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Psych aspects of CVD

Psych aspects of CVD

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Psych aspects of CVD

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  1. Psychiatric Aspects of Cardiovascular Disease Dr. Rashed J. AlHamdan M.D. FRCPC

  2. Psych Aspects of CVD • Clinicians have long observed that many patients with coronary heart disease (CHD) seem to be compulsive, driven overachievers who are unable to relax and are quick to feel angry and frustrated. • Anger, hostility, antagonistic interactions, cynicism, and mistrust have now been associated in long-term, prospective studies with the incidence of CHD, coronary events, and total mortality.

  3. Psych Aspects of CVD • In general it appears that hostility and anger may predispose more to the initial cardiac event than adversely influencing the course of already established CHD. • Although more research is necessary, it does appear that anger and hostility play some role in the development of CHD.

  4. Psych Aspects of CVD • Denollet et al, have examined the effect on CHD outcomes of “type D personality,” a set of traits that combine a pattern of anxious and depressive feelings with a tendency toward social inhibition and isolation. • This group has shown in several controlled studies that people who score high on the 14-item type D questionnaire have higher early mortality rates from CHD disease.

  5. Psych Aspects of CVD • Depression is prevalent in CHD patients but is consistently under-diagnosed by their cardiologists and primary care physicians. • Clinically significant depressive symptoms are found in 40% to 65% of patients following MI, and major depressive disorder is found in 15% to 25% of such patients. • In one study, 31.5% of patients with MI experienced major depression while in the hospital or in the year following discharge.

  6. Psych Aspects of CVD • The prevalence of depression is also elevated in patients with stable CHD who have not had a recent MI and in patients who have undergone CABG. • Depression is often chronic: 75% of the patients with major depression 2 weeks after a MI remain depressed 3 months later.

  7. Psych Aspects of CVD • Clinically significant depression was present in 21.5% of HF patients, and varied by the use of questionnaires versus diagnostic interview (33.6% and 19.3%, respectively) and New York Heart Association– defined HF severity (11% in class I vs. 42% in class IV), among other factors.

  8. Psych Aspects of CVD • Combined results suggested higher rates of death and secondary events (risk ratio 2.1, 95% c.i. 1.7 to 2.6), trends toward increased health care use, and higher rates of hospitalization and emergency room visits among depressed patients.

  9. Psych Aspects of CVD • Although most subjects in these studies have been men, the risk of depression in women with CHD is twice as high as that of men. • Depression is important in itself because of the considerable suffering it imposes. In addition, depression exacerbates and amplifies cardiac symptoms.

  10. Psych Aspects of CVD • Depressed CHD patients have more severe cardiac symptoms than non-depressed CHD patients, even after controlling for the severity of cardiac disease: 1-They have more angina during exercise treadmill testing, 2-They terminate the exercise treadmill test sooner, and 3-They have more persistent angina following MI.

  11. Psych Aspects of CVD • Depression adversely affects compliance with medical therapy, and it is detrimental to cardiac rehabilitation. • Depression also predicts a slower resumption of activities, poorer social readjustment, a lower likelihood of returning to work, and poorer quality of life following MI.

  12. Psych Aspects of CVD • Depression both worsens the prognosis of established CHD and constitutes a risk factor for the development of CHD in healthy individuals; that is, it confers an increased risk of cardiac mortality in both those with and without CHD at baseline.

  13. Psych Aspects of CVD • In patients with documented CHD, depression predicts future cardiac events and is associated with significantly elevated rates of cardiac mortality, mostly as a result of sudden cardiac death (SCD). • Following MI, depression increases the risk of reinfarction, cardiac arrest, and death, after adjusting for CHD severity.

  14. Psych Aspects of CVD • This risk is elevated for women as well as men, and is not limited to major depressive disorder but also includes milder depressive symptoms. • There is a continuous, linear relationship between the severity of depression and the risk of subsequent cardiac events.

  15. Psych Aspects of CVD • For longer follow-up periods, from 5 to 15 years, the relative risk of recurrent MI or cardiac mortality associated with depression is between 1.5 and 6, after controlling for disease severity, smoking, diabetes, and age in multivariate analyses. • The degree of risk associated with depression is as great as that associated with traditional risk factors (e.g., cholesterol, smoking) and is largely independent of them.

  16. Psych Aspects of CVD • Much of the increased cardiac mortality associated with depression appears to be attributable to SCD caused by arrhythmias. This suggests that the effect of depression may be more arrhythmogenic than atherogenic. • An interaction effect may exist, in which the co-occurrence of depression with ventricular arrhythmias constitutes a particularly ominous prognostic factor.

  17. Psych Aspects of CVD • Depression also appears to be a risk factor for the development of CHD in healthy individuals, though the evidence here is somewhat less conclusive. • In prospective studies of initially healthy community residents without a history of CHD, depression has been associated with an adjusted relative risk between 1.5 and 2 for the subsequent development of CHD, MI, and cardiac death over 6- to 40-year periods in men and women, independent of the other risk factors.

  18. Psych Aspects of CVDBehavioral Mechanisms • Depressed individuals take poorer care of themselves; are less physically active; pay less attention to diet; drink more alcohol; smoke more and have worse quitting rates; have less motivation and energy to exercise regularly; and may be less likely to seek medical care.

  19. Psych Aspects of CVDBehavioral Mechanisms • Depression is associated with poorer adherence to the medical regimen and to cardiac risk factor modification and rehabilitation, and depressed patients are more likely to drop out of exercise programs. • Depressed patients undergo revascularization procedures (PCI and CABG) less frequently than those without psychiatric disorders, even after adjusting for disease severity.

  20. Psych Aspects of CVDPathophysiological Mechanisms • There many pathophysiological mechanisms that can link depression to CHD. • First, depression results in autonomic arousal and hypothalamic-adrenocortical and sympathoadrenal hyperactivity.

  21. Psych Aspects of CVDPathophysiological Mechanisms • Depressed patients show hyperactivity of the hypothalamic-pituitary-adrenocortical axis and hypercortisolemia, and corticosteroids have atherogenic effects including the induction of high blood pressure and increases in cholesterol and free fatty acids, as well as possible effects on arterial endothelial function.

  22. Psych Aspects of CVDPathophysiological Mechanisms • There is also hypersecretion of norepinephrine in depression. Plasma catecholamines stimulate HR, BP, and myocardial oxygen consumption. • Catecholamines are also proarrhythmic, and an increased incidence of ventricular tachyarrhythmias has been found in depressed patients. (This observation is compatible with the finding that SCD accounts for a large share of the excess cardiac mortality found in depressed CHD patients.).

  23. Psych Aspects of CVDPathophysiological Mechanisms • Second, depressed cardiac patients exhibit diminished heart rate variability, resulting from a relative increase in sympathetic tone and/or a relative decrease in parasympathetic tone, which increases the risk of fatal arrhythmias.

  24. Psych Aspects of CVDPathophysiological Mechanisms • Third, depression may be accompanied by changes in platelet aggregability. Serotonin plays a major role in depression, and it is also known to influence thrombogenesis and enhance platelet activation and responsiveness to other thrombogenic agents. • Serotonin reuptake inhibitor antidepressants appear to normalize this platelet hyperactivity seen in depression.