Sertraline plus psychological intervention for acute myocardial infarction with anxiety-depression comorbidity: Cardiac function, adverse mood, and resilience impacts

Abstract

BACKGROUND

Medication compliance in patients with acute myocardial infarction (AMI) is often affected by negative emotions, hindering recovery.

AIM

To elucidate the effects of sertraline (STL) combined with psychological intervention on the cardiac function, adverse mood, and resilience in AMI patients with comorbid anxiety and depression (CAD).

METHODS

A total of 133 patients with AMI + CAD visiting our hospital between December 2021 and December 2024 were enrolled, including 60 patients receiving psychological intervention alone (control group) and 73 receiving STL in addition to the same intervention (research group). Data on cardiac function [cardiac output (CO), stroke volume (SV), left ventricular ejection fraction (LVEF)], adverse mood Hamilton Anxiety/Depression Scale (HAMA/HAMD), resilience Conner-Davidson Resilience Scale (CD-RISC), sleep quality Pittsburgh Sleep Quality Index (PSQI), and quality of life Short-Form 36 (SF-36) were analyzed.

RESULTS

Posttreatment, the research group showed significantly higher CO (4.94 ± 1.04 L/minute vs 4.25 ± 1.48 L/minute), SV (53.89 ± 7.89 mL vs 49.32 ± 5.39 mL), LVEF (64.47% ± 6.80% vs 58.30% ± 6.33%), CD-RISC (82.68 ± 6.74 vs 74.75 ± 6.23), and SF-36 scores [physical functioning: 75.74 ± 7.81 vs 70.65 ± 6.47; social functioning: 76.34 ± 7.49 vs 72.35 ± 6.98; role-emotional: 78.53 ± 7.05 vs 72.32 ± 6.92; mental health: 82.00 (76.00, 87.00) vs 77.00 (74.00, 79.00)], and lower HAMA (12.86 ± 3.65 vs 17.87 ± 4.29), HAMD (10.11 ± 2.90 vs 15.63 ± 3.04), and PSQI component scores than the control group.

CONCLUSION

The results indicate that STL combined with psychological intervention improves cardiac function, resilience, mood, sleep, and quality of life in AMI patients with CAD.

Key Words: Acute myocardial infarction; Comorbid anxiety and depression; Sertraline; Psychological intervention; Cardiac function

Core Tip: Acute myocardial infarction (AMI) complicated by anxiety and depression adversely affects treatment compliance and smooth recovery. This study evaluated whether adding sertraline (STL) to psychological intervention can further improve heart function, mood, and resilience of such patients. The results indicate that STL combined with psychological intervention was more effective than psychological intervention alone in improving cardiac function, mood, resilience, sleep, and quality of life, supporting its clinical value in managing AMI patients with comorbid anxiety and depression.

INTRODUCTION

Acute myocardial infarction (AMI), a coronary artery disease characterized by acute myocardial injury and ischemia, accounts for approximately 33.3% of global deaths[1,2]. In China alone, an estimated 500000 cases occur annually, with incidence continuing to rise[3].

Beyond its physical burden, AMI significantly impairs quality of life and life expectancy, often leading to psychological disorders, particularly anxiety and depression[4]. Comorbid anxiety and depression (CAD) not only compromise medication compliance but also increase the risk of recurrent cardiovascular adverse events, including coronary heart disease[5,6]. However, most current research focuses on evaluating the effectiveness of different treatment strategies for AMI, ignoring psychological impacts[7].

Although standard treatments, including medication and/or surgery, improve survival, patients often continue to experienced reduced working ability and require lifelong secondary prevention medications[8].

Psychological intervention aims to improve mental health by alleviating negative emotions (e.g., anxiety and depression), enhancing well-being, promoting treatment compliance, and encouraging healthy behaviors[9]. Sertraline (STL), a selective serotonin reuptake inhibitor (SSRI), has demonstrated superior efficacy and safety among SSRIs, particularly in managing poststroke depression[10]. Shapiro et al[11] reported a > 85% tolerability in patients with major depressive disorder (MDD) post-AMI, along with significant improvements in mood and clinical outcomes.

