– by Dr. Irving Loh, MD
An interesting article (1) last month in Circulation: Cardiovascular Quality and Outcomes quantified something that has been quite subjective for experienced clinicians when dealing with coronary heart disease patients. When objectively diagnosed with stress and depression, CHD patients had a 48% higher risk of increased MI or death in 2.5 years of followup compared to the low stress and depression cohort. As a profession, it looks like we’re all in big trouble.
This study came out of Columbia University in New York and was lead by Dr. Carmela Alcántara. They examined the profiles of 4487 patients aged 45 or older enrolled in the Reasons for Geographic and Racial Differences in Stroke study and thus were known to have coronary heart disease. From 2003 to 2007, patients were interviewed at home or asked by questionnaires how often during the past week they felt depressed, lonely or sad, or had crying spells. They were also asked how often they felt unable to control important things in their lives, felt overwhelmed, felt confidence in their ability to handle personal problems and felt things were going their way during the past month. The implications of unrecognized or inadequately treated stress and depression can be manifested internally by adverse cardiovascular outcomes or externally as with the co-pilot of the Germanwings tragedy last month.
It was determined that it was the interaction between self-reported stress and depression, rather than just each independently that seemed to be related to the outcome measures, though no clear causal mechanism was discerned. Each of these symptoms separately did not seem to increase risk. Segregation of these factors as clinicians know is hardly a clean science, so their cohabitation in an affected patient is enough to warrant more focused attention on not only the patient’s cardiovascular risk factors, but on mitigating the psychosocial exacerbation of major cardiovascular adverse event risk. We all know about the sophisticated lifestyle and pharmacologic strategies needed to manage the classic cardiovascular risk factors. This study suggests that there may remain significant gaps in psychosocial care that may have similar implications for clinical outcomes. Indeed, coronary heart disease is a process that trends in the older population, and there are inadequately addressed issues in both the medical and sociological arenas that can alleviate the stress and depression that disproportionately afflict the elderly.
A multidisciplinary team approach with targeted care coordination is needed. Our society generally and our healthcare system specifically are not well prepared to effectively manage this scenario, but with a potentially manageable 50% increased risk, perhaps we need to implement concepts like care circles and care coordination tools like Tiatros™ (reader warning: I am a Tiatros™ advisor, so it’s one with which I am familiar, but there are other similar programs as well so no product endorsement should be interpreted or implied) that can help alert the care giver team. More research is required to determine mechanisms and optimal interventions to positively effect outcomes.
References:
1. http://bit.ly/1B1S14d Circulation: Cardiovascular Quality and Outcomes, online March 10, 2015
Bio:
Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.
Leave a Reply