Stress Reactions and. Depression After. Cardiovascular Events

Transcription

1 Stress Reactions and Depression After Cardiovascular Events Kim G. Smolderen, PhD Tilburg University, the Netherlands Saint Luke s Mid America Heart Institute, Kansas City, MO ESC Munich 2012

2 Disclosures Dr. Smolderen is supported by an unrestricted grant from W.L. Gore & Associates, Inc. (Flagstaff, AZ)

3 Overview of Today s Presentation 1. Do we call it depression or stress? 2. Depression after a cardiac event major risk factor for adverse outcomes 3. Stress and outcomes after cardiac events gaps in knowledge 4. Challenges and future directions

4 Do We Call it Depression or Depression Stress? Stress Major depressive disorder (MDD) according to DSM- IV criteria depressive symptoms as assessed by self-report instruments ( MDD) Chronic stress Acute stress Global stress vs. eventspecific Objective vs. subjective measures of stress

5 Major Depressive Disorder (DSM-IV) 5 symptoms during at least 2 weeks; 1 of the core symptoms is (1) depressed mood; or (2) loss of interest or pleasure Depressed mood Loss of interest or pleasure Significant weight loss when not dieting or weight gain (or decrease or increase in appetite nearly every day. Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Diminished ability to think or concentrate, or indecisiveness recurrent thoughts of death, recurrent suicidal ideation

6 Self-Reported Depressive Symptoms Interview-based or self-administered Usually short instruments Most known instrument in cardiac disease: Patient Health Questionnaire 9-item version (PHQ-9)

7 PHQ-9 Can be used as a 2-step screening protocol; PHQ-2 followed by remaining 7 questions Positive Score on PHQ-2 triggers administration full PHQ-9. Scores 10 on PHQ-9 are indicative of clinically relevant depressive symptoms 7

8 Depression Awareness ESC Guidelines Depression and stress at work and in family life are a few of the psychosocial risk factors that are highlighted as risk factors for cardiovascular disease. Psychosocial risk factors should be assessed by clinical interview or standardized questionnaires. Tailored clinical management should be considered in order to enhance quality of life and CHD prognosis Perk et al.

9 What is Stress?

10 What is Stress? Situation or Event Appraisal (Primary) Perceived Threat No Threat Perceived Appraisal (Secondary) Perception of the Inability to Cope With the Threat Perception of the Ability to Cope With the Threat No Stress Negative Stress Positive Stress Lazarus & Folkman, 1964 Transactional Model of Stress

11 What is Stress? Acute Stress e.g. experiencing an MI Chronic Stress e.g. job stress, divorce process Global stress (e.g. daily hassles) vs. event-specific (bankruptcy) Objective measures # of events Biometric measurements (e.g., heart rate) Subjective measures Self-report instruments ( perceived stress ) Post-traumatic Stress Disorder (DSM-diagnosis)

12 Important to Note Expression and Severity of Major Depression is Commonly Associated with Stressful Experiences Magalhaes et al., 2010 in Nat Neurosci

13 Overview of Today s Presentation 1. Do we call it depression or stress? 2. Depression after a cardiac event major risk factor for adverse outcomes 3. Stress and outcomes after cardiac events gaps in knowledge 4. Challenges and future directions

14 Depression After a Cardiac Event Major Risk Factor for Adverse Outcomes Depression is common and persistent in acute myocardial infarction (AMI) survivors 1 in 5 MDD 1 in 3 clinically relevant depressive symptoms Only 1/3 rd of patients recognized as depressed during AMI admission Depression also a prevalent condition in other cardiovascular disorders (PAD, stroke, heart failure ) Thombs et al., 2006 in J Gen Int Med; Smolderen et al., 2009 in Circ Cardiovasc Qual Outcomes; Smolderen et al., 2010 in J Vasc Surg; Hacket et al., 2005 in Stroke

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16 Depression After a Cardiac Event Major Risk Factor for Adverse Outcomes Later replicated looking at Larger cohorts (2000+ patients) Longer follow-up studies Cardiac-specific mortality Wide range of cardiovascular pt groups Not only at risk of adverse prognosis but also: Quality of life affected Poorer adherence, lack of physical exercise Frasure-Smith et al., 1999 in Psychosom Med; Lesperance et al., 2000 in Arch Int Med; Lesperance et al in Circ; Frasure-Smith & Lesperance 2008 in Arch Gen Psych; Whooley et al., 2006 in JAMA; Smolderen et al., 2009 in Circ Cardiovasc Qual Outcomes

17 Overview of Today s Presentation 1. Do we call it depression or stress? 2. Depression after a cardiac event major risk factor for adverse outcomes 3. Stress and outcomes after cardiac events gaps in knowledge 4. Challenges and future directions

