Effects of Depression on Effects of Depression on Risks and Prognosis of CV Risks and Prognosis of CV

Disease Disease

Chad D. FosterChad D. Foster

Background InfoBackground Info

• CV Disease kills 1 in 3 people in the CV Disease kills 1 in 3 people in the US.US.

• Heart disease has been the biggest Heart disease has been the biggest killer of Americans since 1900, killer of Americans since 1900, excluding one year.excluding one year.

• What year was it and what was the What year was it and what was the #1 killer of Americans that year???#1 killer of Americans that year???

S/Sx of DepressionS/Sx of Depression

• HopelessnessHopelessness

• PessimismPessimism

• Feeling of Feeling of worthlessnessworthlessness

• Loss of interest in Loss of interest in hobbies or hobbies or activities that were activities that were once enjoyedonce enjoyed

• Decreased energy Decreased energy

• Fatigue Fatigue

• InsomniaInsomnia

• Thoughts of death Thoughts of death of suicideof suicide

• Change in appetite Change in appetite or weightor weight

Hypothalamic Pituitary Adrenal Hypothalamic Pituitary Adrenal (HPA)(HPA)

• Depressed patients tend to Depressed patients tend to have higher levels of have higher levels of cortisolcortisol

• The increased cortisol The increased cortisol levels cause negative levels cause negative feedback to the anterior feedback to the anterior Pituitary and HypothalamusPituitary and Hypothalamus

• This dysregulation is related This dysregulation is related to many cardiovascular to many cardiovascular disease risk factors such as disease risk factors such as obesity, obesity, hypercholesterolemia, hypercholesterolemia, hypertriglyceridemia, hypertriglyceridemia, hypertension, as well as hypertension, as well as increased heart rate. increased heart rate.

Depression and Inflammation Depression and Inflammation -Who would have thought?-Who would have thought?

• Research also supports that depression Research also supports that depression leads to inflammationleads to inflammation

• So what is the big deal about inflammation?So what is the big deal about inflammation?

• It may contribute to the development and It may contribute to the development and clinical manifestations of CADclinical manifestations of CAD

• The body responds to hypercholesterolemia The body responds to hypercholesterolemia and hypertension by an inflammatory and hypertension by an inflammatory response which can contribute to response which can contribute to atherosclerosis atherosclerosis

Inflammation Cont.Inflammation Cont.

• It has been shown in both the general It has been shown in both the general population as well as CAD patients population as well as CAD patients that there is in fact a link between that there is in fact a link between depression and inflammation. depression and inflammation.

• The inflammation can in turn cause The inflammation can in turn cause the development of more CAD risk the development of more CAD risk factors such as the metabolic factors such as the metabolic syndrome.syndrome.

Depression and Platelet Depression and Platelet activity-activity-

No I am not kiddingNo I am not kidding• Higher levels of platelet factor IV and beta Higher levels of platelet factor IV and beta

thromboglobulin have been demonstrated in thromboglobulin have been demonstrated in depressed patients depressed patients

• Platelet activity is a significant risk factor for Platelet activity is a significant risk factor for developing atherosclerosis, acute coronary developing atherosclerosis, acute coronary syndromes, and thrombosis syndromes, and thrombosis

• Serotonin has been shown to increase Serotonin has been shown to increase platelet activity, which lead to an over platelet activity, which lead to an over reactive platelet response and platelet reactive platelet response and platelet aggregation in depressed individuals aggregation in depressed individuals

• This is why it is imperative to give CAD This is why it is imperative to give CAD patients with depression anti-platelet patients with depression anti-platelet medications to prevent platelet aggregation medications to prevent platelet aggregation and clotting.and clotting.

So what are some of the So what are some of the problems??problems??

CAD-What in the heck is it?CAD-What in the heck is it?

• This condition occurs when the coronary This condition occurs when the coronary arteries, carrying oxygenated blood to the arteries, carrying oxygenated blood to the heart, become narrowed or even blocked heart, become narrowed or even blocked by plaque in the walls of the arteries by plaque in the walls of the arteries

• The underlying causes of the plaque build The underlying causes of the plaque build up are things such as up are things such as hypercholesterolemia, hypertension, hypercholesterolemia, hypertension, diabetes and smoking diabetes and smoking

• TX: angioplasty, stent, CABG (oh NO!)TX: angioplasty, stent, CABG (oh NO!)

