Matters of the Heart: Cardiac Disease and Psychosocial Issues in Women

You are listening to ReachMD, The Channel For Medical Professionals. Welcome to Advances in Women's Health sponsored in part by Eli Lilly.

Your host is Dr. Lauren Streicher, Assistant Clinical Professor of Obstetrics and Gynecology at Northwestern University Medical School, the Feinberg School of Medicine.

The matters of the heart and the impact of psychosocial risk factors on heart disease.

You are listening to ReachMD XM157, The Channel For Medical Professionals. Welcome to Advances in Women's Health.

I am Dr. Lauren Streicher, you host and with me today is Dr. Kim Lebowitz, an Assistant Professor in the Division of Cardiothoracic Surgery with the conjoint appointment in the Department of Psychiatry at Northwestern University's Feinberg School of Medicine in Chicago. Director and Founder of the Cardiac Behavioral Medicine Program of the Bluhm Cardiovascular Institute.

Preexisting and coexisting depression in cardiac patients is often underdiagnosed and undertreated, but it is now recognized as an important factor in predicting cardiac risk. In addition, prognosis after a major cardiac event is often directly related to emotional factors. Recent guidelines from the American College of Cardiology and the American Heart Association emphasize evaluation and treatment of symptoms of depression in cardiac patients.

DR. LAUREN STREICHER:

Welcome Dr. Lebowitz.

DR. KIM LEBOWITZ:

Thanks for having me. Glad to be here.

DR. LAUREN STREICHER:

Now, cardiac psychologist that is a new term for me. Can you describe exactly what a cardiac psychologist is and what the rationale behind integrating a psychologist into the care of the cardiac patients would be?

DR. KIM LEBOWITZ:

Absolutely. Cardiology is one of the areas where research has dictated that the mind and body are really connected. So, first of all, if you look at the traditional risk factors for heart disease, you will see that most of the risk factors for heart disease are modifiable and have to do with lifestyle behavior, such as inactivity, exercise, and diet. So, the health psychologist and a cardiac psychologist specifically, we can help patients initiate and maintain changes in their lifestyle behaviors. We are also now identifying that psychosocial and personality factors like depression, stress, anxiety, hostility, and limited social support also increases the risk of someone developing heart disease and can also predict a poor prognostic event. We also know that cardiac patients also experience emotional distress after cardiac event or cardiac diagnosis to higher risk of experiencing depression, anxiety, and stress, so as a cardiac psychologist, I can really work with patients at any point throughout the cardiac process and help make sure that their mind and body are one and that they are improving their quality of life as best as possible.

DR. LAUREN STREICHER:

So, how common is depression in the cardiac patient?

DR. KIM LEBOWITZ:

In the general population at one given point in time, about 3% to 4% of the population will be clinically depressed. If you look at the cardiac population, their risk for depression is much greater. It is about anywhere from 17% to 25%. So, about 2 out of every 5 cardiac patients experience clinical depression and even more than that will experience increased symptoms of depression.

DR. LAUREN STREICHER:

And is there a gender difference?

DR. KIM LEBOWITZ:

Yes. In the general population, women are twice as likely as men to experience depression and that gender deference also holds true in the cardiac population. So, female cardiac patients are at greater risk of experiencing depression. Research also tells us that younger patients are at greater risk of experiencing depression. So younger female cardiac patients age being under 50 or under 60 is at greatest risk of experiencing depression and reporting a poor quality of life after a cardiac event.

DR. LAUREN STREICHER:

So, why is it if we accept the depressed patients are more likely to have a significant cardiac effect? Is there a specific cause and effect reason for this?

DR. KIM LEBOWITZ:

Yeah, that's a great question. We know that depression and heart disease are related and researchers are now investigating the mechanism to understand that link. We know first of that there is a behavioral link in terms of why depressed patients are more likely to develop heart disease and why they are more likely to have a poor outcome. So, individuals, who are depressed are more likely to smoke, they are more likely to be inactive, they are more likely to be noncompliant from the medication regimen, they are more likely to drop out of cardiac rehab, they are more likely to have a poor diet, so certainly the behaviors that depressed individuals can exhibit, puts them at increased risk of a poor prognosis.

DR. LAUREN STREICHER:

Well, it sounds like there are always same risk factors that we see for heart disease you know smoking, obesity, poor diet, all of that.

DR. KIM LEBOWITZ:

Exactly. Depressed patients definitely exhibit that symptom profile. We also know that there is a physiological link between depression and heart disease. It appears that depressed patients while on the exterior they might be more vegetative, they tend to be physiologically hyperarouse, so they tend to have a higher resting heart rate, they tend to have decrease heart rate variability, they exhibit markers of increased inflammation, and they also a kind of exhibit dysfunction of the sympathetic tones, so they could be in sympathetic arousal or have problems with their vagal tone. So, it does appear that there is a physiological mechanism linking depression between cardiac disease.

