MRCGP Exam Update - Managing depression and MI

Current situation 

- In the UK, depression is the third most common reason for a person to consult with a GP.

- Depression is often associated with medical comorbidity. Depression is also present in over 45 per cent of patients who are admitted to hospital following a myocardial infarction (MI).

- Patients with depression and heart disease have poorer medical outcomes including increased risk of reinfarction and all-cause mortality.

- Depressive symptoms are present in around one third of patients with heart failure.

- Prevalence of depression is higher in younger women with acute MI than in men (Arch Intern Med 2006; 166: 991).

What is the evidence?

- One study has shown that depression is a clinically significant risk factor for developing coronary heart disease (CHD), especially in men and women aged 25 to 50 (Am J Prev Med 2005; 29: 428).

- Up to 20 per cent of patients have a major depressive episode within a few weeks of having an MI (BHF Factfile, August 2005).

- Patients with depression following an acute coronary syndrome have a poorer cardiac outcome (Am Heart J 2005; 150: 54)

- Patients with depression have been shown to have much smaller gains in physical functioning following coronary bypass surgery (Circulation 2005; 111: 250).

- SSRIs have proved to be effective in the treatment of depressive symptoms in patients with CHD and one also safe from the cardiovascular point of view (BMJ 2004; 328: 939).

- There are some indications that SSRIs may be beneficial in terms of cardiac morbidity (Arch Gen Psych 2005; 62: 792).

- Although antidepressant treatments are effective in treating depression in medically ill patients, their impact on medical outcomes has yet to be quantified (Curr Opin Psych 2006; 19: 421).

Implication for practice

- Depression is linked with a poorer quality of life and less successful rehabilitation.

- Patients with depression are less likely than other patients to comply with their medication and are more likely to be sedentary.

- Tricyclic antidepressants may be cardiotoxic and should be avoided.

- Because depression after an MI has been associated with adverse outcomes, younger women may benefit from aggressive screening and treatment of post-MI depression.

Useful websites

www.bhf.org.uk/factfiles

- Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners', Pas Test 2006.

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