Measuring both symptoms of depression and plasma brain-natriuretic peptide (BNP) levels can improve risk stratification of chronic heart failure (CHF) patients, Greek researchers report in the journal Heart.

Commentators in a related editorial welcomed such an approach, noting that it seems CHF is a complex disease not sufficiently reflected by plasma BNP levels.

Depression has been independently associated with poorer prognosis in CHF.

John Parissis and colleagues from Attikon University Hospital in Athens studied the clinical and prognostic value of depression rating scales and plasma BNP levels in 155 hospitalized CHF patients with a mean ejection fraction (EF) of 26.9%.

In all, 76 (49%) patients had depressive symptoms, as estimated by both the Beck Depression Inventory (BDI) and Zung Self-rating Depression Scale (Zung SDS).

These patients had lower functional capacity on both the Kansas City Cardiomyopathy Questionnaire and the Duke Activity Status Index, higher BNP levels, and reduced 6-minute walking distance test measurements

**than patients without depressive symptoms.

Zung SDS score and BNP levels were both independently associated with adverse clinical outcomes, including death from any cause or rehospitalization with CHF decompensation, over 6 months of follow-up.

A Zung SDS score of 40 or over predicted future events with a sensitivity of 82% and specificity of 45%.

Corresponding values for the BNP cutoff of 290 pg/ml or over were 94% and 46%.

Furthermore, combining these Zung SDS and BNP cutoffs gave higher prognostic value than either cutoff alone, predicting events with a sensitivity of 77% and specificity of 70%.

"Depression may interfere with neurohormonal activation, contributing to clinical deterioration and CHF progression," Parissis and team remark.

In their editorial, Christoph Herrmann-Lingen, from University of Göttingen in Germany, and Burkert Pieske, from University Hospital of Graz in Austria,

noted that while only the Zung SDS and not the BDI predicted outcome in the current study, "there are insufficient data for recommending one scale over the other."

They proposed that clinicians ask their CHF patients two simple screening questions to ascertain potential depression, pointing out that depression is a comorbidity in its own right, warranting "state-of-the-art" treatment.

"This treatment will at least markedly enhance the effects of standard HF care on patients' quality of life, improve the patients' health behavior, and strengthen the physician-patient relationship," they wrote.

"Most physicians will find it more rewarding to treat whole patients rather than isolated laboratory markers."

Heart 2008; 94: 585-589