Effects of Depression on Risks and Prognosis of CV Disease

1. Effects of Depression on Risks and Prognosis of CV Disease Chad D. Foster

2. 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???

3. 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 S/Sx of Depression

4. 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, hypertriglyceridemia, hypertension, as well as increased heart rate. Hypothalamic Pituitary Adrenal (HPA)

5. 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

6. 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.

7. 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.

8. So what are some of the problems??

9. 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!)

10. MI • You tell me what it is

11. 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 • Tx=tPa (3 hrs, must get to ER quick), angioplasty, or surgery to stop bleeding.

12. 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.

13. 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

14. 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

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

16. 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.

17. 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

18. 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

19. 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.