nMRCGP Exam Update - Depression and heart disease

Current situation- Depression is often associated with medical comorbidity and is present in over 45 per cent of patients admitted to hospital after an MI.

  • Depressed patients with heart disease have poorer medical outcomes, including increased risk of reinfarction and all-cause mortality.
  • Depressive symptoms are also present in around one third of patients with heart failure.
  • The prevalence of depression is high in younger women with acute MI (Arch Intern Med 2006; 24: 876-83).

What is the evidence?

  • One study has shown that depression is a clinically significant risk factor for developing CHD, especially in men and women aged between 25 and 50 (Am J Prev Med 2005; 29: 428-33).
  • A meta-analysis showed that depressed mood moderately increased the risk of cardiovascular disease.Patients with clinically diagnosed major depression had the highest risk for cardiovascular disease, which equalled the risk of smoking and diabetes (Int J Geriatr Psychiatry 2007; 22: 613-26).
  • However, depression during hospitalisation for an MI does not predict a higher risk for death in the long term (Am J Cardiol 2008; 101: 602-6).
  • A recent study found that patients with coronary artery disease who suffer from depression and/or anxiety are more likely to have major adverse cardiac events than those without psychiatric disorders (Arch Gen Psychiatry 2008; 65: 62-71).
  • SSRIs have proved to be effective in the treatment of depressive symptoms in cardiac patients, and are also safe from the cardiovascular point of view (BMJ 2004; 328: 939-43).
  • A recent study found no added benefit of psychotherapy for patients with coronary artery disease and depression (JAMA 2007; 297: 367-9).

Implications for practice

  • Depression is linked with a poorer quality of life and less successful rehabilitation.
  • Depressed patients are less likely than other patients to comply with 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 - who represent a high-risk group - may benefit particularly from aggressive screening and treatment for post-acute MI depression.
  • Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners', PasTest 2006.

Summary points

  • Depression is very common in patients with heart disease.
  • SSRIs seem to be effective.
  • Young women are at a high risk of depression.

Useful websites: www.bhf.org.uk/factfiles

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