Effects of Depression on Risks and Prognosis of CV Disease

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Effects of Depression on Risks and Prognosis of
CV Disease

• Chad D. Foster

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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???

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S/Sx of Depression

• Hopelessness
• Pessimism
• Feeling of worthlessness
• Loss of interest in hobbies or activities that
  were once enjoyed

• Decreased energy
• Fatigue
• Insomnia
• Thoughts of death of suicide
• Change in appetite or weight

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Hypothalamic Pituitary Adrenal (HPA)

• Depressed patients tend to 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, hypertriglyceridemi
  a, hypertension, as well as increased heart rate.

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Depression and Inflammation -Who would have
thought?

• Research also supports that depression leads to
  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

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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.

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Depression and Platelet activity-No I am not
kidding

• Higher levels of platelet factor IV and beta
  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.

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So what are some of the problems??
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CAD-What in the heck is it?

• This condition occurs when the coronary 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!)

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MI

• You tell me what it is

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Stroke

• A stoke occurs when the arteries supplying the
  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
• TxtPa (3 hrs, must get to ER quick),
  angioplasty, or surgery to stop bleeding.

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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 werent
  depressed.

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Depression after MI

• Depression after MI causes decreased quality of
  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

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Stroke-The Same Story

• Depressed patients didnt 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

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Dx of Depression

• Beck Depression Inventory.
• 21 questions that the patient self-reports on.
• Good track record, and is used in most offices
  today.

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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.

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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

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Tx of Depression

• SSRIs always a good choice.
• Ask if patient has ever been on anti-depressant.
  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

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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
  post-cardiovascular event depression.