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Comment & Response
November 27, 2018

Cardiac Outcomes After Treatment for Depression in Patients With Acute Coronary Syndrome—Reply

Author Affiliations
  • 1Department of Psychiatry, Chonnam National University Medical School, Republic of Korea
  • 2Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, England
JAMA. 2018;320(20):2152-2153. doi:10.1001/jama.2018.15950

In Reply In response to Drs Thombs and Ziegelstein, the EsDEPACS trial was preplanned as a component of the larger Korean Depression in Acute Coronary Syndrome (K-DEPACS) study investigating interrelationships between depression and cardiac outcomes following ACS using randomized and prospective observational designs. Cardiovascular outcomes have been described and reported in the previously published design article including both the EsDEPACS and K-DEPACS studies1 and in prior research using this data set.2 We agree that MACE has been inconsistently defined in this field, but our MACE definition (a composite of all-cause mortality, myocardial infarction, and percutaneous coronary intervention) has been used in well-cited cardiovascular research studies and so is not unique to our work.3 Concerning treatment effects, we believe that an incorrect comparison is being made. Thombs and Ziegelstein present results for the primary analysis based on the total sample of 300 patients. However, to compare with the number achieving remission of depression, the post hoc analysis of 217 patients achieving remission must be used. The difference in MACE numbers was 15 between the placebo group (n = 61) and escitalopram group (n = 46), in line with the differences in depression remission. The difference in MACE occurrence appearing beyond 1 year after randomization is a reasonable concern. However, a meta-analysis of 16 studies of depression following ACS found that differences in MACE occurrence became prominent after 1 year and over longer follow-up intervals4; this is in keeping with our findings, although we agree that further replication should be sought.