18 Stress and Outcomes After Cardiac Events Gaps in Knowledge Adverse effects of stress on cardiovascular system and link with incident cardiac disease Event-specific stress: Job strain Marital stress Financial strain Few studies evaluated the effect of chronic stress following an AMI on outcomes Rosengren et al., 2004 in Lancet; Iso et al, 2002; Matthews et al., 2002 in Arch Int Med; Theorell et al., 1991 in Int J Cardiol; Orth-Gomer et al., 2000 in JAMA; Aboa-Eboule et al., 2007 in JAMA; Georgiades et al., 2009 in Int J Cardiol

19 Stress and Outcomes After Cardiac Events Gaps in Knowledge Perceived Stress Scale 4 The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate with a check how often you felt or thought a certain way. 1. In the last month, how often have you felt that you were unable to control the important things in your life? 2. In the last month, how often have you felt confident about your ability to handle your personal problems? 3. In the last month, how often have you felt that things were going your way? 4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them? =never; 1=almost never; 2=sometimes; 3=fairly often; 4=very often Cohen et al., 1983 in Journal of Health and Social Behavior

20 Stress and Outcomes in the TRIUMPH Study AMI admission AMI 1-year disease-specific and generic health status 2-year AMI survival measurement of chronic perceived stress with PSS-4 in 4204 AMI survivors in the US (24 centers) Arnold SV, Smolderen KG, Buchanan DM, Li Y, Spertus JA. JACC, In Press

21 Months Stress and Outcomes in the TRIUMPH Study KM 2-year post AMI survival curves for patients with moderate/high stress levels (scores 6-16) vs. low stress levels (stress scores 0-5) 100 Low stress: n=2,582 (61%) Survival (%) 90 Moderate/ High stress: N=1,622 (39%) Low stress Moderate/high stress Log-rank p<

22 Multivariable-Adjusted* Hazard Ratios and Odds Ratios of the Association Between Moderate/High Stress Levels vs. Low Stress Levels and Long-Term Post- AMI Outcomes *Adjusted for age, sex, race, marital status, avoidance of care due to cost, hypertension, prior bypass surgery, diabetes, chronic lung disease, chronic heart failure, history of stroke or transient ischemic attack, BMI, anemia, depressive symptoms, STEMI, GRACE Risk Score, LVSD, in-hospital PCI, in-hospital bypass graft surgery, and the % of Performance Measures Received

23 PTSD Following an Acute Cardiac Event DSM-IV Criteria Criterion A: stressor Exposure to a traumatic event that involved actual or threatened death or serious injury or a threat to the physical integrity of oneself or others where there was intense fear, helplessness, or horror. Criterion B: intrusive recollection Persistently re-experiencing the event (recollections, dreams). Acting or feeling as if the event were recurring (flashbacks, illusions, hallucinations). Stress and/or physiologic reactivity at exposure to cues that are related to the event. Criterion C: Avoidance/Numbing Avoidance of stimuli associated with the trauma Criterion D: Hyper-arousal Persistent symptoms of increased arousal (e.g. difficulty concentrating, insomnia, ) Criterion E: Duration is 1 month Criterion F: Functional significance Clinically significant distress or impairment in social, occupational, or other important areas of functioning.

24 ~15% meets TSD criteria

25 PTSD Following AMI and Adverse Prognosis Source Diagnostic Tools Type of Trauma Subjects Control for Cardiovasc ular Risk Factors Cardiovascular Endpoints Shemesh et al., 2004 in Psychosom Med IES MI 65 male and female post- MI patients; 20% with PTSD None Higher rate of cardiovascular readmissions (composite index of reinfarction, unstable angina, hypertensive complications, indications of heart failure) in PTSD patients and with more PTSD symptoms Boscarino, 2006 in Ann Epidemiol DIS (DSM- III), Research Triangle Institute PTSD Scale Combat exposure or any other trauma 7924 male veterans, 11% with PTSD Age, race Higher cardiovascular mortality in PTSD patients 30 years after military service

26 To Summarize Reactions of depression and stress are very common after an acute cardiovascular event Not always clear whether they were preexistent prior to acute event or a reaction to the acute event Regardless, depression and stress following an acute cardiovascular event are very impactful in terms of patients quality of life and cardiovascular prognosis

27 Overview of Today s Presentation 1. Do we call it depression or stress? 2. Depression after a cardiac event major risk factor for adverse outcomes 3. Stress and outcomes after cardiac events gaps in knowledge 4. Challenges and future directions

28 Challenges and Future Directions Psychological comorbidities are poorly recognized Often a lack of resources to effectively organize psychological screening/assistance Physician awareness for these problems needs to be increased Lack of consensus on how to assess and followup on these comorbidities

29 Challenges and Future Directions Psychological/psychiatric conditions discussed are treatable Promote better recognition of depression and stress through more robust standards and guidelines Increase awareness for these conditions among treating cardiovascular specialists Large intervention trials needed A screening program only works if a well thought out collaborative care program is in place

30 The Chronic Care Model Community Health Systems Resources and policies Organization of Health Care Self-Management Support Delivery System Design Decision Support Clinical Information Systems Improved Outcomes Wagner 1998

31 Thank You

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