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Pharmacy Times
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Depression often preys on patients with cardiac conditions.
Depression often preys on patients with cardiac conditions.
Coronary heart disease (CHD)— also referred to as coronary artery disease and related to ischemic heart disease and atherosclerosis—is the leading cause of death and disability in the United States.1 Pathophysiology involves multiple pathways, resulting in damage to the inner walls of arteries, which then become susceptible to hard, fatty plaque deposits (atherosclerosis). These deposits narrow the arteries and decrease oxygen- and nutrient-rich blood flow to the heart.1 Symptoms include chest pain (angina), dizziness, palpitations, irregular heartbeat, shortness of breath, jaw pain, nausea, and shoulder or arm pain. While chest pain is the most common symptom for men, women and the elderly are more likely to experience other symptoms.2 Patients in the early stages of CHD are asymptomatic; arteries can be blocked more than 50% before patients experience symptoms.3
Risk Factors
CHD’s risk factors are well documented: age (incidence increases with age), gender (more common in men), heredity, smoking, hypertension, elevated cholesterol levels, diabetes, obesity, inadequate physical exercise, and stress.3 Elevated low-density lipoprotein cholesterol levels in particular play a crucial role in atherosclerosis.4 The statistics on risk factors are daunting (Table5).
Role of Depression and Psychosocial Factors
Depression is an independent risk factor for CHD; prevalence for clinical depression among CHD patients is 20%.6,7 Untreated depression and those with treatment-resistant depression have poorer outcomes.6,7 CHD patients with depression taking a selective serotonin reuptake inhibitor, for example, are 42% less likely to experience recurrent myocardial infarction than those without treatment.8 The American Heart Association now recommends depression screenings for all CHD patients.
Along with depression, anger, hostility, and irritability are likewise linked to CHD. Other psychosocial risk factors include low socioeconomic status, lack of social support systems, the existence of family and job stress, and the death of a loved one. Marital stress, for example, is associated with a 2.9-fold increased risk for a recurrent coronary event.8 Like depression, addressing psychosocial factors and treating stress-induced anxiety are critical; those without treatment have poorer outcomes.7
Treatment
Effective treatment of CHD requires a multidisciplinary approach, incorporating pharmacotherapy, counseling, and lifestyle changes. Treatment’s objectives include1,8:
Pharmacotherapy and lifestyle changes are the cornerstones for treating CHD. Severe CHD may require surgical intervention (eg, coronary stents, coronary artery bypass grafting). Drug regimens are patient specific and target obesity, diabetes, hypertension, and dyslipidemia. Aggressive treatment of hypertension and dyslipidemia significantly reduces morbidity and mortality.8 Patients with low risk factors live 9.5 years longer than those with elevated risk factors, underscoring the importance of minimizing or eliminating risk factors.4
Aspirin (or other antiplatelet agents), angiotensin-converting enzyme inhibitors, and beta blockers reduce recurrent cardiac events in patients after a myocardial infarction. Other commonly used agents for treating CHD include niacin, fibrates, bile acid sequestrants, angiotensin II receptor blockers, nitroglycerin, and calcium channel blockers and statins. Depression is treated with serotonin reuptake inhibitors; sertraline and citalopram are preferred first-line agents.7
Lifestyle changes—weight management, physical activity, tobacco cessation, and dietary modification—are universally recommended by evidence-based guidelines.1 One meta-analysis, for example, found that moderate physical activity reduced CHD and risk of stroke up to 30% and 20% for men and women, respectively.9 Because obesity is pleiotropic, it is often the most urgent risk factor requiring intervention.
Counseling CHD Patients
Counseling begins with reviewing the causes of CHD, emphasizing that some risk factors are modifiable. Stress the importance of lifestyle changes, noting that optimum outcomes will not be achieved through medication alone. Physical activity is one of the most important components in minimizing risk, positively impacting weight management, blood pressure, cholesterol, and triglycerides.8 Ideally, patients should exercise 30 to 60 minutes each day.
Along with exercise, lifestyle changes must include weight and dietary management, prudent alcohol consumption, and tobacco cessation. Following a myocardial infarction, for example, patients who quit smoking reduced their mortality risk by 33%.8
Final Thought
CHD is largely preventable, but undertreatment is common, making pharmacist counseling all the more critical.5
Counseling Guidelines for CHD
CHD = coronary heart disease; LDL = low-density lipoprotein.
Adapted from references 1, 2, 4, 6-8, and 10-12.
Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Virginia.
References