Based on the findings, we hypothesized that STL combined with psychological intervention would provide greater clinical benefits-particularly in cardiac function, emotional status, and resilience-than psychological intervention alone in patients with AMI + CAD. This study was conducted to test this hypothesis and provide reliable evidence to inform clinical management.

MATERIALS AND METHODS

Patient selection

This study included 133 patients with post-AMI CAD treated at our hospital between December 2021 and December 2024. Sixty patients received psychological intervention alone (control group), and 73 received additional STL (research group). The selection criteria were as follows.

Inclusion criteria: (1) Confirmed AMI diagnosis via coronary angiography[12]; (2) Age 18-80 years old; (3) New York Heart Association (NYHA) class II-IV[13]; (4) Cardiac troponin elevation > 99^th percentile of the upper normal limit; (5) 14-item Hamilton Anxiety Rating Scale (HAMA-14) ≥ 14 and 17-item Hamilton Depression Rating Scale (HAMD-17) ≥ 17[14]; and (6) Normal cognition; and complete clinical data.

Exclusion criteria: (1) History of mental illness or antidepressant use within one month; preexisting anxiety and depression before myocardial infarction; (2) Allergies or contraindications to study medication; (3) Severe hepatic or renal disease; (4) Coagulopathy or hematological diseases; and (5) Malignant tumors. Baseline data differed insignificantly between groups (P > 0.05), indicating comparability.

Intervention methods

The control group received standard medical therapy, including statins, aspirin, clopidogrel, nitrates, β-blockers, and calcium channel antagonists, along with psychological intervention. Psychological intervention was conducted by trained psychological physicians from the hospital twice weekly (30 minutes/session), with continuous monitoring and timely counseling. Interventions included: (1) Awareness education on AMI pathogenesis, treatment, medical compliance, and proper use of medication to reduce patients’ fear and anxiety; (2) Psychological counseling through active communication, emotional expression, stress relief, confidence building, and attention-diversion techniques; and (3) Family support, encouraging emotional support and reinforcing treatment confidence using successful case examples. The research group received STL (50 mg orally once daily) in addition to the above interventions. Both groups were treated for one month.

Data collection and outcome measures

Cardiac function: Cardiac output (CO), stroke volume (SV), and left ventricular ejection fraction (LVEF) were assessed via echocardiography pre and postintervention.

Adverse mood: Patients underwent pre- and postintervention anxiety and depression measurements using HAMA-14 (score range 0-56) and HAMD-17 (score range 0-52), respectively. HAMA-14 is an observer-rated scale with 14 items scored 0-4; 0 indicates symptom free and 4 indicates extremely severe symptoms. HAMD-17 includes 17 items, with 9 scored on a 5-point scale (0-4, with 0 indicating no symptom and 4 indicating extremely severe symptoms) and 8 on a 3-point scale (0-2, with 0 indicating no symptom and 2 indicating severe symptoms). Higher scores indicate greater severity[15].

Resilience: Patients’ resilience levels pre- and postintervention were assessed using the Conner-Davidson Resilience Scale (CD-RISC; total score 0-100), including strength (8 items), tenacity (13 items), and optimism (4 items). Each item is scored from 0 to 4, with higher scores indicating greater resilience[16].

Sleep quality: Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), comprising seven dimensions-sleep quality, latency, duration, efficiency, and disturbances, as well as hypnotic drug use and daytime dysfunction. Each dimension is scored from 0 to 3, totaling 21 points. Lower scores indicating better sleep quality[17].

Quality of life: Quality of life was assessed using the Short-Form 36 (SF-36). The scale has eight dimensions, with four selected for this study-physical functioning, social functioning, role-emotional, and mental health-with a total score of 0-100/dimension. Higher scores indicate better quality of life[18].

