Depression and 18-month prognosis after myocardial infarction

Psychiatric aspects of cardiovascular disease

The co-occurrence of psychiatric and cardiac disease in many patients exemplifies the complexity of psychosomatic medicine, with both psychosomatic and somatopsychic effects. Psychological factors including depression, anxiety, and hostility influence the development, clinical expression, and prognosis of coronary heart disease. Depression and anxiety are especially common problems complicating cardiac disease. The physician must approach the patient with an appreciation of the confounding aspects of diagnosis and a readiness to think flexibly about the nature of the problems encountered. SSRIs play an increasingly prominent role in psychopharmacotherapy of this population. Innovative treatments in cardiology, such as heart transplantation, defibrillators and mechanical ventricular assist devices are associated with characteristic psychiatric problems for which psychiatrists must devise treatment strategies.

Is anxiety early after myocardial infarction associated with subsequent ischemic and arrhythmic events?

OBJECTIVE

Acute myocardial infarction is often accompanied by anxiety, but the effect of this emotion on recovery is unclear. The purpose of this study was to determine the association between patient anxiety early after acute myocardial infarction and the incidence of subsequent in-hospital complications.

METHODS

We assessed anxiety level within 48 hours of patient arrival at the hospital in 86 confirmed myocardial infarction patients. Anxiety was measured using the Brief Symptom Inventory. Myocardial infarction complications were defined as reinfarction, new onset ischemia, ventricular fibrillation, sustained ventricular tachycardia, or in-hospital death.

RESULTS

More complications were seen in patients with higher versus lower levels of anxiety (19.6% vs 6%; p = .001). Multiple logistic regression was used to control for those clinical and sociodemographic factors that can influence the incidence of complications and demonstrated that higher anxiety level was independently predictive of complications. Patients with higher anxiety levels were 4.9 times (p = .001) more likely to have subsequent complications.

CONCLUSIONS

Anxiety early after myocardial infarction onset is associated with increased risk of ischemic and arrhythmic complications. This finding suggests that anxiety should be considered among the conventional risk factors for in-hospital acute myocardial infarction complications.

Personality as independent predictor of long-term mortality in patients with coronary heart disease

BACKGROUND

Emotional distress has been related to mortality in patients with coronary heart disease (CHD), but little is known about the role of personality in long-term prognosis. We postulated that type-D personality (the tendency to suppress emotional distress) was a predictor of long-term mortality in CHD, independently of established biomedical risk factors.

METHODS

We studied 268 men and 35 women with angiographically documented CHD, aged 31-79 years, who were taking part in an outpatient rehabilitation programme. All patients completed personality questionnaire at entry to the programme. We contacted them 6-10 years later (mean 7-9) to find out survival status. The main endpoint was death from all causes.

FINDINGS

At follow-up, 38 patients had died; there were 24 cardiac deaths. The rate of death was higher for type-D patients than for those without type-D (23 [27%]/85 vs 15 [7%]/218; p < 0.00001). The association between type-D personality and mortality was still evident more than 5 years after the coronary event and was found in both men and women. Mortality was also associated with impaired left ventricular function, three-vessel disease, low exercise tolerance, and the lack of thrombolytic therapy after myocardial infarction. When we controlled for these biomedical predictors in multiple logistic regression analysis, the impact of type-D remained significant (odds ratio 4.1 [95% CI 1.9-8.8]; p = 0.0004). In this group of CHD patients, type-D was an independent predictor of both cardiac and non-cardiac mortality. Social alienation and depression were also related to mortality, but did not add to the predictive power of type-D.

INTERPRETATION

We found that type-D personality was a significant predictor of long-term mortality in patients with established CHD, independently of biomedical risk factors. Personality traits should be taken into account in the association between emotional distress and mortality in CHD.

Psychosocial characteristics and recurrent events after percutaneous transluminal coronary angioplasty

This study examines the effect of anger and vital exhaustion on recurrent events after percutaneous transluminal coronary angioplasty (PTCA). Data came from 149 patients (123 men and 26 women) who underwent successful PTCA. During 18 months of follow-up, there were 37 recurrent events (25%) for which there was objective evidence of new or progression of coronary disease. The 123 male patients with high anger were significantly more likely to have multivessel disease before PTCA (odds ratio 2.42; p = 0.04), after controlling for standard heart disease risk factors. High-anger male patients also had a threefold increased risk for recurrent events after PTCA (RR 2.94; p = 0.01), which remained marginally significant after accounting for other heart disease risk factors and residual stenosis after PTCA (RR 2.33; p = 0.09). Among female patients, these relations were much weaker and not statistically significant. Among male patients, additional adjustment for vital exhaustion did not change the risk for recurrent events associated with high anger. A composite index of psychosocial risk based on anger and vital exhaustion was significantly related (p = 0.02) to events after PTCA after adjustment for standard heart disease risk factors. These findings add to the growing body of research on the role of psychosocial factors on clinical course in patients with coronary artery disease.

Psychosocial factors: role in cardiac risk and treatment strategies

Recent epidemiologic research has identified several psychosocial factors that impact unfavorably on prognosis among patients with established coronary heart disease (CHD). Several biologic and behavioral characteristics have been identified in patients with these psychosocial risk factors that are biologically plausible mediators of their adverse impact on prognosis. Several small-scale clinical trials offer encouraging evidence that both behavioral and pharmacologic interventions have the potential to ameliorate the health-damaging effects of psychosocial risk factors in patients with CHD. In this article we review the evidence on these points and offer recommendations as to how incorporation of this new knowledge into clinical care of the patient with CHD can lead to reduced mortality and morbidity rates in this population.

On the Inseparability of Mental and Physical Health in Aged Persons: Lessons From Depression and Medical Comorbidity

Recent research findings demonstrate that general medical and mental health are inseparable in older individuals. The medical consequences of depression can be summarized with the unifying hypothesis that depression interacts with medical or neurological illness to modify the course of disease and to amplify its associated effects. The medical causes of depression can be divided into specific mechanisms of certain diseases or medications and general mechanisms that may integrate effects of a number of the common chronic disorders of late life. The authors discuss two general hypotheses: One suggests that depression may be associated with subclinical cerebrovascular disease in older patients with cerebrovascular risk factors; the other suggests that depression occurring in association with various conditions may be related to cytokine-mediated "sickness behavior." The research literature makes a compelling case for the need to address psychiatric-medical comorbidity in late life as a central issue in public policy and the design of health care systems.