A 54-year-old woman presents to the office for a follow-up visit 6 months after an inferior ST-segment elevation myocardial infarction (MI). She underwent timely revascularization of the right coronary artery with a drug-eluting stent at the time of her MI and has had normal right and left ventricular function. Post MI, the patient underwent cardiac rehabilitation. Since the MI, she has had intermittent episodes of chest discomfort that are unrelated to exertion and not relieved by nitroglycerin. She had a stress echocardiogram 2 months ago that was normal. She denies any episodes of shortness of breath on exertion, palpitations, or pedal edema. The patient reports that for the past 6 months, she has been feeling very fatigued and has significant difficulty sleeping at night. She spends a lot of her time worrying about her health and that she might die of another heart attack. She has not returned back to her job as a school teacher and has lost interest in activities that she previously enjoyed like reading and hiking. On examination, the patient's temperature is 98.2 degrees F, heart rate is 86 bpm, and blood pressure is 128/74 mmHg. She is saturating 98% on room air, and her physical examination is unremarkable. The patient is currently on aspirin 81 mg daily, clopidogrel 75 mg daily, metoprolol 25 mg twice daily, and rosuvastatin 40 mg daily. She has been compliant with all her medications.
Which of the following interventions is recommended at this time?
Show Answer
The correct answer is: C. Patient Health Questionnaire-9 screening and consider selective serotonin reuptake inhibitors
This is a patient with history of an MI who now presents with symptoms suggestive of depression. The Patient Health Questionnaire-9 is a readily available, simple screening questionnaire that can help evaluate underling depressive disorder in this patient. Patients with coronary artery disease (CAD) have a higher prevalence of depression than the general population (estimated between 20% and 40% of patients with CAD), and depression has been linked to worse mortality and morbidity in patients with underlying CAD.1 Available evidence is strongly supportive of improved long-term cardiovascular outcomes with the treatment of depression in patients with acute coronary syndromes and CAD.2 If the Patient Health Questionnaire-9 score is suggestive of depression, then management can include behavioral therapy, selective serotonin reuptake inhibitors, or referral to a psychiatrist based on the severity of depression.
Reassuring the patient at this time is not a good choice because she does have symptoms of an underlying illness that can be treated if diagnosed in a timely manner. The patient has CAD that was previously revascularized, and her current symptoms do not appear to be related to angina. Increasing the beta-blocker dose in this setting may not offer any additional benefit. Stress echocardiography will not provide any prognostic information in the absence of anginal or heart failure symptoms and is not indicated at this time.
References
May HT, Horne BD, Knight S, et al. The association of depression at any time to the risk of death following coronary artery disease diagnosis. Eur Heart J Qual Care Clin Outcomes 2017;3:296-302.
Smolderen KG, Buchanan DM, Gosch K, et al. Depression Treatment and 1-Year Mortality Following Acute Myocardial Infarction: Insights from the TRIUMPH Registry. Circulation 2017;135:1681-9.
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