DR. LAUREN STREICHER:

You know, as physicians of course, if we identify a risk factor in our patients such as obesity, poor diet, smoking, and we try and change that behavior, is the depression itself a barrier to that behavior change?

DR. KIM LEBOWITZ:

Yes, which is a great question. Individuals who are depressed, they have a much difficult time making behavior changes. So, if a physician or a nurse recommends to a patient that they need to make a behavior change whether start exercising, losing weight, stopping smoking, definitely want to ensure that they are not depressed. Depression would want to be treated first before the patient can successfully maintain a behavior change.

DR. LAUREN STREICHER:

Of course, that’s the big issue. <_____> not asking about depression or saying you are overweight, you have to change, not realizing that that’s just not going to happen unless you also deal with the underlying depression. You know, I want to go on, we are talking about there are really 2 groups here. We are talking about patients, women, who have depression, who are more likely to subsequently develop heart disease, but then there is also the group of patients who are not known to be depressed, who are not clinically depressed, but become depressed as a consequence of a cardiac event and these are really 2 separate groups because my question is can you predict, which patients that were not depressed prior to a cardiac event are more likely to be depressed afterwards.

DR. KIM LEBOWITZ:

That's a really good question and we don’t know the exact answer yet, so individuals are going to be at increased risk of developing depression after a cardiac event or after undergoing cardiac surgery, or even just after diagnosis of coronary artery disease. Individuals who are more likely to become depressed in those circumstances are ones, who have an individual or a family history of depression, individuals who have lower social support, individuals, who are female, and individuals who are diagnosed or experienced that cardiac event at the younger age. So, that can kind of make us aware of who might be more likely to experience depression, but we really cannot predict, who is going to experience depression after cardiac event and there are certainly a subgroup of those individuals, who do experience symptoms of depression or that depression does remit over time and for those individuals, who do not maintain those symptoms of depression, they are not at increased risks of morbidity and mortality problems, but we are unable to really identify at this point who is going to experience the depression that is going to persist, and who is going to experience symptoms of depression that is going to remit in a short period of time.

DR. LAUREN STREICHER:

So, then how important is it to recognize and treat this situational depression because if things sometimes do get better on their own, how do you know when it's important to intervene and when it's not. How long you wait to see if things just get better with time and return to normal activities.

DR. KIM LEBOWITZ:

Well, depression is something that needs to be evaluated and recognized and treated as soon as symptoms develop because we don’t not know, which patients are going to spontaneously remit and which ones are going to persist. So, anyone in any medical setting, cardiac patients really need to be screened for depression.

DR. LAUREN STREICHER:

Now, you mentioned of course that depression is in and out itself a risk for predicting another cardiac event. How much of the factor is that?

DR. KIM LEBOWITZ:

Yes, research has shown that individuals following a heart attack are following coronary artery bypass surgery, individuals, who exhibit symptoms of depression in the hospital, so that was in a week after that specific event, so that actually does not meet the standard criteria for clinical depression, which needs to be experienced for 2-4 weeks. So, individuals who are experiencing symptoms of depression within several days after heart attack or after cardiac surgery can be at least 2-4 times more likely to have fatal or nonfatal ischemic event or re-hospitalization, or a mortality in the 6, 12, or even 18 months following that cardiac event.

DR. LAUREN STREICHER:

That is why it is striking. How does that compare to objective findings that we know to be risk factors for repeat event such as ejection fraction, hypertension, things such as that.

DR. KIM LEBOWITZ:

There are some studies that have shown that the presence of depression is as stronger even stronger than standard traditional risk factors, such as hypertension, previous history of heart attack and left ventricular ejection fraction. So, it is definitely pretty astounding that depression has really emerged as a risk factor for morbidity and mortality after cardiac event, independent of the disease severity or location of the heart attack, and it is still underdiagnosed and undertreated.

DR. LAUREN STREICHER:

Why do think traditionally the role of depression as a risk factor has not gotten adequate attention by cardiologists?

DR. KIM LEBOWITZ:

I think there are a couple of reasons. I think first of all, a lot of cardiologist might look at symptoms of depression and assume that that’s typical adjustment after heart attack or after cardiac surgery, but what we know now from research is even experiencing symptoms of depression in those few days or in that week or two following that cardiac event, it still can be a risk factor for poor prognosis. I think also there might just not be enough education and information out there, cardiologists might be hesitant to recognize depression as a risk factor because there is yet no good information showing that lowering depression can result in reduced cardiac endpoint.

DR. LAUREN STREICHER

I would like to thank my guest Dr. Lebowitz, who has given us new insight into the role of preexisting and coexisting depression in cardiac patients as an important factor in predicting cardiac risk. I am Dr. Lauren Streicher. You are listening to ReachMD, The Channel for Medical Professionals. For complete program guide and podcast, visit reachmd.com.

Thank you for listening to advances in Women's Health sponsored in part by Eli Lilly with your host, Dr. Lauren Streicher. For more details on the interviews and conversations in this week show or to download the segment, please go to reachmd/women's health.

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