Depression, hostility, and social isolation in patients with coronary artery disease
- 56 Downloads
Psychosocial risk factors such as depression, hostility, and social isolation are substantially more prevalent in patients with coronary artery disease (CAD) than is widely recognized. It has been demonstrated that patients with CAD who have these risk factors, individually or together, may have a substantially increased risk for recurrent ischemic events, as well as cardiac death, when compared with unaffected CAD patients. Numerous adverse physiologic changes that appear to occur as a consequence of these psychosocial risk factors have been identified, including increased platelet aggregation, hyperadrenergic states, elevated cortisol levels, abnormal endothelial function, and an increased propensity towards malignant ventricular arrhythmias. Each of these may explain the increased risk of recurrent coronary events (including death) among afflicted patients.
Under-recognition, and hence under-treatment, remains a principal obstacle for improvements in the care of patients with CAD who have psychosocial risk factors. The diagnosis of psychosocial risk factors depends on systematic patient evaluation by experienced clinicians trained in the recognition of these disorders. All clinicians must be aware of the potential importance of these factors, their sometimes subtle presenting characteristics, and the available treatment options. The universal use of comprehensive cardiovascular rehabilitation offers the ideal conduit for such evaluation and management.
Nonpharmacologic therapies for psychosocial risk factors include psychotherapy, stress-reduction techniques, and exercise therapy. Studies suggest that the reduction of social isolation among depressed patients with CAD may result in a reduced mortality rate in comparison with those without improvements in isolation. Pharmacologic therapies are mainly for the management of depression, and largely center on the use of selective serotonin reuptake inhibitors (SSRIs). Several SSRIs (paroxetine and sertraline) recently have been shown to be safe and effective for the treatment of depression in patients with ischemic heart disease. Whether use of antidepressants attenuate the increased cardiac risk from depression in the setting CAD remains to be proven; however, their use improves the quality of life in properly selected patients.
KeywordsCoronary Artery Disease Paroxetine Sertraline Social Isolation Bupropion
Unable to display preview. Download preview PDF.
References and Recommended Reading
- 1.Januzzi JL, Stern TA, Pasternak RC, DeSanctis RW: The influence of anxiety and depression on outcomes of patients with coronary artery disease. Arch Intern Med 2000, 160:1913–1921. A comprehensive review of two common psychosocial risk factors among patients with CAD and their effects on outcomes. Includes an extensive list of references.PubMedCrossRefGoogle Scholar
- 2.Rozanski A, Blumenthal JA, Kaplan J: Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999, 99:2192–2217. A well-written summary of both experimental and clinical data supporting the link between psychosocial risk factors and CAD.PubMedGoogle Scholar
- 3.Frasure-Smith N, Lesperance F, Talajic M: Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993, 270:1819–1825. A landmark paper demonstrating that depression is not only common following acute MI, but is associated with a fourfold increase in mortality.PubMedCrossRefGoogle Scholar
- 4.Frasure-Smith N, Lesperance F, Talajic M: Depression and 18-month prognosis after myocardial infarction. Circulation 1995, 91:999–1005. The follow-up of Frasure-Smith et al.’s original study , which demonstrates a persistently negative effect from depression on the prognosis of patients with CAD over 18 months of follow-up.PubMedGoogle Scholar
- 5.Lesperance F, Frasure-Smith N, Juneau M, Theroux P: Depression and 1-year prognosis in unstable angina. Arch Intern Med 2000, 160:1354–1360. A recent published study that suggests that the risk of depression not only extends to patients with acute MI, but also to those with unstable angina pectoris as well.PubMedCrossRefGoogle Scholar
- 16.Berkman LF, Leo-Summers L, Horowitz RI: Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly. Ann Intern Med 1992, 117:1003–1009. A landmark study demonstrating a significant increase in mortality among socially isolated elderly patients.PubMedGoogle Scholar
- 18.Knox SS, Siegmund KD, Weidner G, et al.: Hostility, social support, and coronary heart disease in the National Heart, Lung, and Blood Institute Family Heart Study. Am J Cardiol 1998, 82:1192–1196. A well-designed study examining the effects of hostility and social isolation on the development of CAD.PubMedCrossRefGoogle Scholar
- 25.Enhancing recovery in coronary heart disease patients (ENRICHD): study design and methods. The ENRICHD investigators. Am Heart J 2000, 139:1–9.Google Scholar
- 27.Frasure-Smith N, Lesperance F, Gravel G, et al.: Social support, depression, and mortality during the first year after myocardial infarction. Circulation 2000, 101:1919–1924. An important article that suggests that high levels of social support are associated with an attenuation in the risk from depression and CAD.PubMedGoogle Scholar
- 31.qRx: Electronic Pharmacopeia, version 4.0 [computer software]. San Francisco: Epocrates, Inc; 2001.Google Scholar