Depressive symptoms, health-related quality of life, and cardiac event-free survival in patients with heart failure: A mediation analysis

Kyoung Suk Lee, Terry A. Lennie, Jia Rong Wu, Martha J. Biddle, Debra K. Moser

Research output: Contribution to journalArticlepeer-review

12 Scopus citations


Purpose: Health-related quality of life (HRQOL) and depressive symptoms both are associated with an adverse prognosis in heart failure (HF), although their associations with outcomes have been examined only in isolation. Therefore, it is unknown how HRQOL and depressive symptoms might interact in their associations with outcomes. The present study was conducted to determine whether the association between HRQOL and cardiac event-free survival is mediated by depressive symptoms in HF patients given that depressive symptoms are associated strongly with HRQOL. Methods: A total of 209 HF patients (61 ± 11 years, 24 % female, 49 % NYHA III/IV) participated. The Minnesota Living with HF Questionnaire and the Patient Health Questionnaire-9 were used to measure HRQOL and depressive symptoms, respectively. Patients were followed for a median of 357 days to determine cardiac event-free survival. Results: In Cox regression analysis, HRQOL [hazard ratio (HR) 1.013; 95 % confidence interval (CI) 1.001-1.026] and depressive symptoms (HR 1.075; 95 % CI 1.025-1.127) predicted cardiac event-free survival separately, controlling for demographic and clinical variables. HRQOL independently explained 38.7 % of the variance in depressive symptoms (p < 0.05; standardized β = 0.695) in a multiple regression. When HRQOL and depressive symptoms were entered in the model simultaneously, only depressive symptoms independently predicted cardiac event-free survival (HR 1.068; 95 % CI 1.001-1.139), demonstrating a mediation effect of depressive symptoms. Conclusions: Depressive symptoms mediated the relationship between HRQOL and cardiac event-free survival. Interventions targeting HRQOL to enhance patient outcomes must also address patient depressive symptoms to be fully efficacious.

Original languageEnglish
Pages (from-to)1869-1876
Number of pages8
JournalQuality of Life Research
Issue number6
StatePublished - Aug 2014

Bibliographical note

Funding Information:
Acknowledgments Funding was received through NIH R01 NR008567 from the National Institute of Nursing Research and a Center grant from NIH National Institute of Nursing Research 1P20NR010679. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.


  • Depressive symptoms
  • Health-related quality of life
  • Heart failure
  • Survival

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health


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