The presentation discusses the epidemiology, mechanism, screening and diagnosis of depression and cardiovascular disease and how to mange this association

1. E.Mahfouz, CardioEgypt 2008

2. By
Essam Mahfouz, MD
Professor of Cardiology, Mansoura
University

3. Introduction
Epidemiology
Definitions and diagnosis
Depression and CAD
Pathophysiologic mechanisms
Depression and HF
Unresolved issues
Take home messages

4. A figurative interdependence between the heart
and sadness has long existed in language and in
literature.
In 1628, English physician William Harvey noted
“every affection of the mind that is attended either
with pain or pleasure, hope or fear, is the cause of
an agitation whose influence extends to the heart”
1970s-epidemiologists start to associate/correlate
heart disease and depression.

6. Depression is a mood disturbance characterized by
feelings of sadness, despair, and loss of interest or
pleasure in activities. It include:
Major depressive episode
Dysthymia
The key features of the depressive disorders are:
Low mood;
Reduced energy; and
Loss of interest or enjoyment

7. Loss of
Interest
Guilty
Thoughts
Reduced
Self
Confidence
Poor
Concent.
Sleep &
Appetite
Disturb.
Pessimism
Suicide
Reduced
Energy
Low
mood
Key
features of
depression
SIGECAPS

8. E.Mahfouz, CardioEgypt 2008

9. Major depression strikes 10-15% of adults,
affecting all racial, ethnic, age, and
socioeconomic groups. It's twice as common in
women as in men and is especially prevalent
among adolescents.
Depression is associating 20-30% of patients
with cardiac disease
Recently new risk factors for CAD have been
identified, among them emotional distress and
depression. With 1.5-2 fold increase in CAD

10. Relative risk for myocardial infarction in patients
with depressive symptoms versus non-depressive
patients ranged from 1.5 to 4.5
The prevalence of depression was about 17% in
patients with stable CAD and about 25% in
patient with acute MI while minor depressive
symptoms ranged from 27 to 65 %
Depressed patients with stable coronary disease
are much more likely to perceive greater coronary
symptom burden and physical limitation
compared to non-depressed coronary patients

11. Depressed patients with ACS was shown to have
poor quality of life and functional disability than
non depressed patient
In patients with CABG, it has been shown that
depression diagnosed before surgery was related to
higher hospital re-admission rates and was an
independent risk factor for cardiac events after
surgery

12. Depression is now a recognized independent risk
factor of CAD.
Patients with MDD and type 2 DM have 30%
increased risk of AMI but patients with both
disorders have 82% risk ( Scherrer et al diabetic care 2011)
Post-MI patients with a depressive disorder or self-
reported depressive symptoms carry a 2.0- to 2.5
fold increased relative risk of new CV events and
cardiac mortality*
However, why depression is a risk factor for poor
prognosis is unclear

14. de Jonge et al JACC,2006

15. Lesperance et al, Circulation 2002;105:1049–53
Long-term survival after MI in relation to Beck
Depression Inventory Score during hospitalization

16. Hypothalamic-adrenocortical and sympatho-
adrenal effects
Cortisol.
Blood glucose.
Cholesterol.
Free fatty acids.
Insulin.
Hematological effects
Plasma fibrinogen.
Platelets aggregation.
Platelet factor 4.
B-Thromboglobulin.

17. Cardiac autonomic dysregulation
Arrhythmias ( sinus tachycardia to SCD)
Decreased heart rate variability.
Increased Q-T dispersion
Cardiac and vascular effects
Carotid-intima media thickness.
Endothelial dysfunction.
Left ventricular mass.

18. Inflammatory markers
Increased CRP
Other markers ( IL6, TNF, adhesion molecules) show
controversial data
Increased Abs to certain viruses e.g. Epstein Barr,
CMV& HS
Behavioral mechanisms:
Delay in seeking medical treatment
Failure of risk factors modifications:
• Smoking cessation
• Control of DM
Poor adherence to medications

19. Genetic factors
Depression and CHD may be different phenotypic
expressions of the same genetic substrates
Depression may be genetically related to other CAD risk
factors
Depression and vascular disease may share certain
vulnerability genes

22. Most are never diagnosed
Even when diagnosed, the treatment
options are unclear
No evidence-based clinical guidelines
available

23. PHQ 2
Over the past 2 weeks, how often have you been
bothered by any of the following problems?
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
If the answer is yes to either question -- go to
PHQ 9

24. Over the past 2 weeks, how often have you been
bothered by any of the following problems?
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling asleep, staying asleep, or sleeping
too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself, feeling that you are a
failure, or feeling that you have let yourself or your
family down.

