Cardiovascular Journal of Africa: Vol 32 No 2 (MARCH/APRIL 2021)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 2, March/April 2021 70 AFRICA
The effect of lifestyle modification on depression among
myocardial infarction patients after revascularisation
Aminu Arzet, Wilbert Sibanda, DP Naidoo, Ponnusamy Somalingum
Abstract
Background: Patients with coronary artery disease (CAD)
are prone to depression, and its presence is associated with
poor adverse cardiac outcomes. Although lifestyle modifica-
tion (LSM) has been shown to be beneficial in managing
depression in patients with CAD, it is not known whether
the mode of cardiac intervention [(coronary artery bypass
graft surgery (CABG) versus percutaneous coronary inter-
vention (PCI)] influences the outcome.
Objectives: We examined the prevalence of depression
among myocardial infarction (MI) patients after revascu-
larisation and compared the effect of LSM on incidence of
depression in patients who underwent CABG versus PCI.
Methods: We evaluated the risk-factor profile, depression
characteristics and lifestyle changes of 100 consecutive
participants undergoing coronary revascularisation over a
15-month period (January 2017 to May 2018). The Beck
depression inventory II (BDI-II) was used to assess depres-
sion and the Goldin leisure-time exercise (GLTE) question-
naire to assess physical activity (PA).
Results: One hundred patients were recruited (mean age:
males 60.73 ± 4.52 years, females 60.29 ± 3.64 years) but five
dropped out, leaving 95 patients for complete analysis. Most
of the patients were low-income earners [53 (53.0%)], and
21 (21.0%) had tertiary-level education. The majority had
multiple CAD risk factors and co-morbidities (79.0%). Prior
to the LSM programme, 51 patients (51.0%) had depression
and depressive traits [CABG 34 (66.7%) vs PCI 17 (33.3%),
p = 0.047]. After LSM the overall prevalence of depression
and depressive traits fell to 33 patients (34.7%) [PCI eight
(23.0%) vs CABG 25 patients (72.0%), p = 0.001]. The mean
depression scores also fell from 21.11 ± 7.75 to 14.98 ± 9.61
( p = 0.002). At baseline, PCI patients were more physically
active compared to CABG patients [three (60.0%) vs two
patients (40.0%), respectively, p = 0.715]. After LSM, more
PCI patients undertook PA compared to CABG subjects [24
(60.0%) vs 14 patients (35.0%), respectively, p = 0.012]. The
PA score was also higher among the PCI group compared to
the CABG group [14.16 ± 9.73 vs 9.40 ± 10.94, respectively,
p = 0.024]. In fully compliant subjects, the benefit derived
was similar regardless of the mode of intervention [OR 1.10,
95% CI: 0.78–4.23, p = 0.191]. Using multivariate analysis,
the main predictors of depression and depressive traits were
female gender (OR 3.29, 95% CI: 1.51–11.03, p = 0.008),
CABG (OR 1.86, 95% CI: 1.68–5.77, p = 0.003), heart failure
(OR 2.65, 95% CI: 5.87–13.62, p = 0.000), kidney failure (OR
1.41, 95% CI: 1.30–5.23, p = 0.041), atrial fibrillation (OR
1.60, 95% CI: 1.40–4.77, p = 0.023), low PA (OR 1.97, 95%,
CI: 11.23–33.20, p = 0.000), previous history of depression
(OR 8.99, 95% CI: 1.90–7.89, p = 0.002) and low income (OR
2.21, 95% CI: 1.40–2.85, p = 0.000).
Conclusions: Depression and depressive traits are common
among subjects undergoing coronary revascularisation, more
so among CABG than PCI participants. LSM reduced the
prevalence of depression and depressive traits, with fully
compliant CABG versus PCI groups deriving nearly the
same benefits from the LSM regime. No significant reduction
in incidence of depression was recorded among LSM partly
compliant patients. This study suggests that failure to imple-
ment lifestyle changes and engage in PA are major barriers to
managing depression after coronary revascularisation.
Keywords: depression, coronary artery disease, coronary artery
bypass graft surgery, percutaneous coronary intervention, life-
style modification, Beck depression inventory II questionnaire,
Goldin leisure-time exercise questionnaire
Submitted 12/7/19, accepted 7/8/20
Published online 26/3/21
Cardiovasc J Afr 2021; 32: 70–77
DOI: 10.5830/CVJA-2020-030
Several studies have shown that depression is very common
among coronary artery disease (CAD) patients, with a prevalence
varying from 10.0 to 65.0%.1-7 Depression is thought to be a risk
factor for CAD as well as being a poor prognostic factor.8-12
Patients with CAD who have depression have been shown to
have worse outcomes and reduced quality of life (QOL).4,6,7 It
is well established that patients with CAD and depression have
higher chances for recurrence of myocardial infarction (MI) and
increased risk of death.13-18
In the Baltimore cohort of the Epidemiologic Catchments
Area study follow up, major depression significantly increased
the risk of acute MI (OR 4.54, 95% CI: 1.651–12.440).19 A
systematic review by the American Heart Association also found
that depressed MI patients had a significant increase in all-cause
mortality, cardiac mortality and chance of recurrence, compared
to non-depressed patients. 12
Although the incidence of CAD is increasing globally,
morbidity and mortality rates are steadily decreasing in
developed countries,20-23 and this has been attributed principally
to better therapy as well as lifestyle modification (LSM), which
Department of Medicine, Nelson Mandela School of
Medicine, University of KwaZulu-Natal, Durban, South Africa
Aminu Arzet, MB BS,
Department of Public Health, Nelson Mandela School of
Medicine, University of KwaZulu-Natal, Durban, South Africa
Wilbert Sibanda, MSc, PhD
Department of Cardiology, Nelson Mandela School of
Medicine, University of KwaZulu-Natal, Durban, South Africa
DP Naidoo, MD, FCP, FRCP, FESC,
Ponnusamy Somalingum, MB ChB, FCP (SA)