Transcript Effects of Depression on Risks and Prognosis of CV Disease

Effects of Depression on Risks
and Prognosis of CV Disease
Chad D. Foster
Background Info
• CV Disease kills 1 in 3 people in the US.
• Heart disease has been the biggest killer
of Americans since 1900, excluding one
year.
• What year was it and what was the #1
killer of Americans that year???
S/Sx of Depression
• Hopelessness
• Pessimism
• Feeling of
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worthlessness
Loss of interest in
hobbies or activities
that were once
enjoyed
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Decreased energy
Fatigue
Insomnia
Thoughts of death of
suicide
Change in appetite or
weight
Hypothalamic Pituitary Adrenal
(HPA)
• Depressed patients tend to
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have higher levels of
cortisol
The increased cortisol levels
cause negative feedback to
the anterior Pituitary and
Hypothalamus
This dysregulation is related
to many cardiovascular
disease risk factors such as
obesity,
hypercholesterolemia,
hypertriglyceridemia,
hypertension, as well as
increased heart rate.
Depression and Inflammation
-Who would have thought?
• Research also supports that depression leads to
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inflammation
So what is the big deal about inflammation?
It may contribute to the development and
clinical manifestations of CAD
The body responds to hypercholesterolemia and
hypertension by an inflammatory response
which can contribute to atherosclerosis
Inflammation Cont.
• It has been shown in both the general
population as well as CAD patients that
there is in fact a link between depression
and inflammation.
• The inflammation can in turn cause the
development of more CAD risk factors
such as the metabolic syndrome.
Depression and Platelet activityNo I am not kidding
• Higher levels of platelet factor IV and beta
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thromboglobulin have been demonstrated in
depressed patients
Platelet activity is a significant risk factor for
developing atherosclerosis, acute coronary
syndromes, and thrombosis
Serotonin has been shown to increase platelet
activity, which lead to an over reactive platelet
response and platelet aggregation in depressed
individuals
This is why it is imperative to give CAD patients
with depression anti-platelet medications to
prevent platelet aggregation and clotting.
So what are some of the
problems??
CAD-What in the heck is it?
• This condition occurs when the coronary
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arteries, carrying oxygenated blood to the heart,
become narrowed or even blocked by plaque in
the walls of the arteries
The underlying causes of the plaque build up are
things such as hypercholesterolemia,
hypertension, diabetes and smoking
TX: angioplasty, stent, CABG (oh NO!)
MI
• You tell me what it is
Stroke
• A stoke occurs when the arteries supplying the
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brain with blood, the carotid and vertebral
arteries, become obstructed (ischemic) or burst
(hemorrhagic)
Nerve cells then begin to slowly die, thus
effecting the part of the body controlled by the
corresponding portion of dying brain cells
Tx=tPa (3 hrs, must get to ER quick),
angioplasty, or surgery to stop bleeding.
Post Cardiovascular Event
Depression
• 25% of patients experience depression
after a CV event.
• Duke study- 19% of depressed post CV
event patients died while 10% died who
weren’t depressed.
Depression after MI
• Depression after MI causes decreased quality of
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life as well as increased mortality.
Symptoms of depresion after an MI have been
associated with an increased risk of recurrent
cardiac events
Older post-MI patients with depression have
more comorbidities than older patients without
depression and have almost four times the risk
of dying within the first 4 months after
dischanged than non-depressed patients
Stroke-The Same Story
• Depressed patients didn’t recover to the
extent that non-depressed patients do
• Depression after stroke leads to a 3.4-fold
increase in mortality up to 10 years after
the incident stroke
Dx of Depression
• Beck Depression Inventory.
• 21 questions that the patient self-reports
on.
• Good track record, and is used in most
offices today.
Example question
• 9.
(0) I don't have any thoughts of killing
myself.
(1) I have thoughts of killing myself, but I
would not carry them out.
(2) I would like to kill myself.
(3) I would kill myself if I had the chance.
How to interpret results
• 1-10These ups and downs are
considered normal
11-16 Mild mood disturbance
17-20Borderline clinical depression
21-30Moderate depression
31-40Severe depression
over 40Extreme depression
Tx of Depression
• SSRIs always a good choice.
• Ask if patient has ever been on anti-depressant.
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How did it work for them?
Couple of notes:
1.) The triccyclics are generally not used to treat
depression in CAD patients because it can have
a cardiotoxic effect on heart rate and rhythm
2.) MOAIs generally are not prescribed either,
because they can interact with tyramine (found
in fish, chocolate, alcohol, soy beans, cheese,
and processed meat) and can cause an increase
in blood pressure, leading to stroke
Conclusions
Depression is associated both with the initial
development of CVD as well as worsening
outcomes of existing CVD
 Because the overwhelming majority of PAs
practice in a clinical setting, its puts us in an
excellent position to screen for depression.
 Clinicians who increase their awareness and
treatment of depression will effectively lower the
number of cardiovascular events, as well as
reduce mortality associated with postcardiovascular event depression.
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