% respectively; p<0.0001 for each group). Mortality was also similarly higher in patients with depression at each time point (7.2% vs 6.2%, 22.4% vs 20.0% and 38.3% vs 33.5% respectively; p<0.0001 for each group). On Kaplan-Meier analysis, patients with depression had more amputations earlier in the disease course than patients without depression [Figure 1] but did not have an increased risk of mortality after accounting for censoring [Figure 2]. In the Cox model, depression was associated with a 16% higher amputation risk as compared to patients with no underlying depression [HR 1.16; 95% CI (1.11, 1.22)]. Depression was also associated with increase in overall mortality of 17% [HR 1.17; 95% CI (1.14, 1.19).
Conclusion:PAD patients with depression have a significantly higher risk of amputation and mortality than patients without depression. These results suggest that concomitant depression in PAD contributes to morbidity and mortality of these patients and could possibly be a target for intervention.