Statistical analysis

Continuous variables are presented as mean ± SD and were analyzed using independent and paired t-tests for between-group and within-group (pre- vs postintervention) comparisons, respectively. Categorical variables are expressed as n (%) and compared using the χ² test. Statistical analyses were performed using SPSS 20.0, with P < 0.05 considered statistically significant.

RESULTS

Baseline data of participants

Comparative baseline data analysis (Table 1) showed no significant inter-group differences in sex, age, disease duration, NYHA class, hypertension, diabetes, hyperlipidemia, or education level (P > 0.05).

Table 1 Baseline data comparison, n (%).

Indicators	Control group (n = 60)	Research group (n = 73)	χ2/t	P value
Sex			0.416	0.519
Male	32 (53.33)	43 (58.90)
Female	28 (46.67)	30 (41.10)
Age (years)	63.95 ± 6.24	64.18 ± 6.37	0.209	0.835
Disease duration (months)	6.62 ± 2.55	7.05 ± 3.08	0.865	0.389
NYHA classification			0.151	0.698
Grade I	25 (41.67)	28 (38.36)
Grade II	35 (58.33)	45 (61.64)
Hypertension	24 (40.00)	21 (28.77)	1.856	0.173
Diabetes	13 (21.67)	17 (23.29)	0.050	0.824
Hyperlipidaemia	16 (26.67)	18 (24.66)	0.070	0.792
Educational level			0.376	0.540
Below junior college	33 (55.00)	44 (60.27)
Junior college or above	27 (45.00)	29 (39.73)

NYHA: New York Heart Association.

Cardiac function analysis

Inter-group comparisons of cardiac function are presented in Figure 1. In the control and research groups, CO was 3.16 ± 0.83 L/minute and 3.00 ± 1.20 L/minute preintervention and 4.25 ± 1.48 L/minute and 4.94 ± 1.04 L/minute posttreatment, respectively. SV increased from 40.37 ± 7.27 mL and 40.92 ± 6.76 mL at baseline to 49.32 ± 5.39 mL and 53.89 ± 7.89 mL postintervention, respectively. LVEF increased from 45.98% ± 6.72% and 48.08 ± 6.37% preintervention to 58.30% ± 6.33% and 64.47% ± 6.80% postintervention, respectively. Baseline CO, SV, and LVEF differed insignificantly between groups (P > 0.05); all parameters increased significantly postintervention (P < 0.05), particularly in the research group (P < 0.05).

Figure 1 Cardiac function comparison A: Cardiac output comparison pre- and post-intervention; B: Stroke volume comparison before and after intervention; C: Left ventricular ejection fraction comparison pre- and post-intervention. ^aP < 0.05 and ^bP < 0.01 vs the pre-interventional level; ^cP < 0.05 vs control group at the same time point. CO: Cardiac output; SV: Stroke volume; LVEF: Left ventricular ejection fraction.

Adverse mood in two patient groups

HAMA and HAMD results are shown in Figure 2. HAMA scores decreased from 30.27 ± 5.49 preintervention to 17.87 ± 4.29 postintervention in the control group and from 30.52 ± 5.54 preintervention to 12.86 ± 3.65 postintervention in the research group. HAMD scores decreased from 24.67 ± 4.33 preintervention to 15.63 ± 3.04 postintervention in the control group and from 25.71 ± 3.90 preintervention to 10.11 ± 2.90 postintervention in the research group. Baseline scores were comparable across groups (P > 0.05). Both groups showed significant reductions postintervention (P < 0.05), with lower posttreatment scores in the research group than in the control group (P < 0.05).

Figure 2 Adverse mood comparison. A: Comparative analysis of Hamilton Anxiety Rating Scale before and after intervention; B: Hamilton Depression Rating Scale comparison pre- and post-intervention. ^aP < 0.05 and ^bP < 0.01 vs the pre-interventional level within the group; ^cP < 0.05 vs control group at the identical time point. HAMA: Hamilton Anxiety Rating Scale; HAMD: Hamilton Depression Rating Scale.