MIMI

• You tell me what it isYou tell me what it is

StrokeStroke

• A stoke occurs when the arteries supplying A stoke occurs when the arteries supplying the brain with blood, the carotid and vertebral the brain with blood, the carotid and vertebral arteries, become obstructed (ischemic) or arteries, become obstructed (ischemic) or burst (hemorrhagic)burst (hemorrhagic)

• Nerve cells then begin to slowly die, thus Nerve cells then begin to slowly die, thus effecting the part of the body controlled by effecting the part of the body controlled by the corresponding portion of dying brain cellsthe corresponding portion of dying brain cells

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

Post Cardiovascular Event Post Cardiovascular Event DepressionDepression

• 25% of patients experience 25% of patients experience depression after a CV event.depression after a CV event.

• Duke study- 19% of depressed post Duke study- 19% of depressed post CV event patients died while 10% CV event patients died while 10% died who weren’t depressed. died who weren’t depressed.

Depression after MIDepression after MI• Depression after MI causes decreased Depression after MI causes decreased

quality of life as well as increased mortality.quality of life as well as increased mortality.

• Symptoms of depresion after an MI have Symptoms of depresion after an MI have been associated with an increased risk of been associated with an increased risk of recurrent cardiac events recurrent cardiac events

• Older post-MI patients with depression have Older post-MI patients with depression have more comorbidities than older patients more comorbidities than older patients without depression and have almost four without depression and have almost four times the risk of dying within the first 4 times the risk of dying within the first 4 months after dischanged than non-months after dischanged than non-depressed patients depressed patients

Stroke-The Same StoryStroke-The Same Story

• Depressed patients didn’t recover to Depressed patients didn’t recover to the extent that non-depressed the extent that non-depressed patients dopatients do

• Depression after stroke leads to a Depression after stroke leads to a 3.4-fold increase in mortality up to 3.4-fold increase in mortality up to 10 years after the incident stroke 10 years after the incident stroke

Dx of DepressionDx of Depression

• Beck Depression Inventory.Beck Depression Inventory.

• 21 questions that the patient self-21 questions that the patient self-reports on.reports on.

• Good track record, and is used in Good track record, and is used in most offices today.most offices today.

Example questionExample question

• 9.9.(0) I don't have any thoughts of (0) I don't have any thoughts of killing myself.killing myself.(1) I have thoughts of killing myself, (1) I have thoughts of killing myself, but I would not carry them out.but I would not carry them out.(2) I would like to kill myself. (2) I would like to kill myself. (3) I would kill myself if I had the (3) I would kill myself if I had the chance. chance.

How to interpret results How to interpret results

• 1-101-10These ups and downs are These ups and downs are considered normal considered normal 11-1611-16 Mild mood disturbance Mild mood disturbance 17-2017-20Borderline clinical depression Borderline clinical depression

21-3021-30Moderate depression Moderate depression 31-4031-40Severe depression Severe depression over 40over 40Extreme depression Extreme depression

Tx of DepressionTx of Depression• SSRIs always a good choice.SSRIs always a good choice.• Ask if patient has ever been on anti-Ask if patient has ever been on anti-

depressant. How did it work for them?depressant. How did it work for them?• Couple of notes:Couple of notes:• 1.) The triccyclics are generally not used 1.) The triccyclics are generally not used

to treat depression in CAD patients to treat depression in CAD patients because it can have a cardiotoxic effect on because it can have a cardiotoxic effect on heart rate and rhythm heart rate and rhythm

• 2.) MOAIs generally are not prescribed 2.) MOAIs generally are not prescribed either, because they can interact with either, because they can interact with tyramine (found in fish, chocolate, alcohol, tyramine (found in fish, chocolate, alcohol, soy beans, cheese, and processed meat) soy beans, cheese, and processed meat) and can cause an increase in blood and can cause an increase in blood pressure, leading to stroke pressure, leading to stroke

ConclusionsConclusions Depression is associated both with the Depression is associated both with the

initial development of CVD as well as initial development of CVD as well as worsening outcomes of existing CVD worsening outcomes of existing CVD

Because the overwhelming majority of PAs Because the overwhelming majority of PAs practice in a clinical setting, its puts us in practice in a clinical setting, its puts us in an excellent position to screen for an excellent position to screen for depression. depression.

Clinicians who increase their awareness Clinicians who increase their awareness and treatment of depression will effectively and treatment of depression will effectively lower the number of cardiovascular events, lower the number of cardiovascular events, as well as reduce mortality associated with as well as reduce mortality associated with post-cardiovascular event depression. post-cardiovascular event depression.