Depression and CAD

Sep 28, 2018   |  Aimee Pragle, PA-C

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Introduction

Patients with coronary artery disease (CAD) often have multiple chronic diseases and conditions that can be treated to improve overall outcomes. These include hypertension, hyperlipidemia, diabetes mellitus, obesity, nicotine dependence, and physical inactivity. At each clinical visit, the goal is to include pharmacological and non-pharmacological interventions to treat these conditions and reduce cardiovascular risk. In addition, depression is another disease that needs to be identified and treated in patients with CAD. Research shows that clinically significant depression affects between 20% and 40% of patients with CAD.1 Patients with CAD have a higher prevalence of depression than the general population.2

Over 25 years ago, the seminal research of Frasure-Smith et al. identified that depression is a significant predictor of mortality in patients with CAD following a myocardial infarction (MI).3 Since that initial research, numerous studies have demonstrated that patients with comorbidities of CAD and depression have poorer health outcomes.4-8 Due to this evidence, in 2014 the American Heart Association presented a scientific statement with the recommendation that depression following acute coronary syndrome should be considered as a risk factor for cardiac morbidity and mortality.9

Research Trials and Studies

The TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) trial was the first study to evaluate the association between patients with acute MI and depression who received treatment for their depression versus those who did not receive treatment for depression. A total of 4,062 patients was enrolled from 24 hospitals in the United States. Findings showed that patients with acute MI and untreated depression had a 70-90% higher 1-year mortality risk than patients without depression or with treated depression.10 Based on these findings, the recommendation of the TRIUMPH research team is that depression screening should be included as a protocol in caring for AMI patients so that early intervention can be implemented to reduce mortality risks.10

The ENRICHD (Enhancing Recovery in Coronary Heart Disease) randomized trial identified patients with a recent MI who met criteria for minor or major depression. Patients were randomized to usual medical care or cognitive behavior therapy (CBT), supplemented with selective serotonin reuptake inhibitor (SSRI) treatment if indicated.11 A total of 2,481 patients was enrolled from 8 clinical centers. Results demonstrated that patients who received CBT intervention showed an improvement in depression and social isolation. However, there was no reduction in mortality or recurrent infarction when the usual medical care and CBT groups were compared. Based on these findings, the researchers of the ENRICHD trial recommend that patients be evaluated for depression following an MI and, if identified, should receive follow-up and treatment as necessary.11

The CREATE (Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy) trial sought to determine if providing treatment with citalopram, an SSRI, and interpersonal psychotherapy to patients with CAD and major depression would reduce depressive symptoms.12 A total of 284 patients from 9 Canadian academic centers participated in the trial. Results showed that citalopram was superior to placebo in reducing depressive symptoms, and interpersonal psychotherapy did not offer any additive benefits when compared with usual clinical management alone. Based on these results, the CREATE research team recommends that a first-step treatment for patients with CAD and major depression is to consider citalopram or sertraline plus clinical management in their care.12

A recent research study completed through the Intermountain Heart Institute found that patients with a diagnosis of depression at any point following a diagnosis of CAD had a two-fold higher risk of death than those patients with CAD and no diagnosis of depression.13 This study included 24,137 patients who had angiographically determined CAD (stenosis ≥70%). In addition, depression was found to be a stronger predictor of death than any other risk factor or comorbidity and was independent of baseline characteristics and CAD severity.13 Based on these findings, the researchers from the Intermountain Heart Institute recommend that during follow-up care for patients with CAD, depression screening should be routinely implemented on a continual basis.

Summary

The significant strides in advancement of therapies for patients with CAD are numerous. Interventions such as surgical revascularization, medication developments, and treatment of risk factors have contributed to the overall decrease in mortality in patients with CAD.14 However, despite these improvements, there continues to be a need for increased focus on diagnosing and treating patients with CAD and depression to improve health outcomes. As discussed, recommendations based on research trials and studies include the following:

  1. Regular depression screening as a protocol for patients with CAD
  2. Consideration of CBT and supplementation of SSRI (citalopram or sertraline) as needed for treatment of patients with major depression and CAD

Effective depression screening tools that can be applied in the clinical setting include Beck's Depression Inventory, Hamilton Depression Rating Scale, Patient Health Questionnaire, and Cross Cutting Level I of Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.15-17 In addition to the standard measurements of blood pressure, lipids, body mass index, and A1C levels that are done for patients with CAD, depression screenings should be conducted to ensure that this important risk factor is identified and treated because its treatment can contribute to reducing morbidity and mortality.

References

  1. Celano CM, Huffman JC. Depression and cardiac disease: a review. Cardiol Rev 2011;19:130-42.
  2. Lett HS, Blumenthal JA, Babyak MA, et al. Depression as a risk factor for coronary artery disease: evidence, mechanisms, and treatment. Psychosom Med 2004;66:305-15.
  3. Frasure-Smith N, Lespérance F, Talajic M. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993;270:1819-25.
  4. Glassman AH, Shapiro PA. Depression and the course of coronary artery disease. Am J Psychiatry 1998;155:4-11.
  5. Barefoot JC, Brummett BH, Helms MJ, Mark DB, Siegler IC, Williams RB. Depressive symptoms and survival of patients with coronary artery disease. Psychosom Med 2000;62:790-5.
  6. Khawaja IS, Westermeyer JJ, Gajwani P, Feinstein RE. Depression and coronary artery disease: the association, mechanisms, and therapeutic implications. Psychiatry (Edgmont) 2009;6:38-51.
  7. Chaddha A, Robinson EA, Kline-Rogers E, Alexandris-Souphis T, Rubenfire M. Mental Health and Cardiovascular Disease. Am J Med 2016;129:1145-8.
  8. Jackson CA, Sudlow CLM, Mishra GD. Psychological Distress and Risk of Myocardial Infarction and Stroke in the 45 and Up Study. Circ Cardiovasc Qual Outcomes 2018;11:e004500.
  9. Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations: a scientific statement from the American Heart Association. Circulation 2014;129:13-69.
  10. 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.
  11. Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA 2003;289:3106-16.
  12. Lespérance F, Frasure-Smith N, Koszycki D, et al. Effects of citalopram and interpersonal psychotherapy on depression in patients with coronary artery disease: the Canadian Cardiac Randomized Evaluation of Antidepressant and Psychotherapy Efficacy (CREATE) trial. JAMA 2007;297:367-79.
  13. 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.
  14. Writing Group Members, Mozaffarian D, Benjamin EJ, et al. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2016;133:e38-360.
  15. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.
  16. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
  17. Worboys M. The Hamilton Rating Scale for Depression: The making of a "gold standard" and the unmaking of a chronic illness, 1960-1980. Chronic Illn 2013;9:202-19.

Keywords: Depression, Coronary Artery Disease, Angina, Stable


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