Dementia and Depression with Ischemic Heart Disease: A Population-Based Longitudinal Study Comparing Interventional Approaches to Medical Management

Abstract

BackgroundWe compared the proportion of ischemic heart disease (IHD) patients newly diagnosed with dementia and depression across three treatment groups: percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical management alone (IHD-medical).Methods and FindingsDe-identified, individual-level administrative records of health service use for the population of Manitoba, Canada (approximately 1.1 million) were examined. From April 1, 1993 to March 31, 1998, patients were identified with a diagnosis of IHD (ICD-9-CM codes). Index events of CABG or PCI were identified from April 1, 1998 to March 31, 2003. Outcomes were depression or dementia after the index event. Patients were followed forward to March 31, 2006 or until censored. Proportional hazards regression analysis was undertaken. Independent variables examined were age, sex, diabetes, hypertension and income quintile, medical management alone for IHD, or intervention by PCI or CABG. Age, sex, diabetes, and presence of hypertension were all strongly associated with the diagnosis of depression and dementia. There was no association with income quintile. Dementia was less frequent with PCI compared to medical management; (HR = 0.65; p = 0.017). CABG did not provide the same protective effect compared to medical management (HR = 0.90; p = 0.372). New diagnosis depression was more frequent with interventional approaches: PCI (n = 626; hazard ratio = 1.25; p = 0.028) and CABG (n = 1124, HR = 1.32; p = 0.0001) than non-interventional patients (n = 34,508). Subsequent CABG was nearly 16-fold higher (p<0.0001) and subsequent PCI was 22-fold higher (p<0.0001) for PCI-managed than CABG-managed patients.ConclusionsPatients managed with PCI had the lowest likelihood of dementia—only 65% of the risk for medical management alone. Both interventional approaches were associated with a higher risk of new diagnosed depression compared to medical management. Long-term myocardial revascularization was superior with CABG. These findings suggest that PCI may confer a long-term protective effect from dementia. The mechanism(s) of dementia protection requires elucidation.

Coronary Artery Bypass Graft Surgery and Dementia Risk in the Cardiovascular Health Study

“…We also included 2 further cohort studies16,17 comparing the risk of all-cause dementia and AD in those with CABG to those with PCI.…”

“…Our meta-analytic results suggest the significant association between history of CABG and dementia risk is unlikely to be driven by the underlying CAD as PCI may be associated with lower dementia risk compared with CABG. One study investigated dementia risk in those with a history of CABG compared with those receiving medical management for CAD and found no significant association, though this was limited by the use of medical records for the primary outcome 16. Further well-designed studies are needed to compare CABG with alternative treatment strategies for CAD.…”

“…A case-control study based on medical records15 did not find a significant association between CABG and odds of all-cause dementia and AD. Another medical records study investigated risk of all-cause dementia in those with CABG compared with those receiving medical management for CAD or those with PCI and found no significant associations 16. However, Lee et al17 also compared CABG to PCI in a medical records study and found a significantly increased risk of AD (Table 1).…”

Perioperative cognitive trajectory in adults

“…4 However, a much larger subsequent Canadian population-based longitudinal study did not replicate this finding. 93 Several population epidemiological studies have recently been published, yielding conflicting and provocative results. Two Taiwanese studies drawn from national databases 94 95 and a large French population study 96 have all found a link between surgery or anaesthesia and subsequent incident dementia.…”

Fixing Hearts and Protecting Minds

“…First, the apolipoprotein E genotype associated with dementia is reportedly unrelated to POCD incidence in patients undergoing CABG surgery. 88 Second, a recent epidemiological study in Canada 89 reported that the proportion of patients with ischemic heart disease who subsequently received a diagnosis of dementia during 3 to 8 years of follow-up was 7.0% for those who were treated with CABG surgery and 12.1% for those who received conservative medical management only; this difference was not statistically significant.…”