Adding Depression to Cardiovascular Risk Scores Offers Minimal Predictive Benefit

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A new study found adding depression to Life’s Essential 8 may have a limited impact on cardiovascular health risk assessment.¹

“…after adding the depression score to the LE8 score, the discrimination and reclassification enhanced a little,” wrote investigators, led by Jinzhuo Ge, BM from the Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovascular Diseases Beijing People’s Republic of China. “…the addition of the depression score slightly increased the predictive ability of the [cardiovascular health] score, but this improvement may not be clinically impactful.”

In 2020, the American Heart Association introduced Life’s Essential 8, an approach to accessing cardiovascular health through the factors of diet, physical activity, nicotine exposure, sleep, body mass index (BMI), lipids, blood glucose, and blood pressure.² The new approach to access cardiovascular health, Life’s Crucial 9, builds off Life’s Essential 8 but adds in the factor of psychological health. The score was calculated as the mean of the LE8 score and the depression score.¹

Investigators conducted a study to assess the link between the predictive performance of LC9 with cardiovascular and all-cause mortality, obtained from National Death Index death certificate records through December 31, 2019. They also wanted to compare the predictive value of LC9 with Life’s Essential 8.

Diet data, collected through 2 24-hour dietary recalls, was measured through the Healthy Eating Index 2015. Data on physical activity, nicotine exposure, sleep duration, history of diabetes, and medication history were collected through standardized self-reported questionnaires. The questionnaires also collected information on age, sex, race or ethnicity, education level, marital status, and the ratio of family income to poverty.

Height, weight, and blood pressure were measured during physical examinations. Blood samples were also collected to determine the levels of blood lipids, fasting blood glucose, and glycated hemoglobin. Lastly, the depression score was measured through the Patient Health Questionnaire (PHQ-9) score.

The study included 16,290 adults > 20 years without cardiovascular disease from the 2007 – 2018 cycles of the National Health and Nutrition Examination Survey (NHANES). The sample had a mean age of 46.50±16.33 years, 51.85% females, and 41.66% non-Hispanic White. Participants had a mean LE8 score of 67.70±14.50 and a mean LC9 score of 70.31±13.44.

During a median follow-up of 7.08 years, 879 (5.40%) participants died and 242 (1.49%) specifically died from cardiovascular disease.

The study found that for every 10-point increase in the LE8 score, the adjusted risk of cardiovascular death decreased by 20% (HR, 0.80; 95% confidence interval [CI], 0.72 to 0.88; P < .001). Likewise, each 10-point increase in the LC9 score led to a 23% reduction in cardiovascular death risk (HR, 0.77; 95% CI, 0.69 to 0.86; P <.001).

Incorporating the depression score into the LE8 score resulted in a minimal increase in the concordance index for predicting cardiovascular mortality (0.001; 95% CI, −0.001 to 0.003; P = .30). The net reclassification improvement was 10.6% (95% CI, −7.6% to 18.9%; P = .073), and the integrated discrimination improvement (IDI) was 0.002 (95% CI, 0.000 to 0.007; P = .033).

As for how the depression score improved the predictive performance for all-cause mortality, the improvement in concordance index for the depression score was 0.002 (95% CI, 0.000 to 0.003; P = .13), the net reclassification improvement index was 8.8% (95% CI, 3.7% –13.1%; P <.001), and the integrated discrimination improvement was 0.002 (95% CI, 0.000–0.006; P = .013).

“…LC9 score was associated with cardiovascular mortality and all‐cause mortality,” investigators concluded. “However, after adding the depression into the LE8, the predictive ability was not remarkably enhanced. Based on the findings, it may not be clinically impactful to include depression in the CVH score. Further studies are warranted to investigate the additional predictive value of other psychological health factors.”

References

1. ^{Ge J, Peng W, Lu J. Predictive Value of Life's Crucial 9 for Cardiovascular and All-Cause Mortality: A Prospective Cohort Study From the NHANES 2007 to 2018. J Am Heart Assoc. 2024;13(20):e036669. doi:10.1161/JAHA.124.036669}
2. ^{Ravichandran S, Gajjar P, Walker ME, et al. Life's Essential 8 Cardiovascular Health Score and Cardiorespiratory Fitness in the Community. J Am Heart Assoc. 2024;13(9):e032944. doi:10.1161/JAHA.123.032944}