Enhanced Depression Care for Patients With Acute Coronary Syndrome and Persistent Depressive Symptoms

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Abstract
Patients with acute coronary syndrome (ACS) (myocardial infarction or unstable angina) who report even subsyndromal levels of depressive symptoms are at increased risk of ACS recurrence or mortality.1,2 This increased risk is observed over many years,3 is largely independent of other known risk factors for coronary heart disease (CHD),4 is strong,5 and has a dose-response association.6 The risk is particularly high for those whose depressive symptoms persist7 or are refractory to treatment.8,9 Although the association is not found in every study10 or with every ACS patient subgroup,11 systematic reviews,1,2,12 recent international data,13 and other accumulating research indicate that depression is a marker of increased risk of CHD events and mortality in this patient population. There have been calls for depression to be recognized as a risk marker14 and recommendations that patients with CHD be regularly screened for depression and be referred for treatment.15 However, we do not know whether patients with CHD and depressive symptoms, including many with subsyndromal symptoms, should be treated.