25. 7. Trouble concentrating on things such as reading
the newspaper or watching television.
8. Moving or speaking so slowly that other people
could have noticed. Or being so fidgety or restless
that you have been moving around a lot more
than usual.
9. Thinking that you would be better off dead or
that you want to hurt yourself in some way.
Questions are scored: not at all0; several days1;
more than half the days2; and nearly every day3.
< 10 Minor 10-20 moderate > 20 major

26. Enhancing Recovery In Coronary Heart Disease
(ENRICHD) trial is RC clinical trial evaluated 2481
patients with evidence of depression after
myocardial infarction who either underwent
treatment for depression (cognitive behavioural
therapy) or usual care.
Despite the treatment group's improvements in
depression and social support, there was no
significant difference in event-free survival
(mortality and recurrent infarction) after an
average follow-up of 29 months, between usual care
(75.9%) and psychosocial intervention (75.8%).

27. Tricyclic antidepressant TCA are contraindicated
in cardiac patients due to:
1. Postural hypotension
2. Arrhythmogenic effects
3. Drug interactions
Monamine oxidase inhibitors MAOI
1. Drug and food interactions
2. Second line treatment in cardiac patient
Serotonine receptor reuptake inhibitors SSRI:
1. More safer and effective
2. Drug interaction with B-Blockers, digitalis, warfaren,

28. Sertraline was found to be safe and effective in
treatment of depression after AMI in SADHRT
trial
Also, citalopram proved to be safe and effective
even than behavioral Treatment in CREAT study
Paroxetine was found to be safe in cardiac patient
in 2 small trials

29. It is reasonable to consider screening SIHD
patients for depression and to refer or treat when
indicated.
Treatment of depression has not been shown to
improve cardiovascular disease outcomes but
might be reasonable for its other clinical benefits.
I IIa IIb III
I IIa IIb III
Management of Psychological
Factors

30. The authors report that the severity of left
ventricular (LV) dysfunction is significantly related
to the severity of depressive symptoms during the
hospitalization.
LV dysfunction was strongly associated with BDI
scores
Use of B-Blockers was not associated with increase
in depressive symptoms
The effect of different depression treatment on CV
mortality is not published yet
Van Melle et. al. Eur. Heart J. 2005 and JACC 2006

31. Van Melle et. al. Eur. Heart J. 2005

33. Major depression was present in 21.5% of patients
with HF
Prevalence of depression increases with the
increased severity of heart failure
There was a strong correlation between the
presence of depression and the poor prognosis in
patient with HF
Treatment of depression though did not affect the
prognosis, it improves compliance to therapy and
quality of life in HF patients
Rutledge et. Al. JACC 2006

34. Milani et.al Am. J Cardiol. 2011

35. Albert et. Al. Am. J Med. 2009

36. Albert et. Al. Am. J Med. 2009

37. CAD and depression which problem lead to the
other
Treatment of depression in patient with CAD have
any implication on the prognosis of cardiovascular
affection
The best line of treatment of depression in
CAD patient whether behavioral
therapy or drugs or combination of both

38. Depression is common disorder that affect 10-15% of
the general population and associated with 20-30% of
cardiac patients
This association was more in CAD, HF, HTN &
arrhythmias
The mechanism of this association is multifactorial,
involving endocrinal, autonomic, inflammatory,
hematological & genetic factors
Although, this association increased morbidity and
mortality of cardiac disease the implication of
treatment of depression on cardiovascular mortality is
not clear

39. Routine screening of cardiac patient especially
CAD for depression is very useful for management
of both comorbidities
Patients with cardiac disease who are under
treatment for depression should be carefully
monitored for adherence to their medical care,
drug efficacy, and safety with respect to their
cardiovascular as well as mental health.
Coordination of care between healthcare providers
is essential in patients with combined medical and
mental health diagnoses.