Depression and Cardiovascular Disease

Question 1

Associations between depression and averse outcomes in CVD

Answer 1

• depression increases risk of CAD by 1.5-2x in otherwise healthy individuals
• depression may account for 3% of DALYs due to ischemic heart disease
• 3% of general population is depressed vs. 20-30% of cardiac pts are depressed
• predicts mortality after acute coronary syndrome
• dose-response relationship: prognosis related to severity of depression
• predicts adverse outcomes among heart failure patients (mortality and rehospitalization)
• strongly associated w/poorer patient health status (e.g. symptoms burden, physical limitation,

Question 2

Major types of mechanisms for association of depression and CAD

Answer 2

• physiologic mechanisms

- behavioral barriers to optimal CV care

Question 3

Tx for depresson that improve outcomes for CV pts

Answer 3

• sertraline=SSRI –> used in pts w/ACS –> safe and improved depressive sx and quality of life
• telephone-delivered depression care
• collabortive care program = antidepressants + psychotherapy (IMPACT study)

Question 4

merits of depression screening in CV pts

Answer 4

• 75% of depressed ACS pts go unrecognized

- can screen with 2 simple questions, and further w/PHQ-9 (patient health questionnaire)

Question 5

Physiologic derangements in depression

Answer 5

• depressive symptoms –> high adrenergic state:
• autonomic dysfunction
• elevated cortisol
• platelet activation
• endothelial dysfunction
• inflammation

Question 6

Amygdala role in physiological regulation & depression

Answer 6

• perceives stress/fear –> mounts flight or fight response
• fxnl MRI shows hyperreactive amygdala in depressive patients
• constant fear –> high stress response
• hypothesis: defective serotonin signaling –> amygdala dysfxn –> autonomic dysfxn and hypercortisolemia

Question 7

Behavioral mechanisms linking depression and CVD

Answer 7

• depressed patients –> much less adherence to meds
• more likely to smoke
• much less physically active
• less likely to engage in health care system and follow-up

Question 8

Depression treatment impact on outcomes

Answer 8

• definitely improves: depression, quality of life, physiology
• not definitively known to improve: adherence, costs of care, CV events

Question 9

First line tx of depression in cardiac pts

Answer 9

• SSRIs = effective, safe, cost-effective
• buproprion (Wellbutrin) = anti-depressant + smoking cessation aid
• cognitive behavior therapy/problem solving therapy
• exercise training/cardiac rehabilitation

Question 10

Cardiac tx for depression considerations

Answer 10

• patient education about tx expectations
• structured follow-up
• dose/med adjustment
• mental health for complicated/refractory cases

Question 11

Summary of Depression in CVD

Answer 11

• depression is predictive of developing CVD
• depression is prevalent among and associated w/adverse outsomes in CV pts
• several mechanisms may explain these associations (biologic and behavioral)
• there are safe and effective screening and tx strategies