Studies suggest that about 30% of patients with acute coronary syndrome (ACS) experience symptoms of depression during hospitalization. These patients are nearly twice as likely to die from ACS or have recurrent cardiac disease when compared with those who aren’t depressed. The ED is often the first point of contact for treating ACS patients, and recent research suggests that psychosocial factors may impact aspects of care in the ED, including length of stay (LOS).
Depression, ACS, & LOS
It has been hypothesized that longer ED LOS may be associated with adverse clinical outcomes for those with ACS, especially among those with depression. In a recent issue of BMC Emergency Medicine, my colleagues and I sought to determine if depressed ACS patients experienced different ED care than those without depression. After reviewing data from 120 participants, we found that currently depressed ACS patients spent an average of 5.4 more hours in the ED than those who had never been depressed.
Not surprisingly, our study also revealed that presentation to the ED during off-peak hours was associated with longer ED LOS. Interestingly, no significant associations were observed with other demographic variables that might be expected to influence ED LOS, including race, ethnicity, or neighborhood income. Furthermore, these variables did not appear to account for the association between depression and ED LOS.
Data from our study are preliminary, but indicate that there is likely an association between depression and longer ED LOS. There are several possible explanations for this finding. Depression may influence how ACS patients present to the ED, report their symptoms, recruit family members or friends to accompany and support them, and interact with medical staff. These potential explanations, however, are speculative and warrant more research. We’re still unsure as to why depressed ACS patients are at risk for poor medical outcomes. Delays to medical inpatient services may be one of many factors contributing to a poor prognosis.
Future research should examine factors that may account for the relationship between depression and increased ED LOS for ACS patients. It would behoove us to focus on social and interpersonal factors in the ED that may interact with psychiatric symptoms. Efforts to better clarify interventions that positively influence outcomes after ACS and those that help moderate the association of depression and ED LOS are clearly needed.
Readings & Resources (click to view)
The Center for Behavioral Cardiovascular Health at Columbia University Medical Center is an interdisciplinary team of scientists dedicated to understanding how and why behaviors, psychological factors, and societal forces influence hypertension and cardiovascular disease. For details on faculty and staff, current enrolling research studies, training, and recent findings, go to http://www.cumc.columbia.edu/cbch/.
Edmondson D, Newman JD, Chang MJ, Wyer P, Davidson KW. Depression is associated with longer emergency department length of stay in acute coronary syndrome patients. BMC Emerg Med. 2012;12(14). Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546889/.
Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y. Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: A meta-analytic review. PLoS One. 2012;7:e38915.
Rosengren A, Hawken S, Ounpuu S, et al. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case–control study. Lancet. 2004;364:953-962.
Cannon CP, Battler A, Brindis RG, et al. American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee). J Am Coll Cardiol. 2001;38:2114-2130.
Grace SL, Abbey SE, Kapral MK, Fang J, Nolan RP, Stewart DE. Effect of depression on five-year mortality after an acute coronary syndrome. Am J Cardiol. 2005;96:1179-1185.
Rathlev NK, Chessare J, Olshaker J, et al. Time series analysis of variables associated with daily mean emergency department length of stay. Ann Emerg Med. 2007;49:265-271.