Resilience of two patient groups

CD-RISC results (Table 2) indicated no significant differences between groups in tenacity, strength, optimism, or total score (P > 0.05). All scores increased significantly postintervention (P < 0.05), with greater improvements in the research group (P < 0.05).

Table 2 Resilience of the two groups.

Indicators	Control group (n = 60)	Research group (n = 73)	Z/t	P value
Tenacity (points)
Before intervention	37.00 (33.00, 40.75)	38.00 (32.00, 43.00)	-0.765	0.444
After intervention	40.00 (38.00, 44.00)a	45.00 (41.00, 49.00)b	-5.093	< 0.001
Strength (points)
Before intervention	21.00 (19.00, 25.00)	24.00 (19.00, 27.00)	-1.646	0.100
After intervention	23.00 (21.25, 26.00)a	26.00 (23.00, 28.50)b	-3.137	0.002
Optimism (points)
Before intervention	7.00 (6.00, 9.00)	8.00 (6.00, 9.00)	-0.701	0.483
After intervention	10.00 (9.00, 12.00)a	12.00 (10.00, 13.50)b	-3.056	0.002
CD-RISC (points)
Before intervention	65.67 ± 7.46	68.23 ± 8.50	1.825	0.070
After intervention	74.75 ± 6.23a	82.68 ± 6.74b	6.985	< 0.001

^aP < 0.05 (intra-group comparison vs pre-intervention).

^bP < 0.01 (intra-group comparison vs pre-intervention).

CD-RISC: Conner-Davidson Resilience Scale.

Sleep quality assessment

PSQI results (Table 3) showed no significant baseline differences across dimensions (sleep quality, latency, duration, efficiency, and disturbances, as well as hypnotic drug use and daytime dysfunction; P > 0.05). All dimensions improved postintervention, with greater reductions in the research group than in the control group (P < 0.05).

Table 3 Sleep quality comparison.

Indicators	Control group (n = 60)	Research group (n = 73)	Z	P value
Sleep quality (points)
Before intervention	2.00 (1.00, 2.75)	1.00 (1.00, 3.00)	-1.013	0.311
After intervention	1.00 (1.00, 2.00)a	1.00 (0.00, 1.00)b	-5.263	< 0.001
Sleep latency (points)
Before intervention	2.00 (1.00, 2.75)	2.00 (1.00, 2.00)	-0.563	0.573
After intervention	1.00 (1.00, 2.00)a	1.00 (0.00, 1.00)b	-2.835	0.005
Sleep duration (points)
Before intervention	2.00 (1.00, 2.00)	1.00 (1.00, 2.00)	-1.424	0.155
After intervention	1.00 (1.00, 2.00)a	1.00 (1.00, 1.00)b	-2.494	0.013
Sleep efficiency (points)
Before intervention	2.00 (1.00, 2.00)	2.00 (1.00, 2.00)	-0.245	0.807
After intervention	1.00 (1.00, 2.00)a	1.00 (1.00, 1.50)b	-2.039	0.041
Sleep disturbances (points)
Before intervention	2.00 (1.00, 2.00)	2.00 (1.00, 3.00)	-0.349	0.727
After intervention	1.00 (1.00, 2.00)a	1.00 (1.00, 1.50)b	-2.319	0.020
Hypnotic drug use (points)
Before intervention	2.00 (1.00, 3.00)	2.00 (1.00, 2.00)	-0.451	0.652
After intervention	1.00 (1.00, 2.00)a	1.00 (1.00, 1.50)b	-2.248	0.025
Daytime dysfunction (points)
Before intervention	2.00 (1.25, 2.00)	2.00 (1.00, 2.00)	-1.284	0.199
After intervention	2.00 (1.00, 2.00)a	1.00 (1.00, 2.00)b	-2.646	0.008

^aP < 0.05 (intra-group comparison vs pre-intervention).

