BHF resources
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• Depression is a risk factor for future coronary heart disease, and is also common in patients with clinical coronary disease and congestive • Depressive symptoms following acute coronary events are associated with increased cardiovascular morbidity, impairment in quality of life, and greater versions of our Factfiles fromour website • Depressed mood can be assessed using short questionnaires in patients who have been discharged from hospital following acute cardiac events or cardiac Our research
surgery, and in individuals suffering from heart failure. Positive scores should be followed up with further evaluation.
• Discuss issues of adherence to medication and lifestyle advice with patients who are identified as depressed. If patients have been prescribed drugs for secondary prevention, ensure that these are being taken reliably. • Consider treatment with selective serotonin uptake inhibitors in patients Introduction
Depression is a common problem in patients following acute cardiac events
such as myocardial infarction. Up to 20% of individuals have a major depressive
episode within a few weeks, and a further 25% experience minor depression
or elevated levels of depressive symptoms.
Depressive symptoms are present in around one quarter of patients withcongestive heart failure as well. It used to be thought that depressed mood was a normal part of coming to terms with the cardiac event and had no lastingimpact on health, but this is not the case. Depression and cardiovascular health
Research over the last 15 years has demonstrated that patients who are
depressed in the weeks following an acute coronary syndrome have a poorer
cardiac outcome.1 Most studies have found at least a twofold increase in
death and recurrent cardiac events over the first 12 months after discharge
from hospital. Depression is also linked with greater use of health services,
poor quality of life and less successful rehabilitation.
Outcome is worst for the seriously depressed, but even patients with moderatelydepressed mood tend to have less good cardiovascular health over the next fiveyears. The same pattern is present in patients with congestive heart failure, withan increased risk of early mortality in depressed individuals.2 Depressed patientsalso show smaller gains in physical functioning following coronary arterybypass surgery.
Why is depression bad for cardiovascular health? We do not completely understand the mechanisms through which H. Depression as an aetiologic and prognostic factor in coronary heart depression affects cardiovascular health. However, it is linked with several biological processes that influence vascular pathology, including dysfunction events among 146 538 participants in 54 observational studies. Eur Heart of the vascular endothelium and activation of platelets. 2. Rutledge T, Reis VA, Linke SE, Greenberg Depressed individuals have reduced heart rate variability that is indicative BH, Mills PJ. Depression in heart failure of disturbances in cardiac autonomic control, and alterations in the secretion a meta-analytic review of prevalence, intervention effects, and associations of the stress hormone cortisol.3 Additionally, depressed people are less likely than other patients to adhere to treatment advice and take medication reliably, and tend to be more sedentary. Thus biological and behavioural factors may both contribute to the link between depression and poor et al. Psychophysiological biomarkers explaining the association between depression and prognosis in coronary artery patients: A critical review of the literature. Neurosci Biobehav Rev Depression is known to be a risk factor for coronary disease, an association 4. Lichtman JH, Bigger JT, Jr., Blumenthal that is independent of standard risk factors such as smoking, hypertension JA, et al. Depression and coronary heartdisease: recommendations for and high cholesterol levels.1 This means that some patients suffering with acute coronary disease will have experienced depression before their a science advisory from the American Heart Association Prevention cardiac event, while in others the depressed mood will be a new experience. Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on There is some evidence that new onset depression is more cardiotoxic, but findings have not been completely consistent. Depressive problems Interdisciplinary Council on Qualityof Care and Outcomes Research: can be reliably assessed by clinical interviews and simple questionnaires such as the Hospital Anxiety and Depression scale or the Patient Health Association. Circulation2008;118:1768-75.
Questionnaire administered following discharge from hospital.4 High scoreson these measures will identify the majority of individuals who are 5. Thombs BD, de Jonge P, Coyne JC, et al. depressed. However, care is needed in the interpretation of somatic symptoms of depression such as fatigue, since these may also be signs a systematic review. JAMA 2008;300:2161-71.
M, et al. Safety and efficacy of Sertraline Management of depression
for depression in patients with heart failure results of the SADHART-CHF The management of depression in cardiac patients is a field of intense clinical investigation at the moment. The only randomised clinical trial published Heart Disease in Chronic Heart Failure) Trial. J Am Coll Cardiol 2010;56:692-699.
to date that was statistically powered to assess cardiac outcomes was a comparison of cognitive-behaviour therapy with usual care. This showed 7. Pizzi C, Rutjes AW, Costa GM, Fontana F, modest effects on depression, but no differences in event free survival.5 Cardiac rehabilitation programmes that incorporate stress management in patients with depression andcoronary heart disease. Am J Cardiol methods such as The Heart Manual developed by the BHF Care and Education Research Group lead to decreases in depressive symptomlevels, though whether they reduce future cardiac morbidity is not known. Factfile is an information resource producedby the British Heart Foundation for GPs based Selective serotonin uptake inhibitors (SSRIs) have proved quite effective on up to date clinical evidence and expert in the treatment of the depressive symptoms of patients with coronary heart opinion. As a digest of many data sources, it is necessarily the culmination of assessments disease, but have less effect on patients with heart failure.5,6 But there is made by the BHF’s medical professionals andshould not be taken as a definitive statement no robust evidence to date that treatment with SSRIs is beneficial in terms of correct clinical practice in any given situation. Consequently, the BHF is notable of cardiac morbidity and mortality.7 Other medications, in particular tricyclic to give any warranties in relation to particular anti-depressants, may have cardiac side effects and should be avoided.
clinical decisions taken or courses of treatment or action pursued based upon the information contained in the Factfiles.
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