^bP < 0.01 (intra-group comparison vs pre-intervention).

Quality of life evaluation

SF-36 results (Table 4) demonstrated comparable baseline scores across domains (P > 0.05). All domains improved significantly postintervention (P < 0.05), with greater improvements in the research group (P < 0.05).

Table 4 Quality of life comparison.

Indicators	Control group (n = 60)	Research group (n = 73)	Z/t	P value
Physical functioning (points)
Before intervention	64.07 ± 7.68	62.36 ± 8.75	1.184	0.238
After intervention	70.65 ± 6.47a	75.74 ± 7.81b	4.036	< 0.001
Social functioning (points)
Before intervention	68.55 ± 6.66	68.64 ± 6.91	0.076	0.940
After intervention	72.35 ± 6.98a	76.34 ± 7.49b	3.152	0.002
Role-emotional (points)
Before intervention	65.72 ± 6.28	66.32 ± 6.81	0.524	0.602
After intervention	72.32 ± 6.92a	78.53 ± 7.05b	5.097	< 0.001
Mental health (points)
Before intervention	70.00 (65.00, 74.00)	71.00 (65.50, 76.00)	-1.162	0.245
After intervention	77.00 (74.00, 79.00)a	82.00 (76.00, 87.00)b	-4.012	< 0.001

^aP < 0.05 (intra-group comparison vs pre-intervention).

^bP < 0.01 (intra-group comparison vs pre-intervention).

DISCUSSION

As a major cause of mortality worldwide, AMI risk increases with age and shows a trend toward younger onset[19]. CAD is common in patients with AMI following percutaneous coronary intervention, and depressive symptoms may exacerbate disease progression[20]. However, studies focusing on AMI patients with CAD remain limited; therefore, this study conducted a targeted analysis.

This retrospective study first demonstrated that STL combined with psychological intervention significantly improved cardiac function (CO, SV, and LVEF) in AMI + CAD patients. McFarlane et al[21] reported that STL improved cardiac autonomic function in post-AMI depression, suggesting its ability to accelerate cardiac function recovery through neuroregulatory mechanisms. Finkel et al[22] reported that STL was superior to nortriptyline in efficacy and tolerability in older adults (≥ 70 years) with MDD, consistent with our findings. Moreover, STL is effective and safe for AMI patients with MDD and may reduce adverse cardiac events[23].

STL combined with psychological intervention also more effectively reduced anxiety and depression than psychological intervention alone. This effect may relate to STL-mediated inhibition of presynaptic Na⁺ channel activity in hippocampal nerve endings[24]. Another study on mice further suggests that STL reduces fear memory retrieval, partially explaining its anxiolytic and antidepressant effects[25]. Additionally, the combined intervention significantly improved resilience and sleep quality than psychological intervention alone. Finally, STL combined with psychological intervention significantly improved overall quality of life in AMI patients with CAD. Lewis et al[26] similarly reported improvements in anxiety, self-assessed mental health, and quality of life with STL in primary care surgeries.

Several previous studies have extensively evaluated STL in clinical applications. Chambergo-Michilot et al[27] reported synergistic effects of STL combined with omega-3 fatty acids in alleviating depressive or anxiety symptoms in adult patients with depression. O'Connor et al[28] found STL to be cost-effective in treating MDD in patients with unstable angina pectoris or recent AMI. Compared with placebo, it validly reduced the rates of psychiatric or cardiovascular hospitalizations without significantly increasing treatment costs. Liu and Qin[29] demonstrated comparable efficacy and cardiac safety between STL and Shugan Jieyu capsules in AMI patients with concurrent depression.

CONCLUSION

In summary, STL combined with psychological intervention is more effective than psychological intervention alone in patients with post-AMI CAD. It significantly improves patients’ cardiac function, reduces anxiety and depression, strengthens resilience, and improves sleep quality and overall quality of life, supporting its clinical application.