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dr.

Ralph Kairupan, SpKJ(K)


Makassar, 23 Mei 1961

STATUS PERKAWINAN:
 Isteri : dr. Nova H. Kapantow, DAN, MSc.
 Anak-anak: Tara (16), Timothy (15), Tiffany (11)

PENDIDIKAN / SERTIFIKASI:
 Dokter Umum: FK UNSRAT 1987
 Dokter Spesialis I: FK UI 1996;
 Dokter Spesialis II: FK UI 1999
 Dokter Spesialis Konsultan (Kolegium PDSKJI 2004)

PEKERJAAN:
 Staf Bagian Psikiatri FK Unsrat 1987 –
 Sekretaris Pusat Bimb. & Kons. LP3 UNSRAT 2004 –
Anggota Tim SP4 UNSRAT 2006 -
COMORBIDITY OF
ANXIETY – DEPRESSION IN
CAD PATIENTS :
HOW TO MANAGE

Ralph Kairupan
What is Comorbidity?

The term comorbidity first appeared in the


psychological & psychiatric literature in the
mid 1980’s (1986: 2 articles).
Since that time there has been a dramatic
increase in interest in this topic as reflected in
the number of journal articles containing the
term comorbidity in the title.
 1993: 243 artikel.
 Now: >>>
What is Comorbidity?
Definition (Blashfield): The co-occurence
of different diseases in the same
individual.
Possible comorbidities:
 Psycho-somatic:
 Anxiety & CAD ; Depression & CAD
 Somato-psychic:
 CAD & Anxiety ; CAD & Depression
 No causal relationship vv:
 Anxiety & CAD ; Depression & CAD
 Anxiety – Depression - CAD
ANXIETY (PD)
& CAD
Anxiety (PD) & CAD
Anxiety will increase the mortality & morbidity of
CAD. PD is one of the anxiety disorders that must
be recognized.
Anxiety  CAD: Etiology; Precipitating;
Exacerbating; Worsening prognosis; Cause of
sudden death.
Among individuals with CAD, anxiety has been
found to be associated with an approx. 6 fold
increase in the risk of sudden cardiac death.
21% of CAD patients admitting ICCU suffer
from PD
 Carter C, et al. Psychosomatic, 1992;33:302-09
6% of coronary angiography suffer from
anxiety
 Katon W, et al. Am J Med, 1988;18:315-23
59% of chest pain complaining from treated
CAD patients is caused by anxiety
 Ros E, et al. Dig Dis sei, 1977;42:1344-53
Cardiovascular
Consequences
of Anxiety

Arrhythmias
Hypertension
Chest pain
Coronary artery disease
Cardiovascular Symptoms of
Anxiety
Increased cardiac awareness
Palpitations (often unassociated with
arrhythmia)
Chest pain
Dyspepsia
Fatigue
Dizziness
Sweating
Tremor
Heart Disease, Cardiovascular
Symptoms and Anxiety Are All
Interrelated
HEART
DISEASE

CARDIOVASCULAR
SYMPTOMS

ANXIETY

Jefferson JW, 1996


ANXIETY
AMYGDALA

CORTEX PARABRACHIAL HYPOTHALAMUS PONTIN (CAUDAL)


AREA NUCLEUS PVN NUCLEUS

COGNITIVE HYPERVENTI ENDOCRINE EASILY


DISTORTION LATION ACTIVATION STARTLED
STRIATUM

PERIAQUADUCT HYPOTHALAMUS VAGUS (DORSAL


(GREY) (LATERAL) MOTOR) NUCLEUS MOTORIC
HYPERACTIVITY

ANXIETY BEHAVIOR SYMPHATIC GIT


HYPERACTIVITY DISTURBANCES next….
Mental Stress

Central and Autonomic Nervous System Activity

Catecholamine
Heart Rate
Blood Pressure
Plasma volume
Coronary circulation
Atherosclerosis
 Platelet activity
Prior MI
LV dysfunction
Electrical instability
Demand O2
Supply O2

VTach, VFib Acute Coronary


Sudden
Plaque rupture Syndrome
death
Coronary thrombosis
DEPRESSION
& CAD
Depression & CAD
Since mid 1970s, epidemiologists
began to report consistent associations
between depression and cardiovascular
morbidity & mortality
Many large studies have identified
depression as a significant independent
risk factor for both first MI & CV†, with
an adjusted relative risk 1,5 - 2
Am J Psychiatry 1998;155:4-11
Epidemiology,1993;4:285-294
Arch Intern Med.1998;158:1422-1426
Cont’d…

Among individuals with established


ischemic heart disease, depression has
been found to be associated with an
approx. 3-4 fold increase in the risk of
subsequent cardiovascular morbidity &
mortality
The prevalence of major depression in
CAD pts is 15 – 23%
Circulation 2000;102:1773-1779
JAMA 1993;270:1819-1825
Am J Cardiol 2001;88:337-341
Symptoms of
Depression
Emotional disturbances
Cognitive disturbances
Psychomotor disturbances
Vegetative disturbances
Somatic disturbances
Depression & CAD Risk
Factors
Less –(un)compliance:
 Depression marker
Smoking:
 smoking cessation
Hypertension:
 Autonomic system
DM
 Glycemia control
Biologically Plausible Mechanism Linking
Depression with CAD

Less
compliance?

Abnormalities in

Abnormal
Platelet function? Vasomotion?

← Depression or
stress →
Autonomic Abnormal

↓ Inflammatory
Dysfunction?
Hyper-adrenergic? Responses

Sicker
Abnormal Platelet
Function

Increased platelet activity


Increased levels of platelet factor 4
(PF4) & - thromboglobulin
Increased platelet reactivity to serotonin
Decreased platelet reactivity to ADP

Eur HJ 2004;25:3-9
Less Compliance
Less compliance / non adherence to
risk factor modification in many medical
conditions :
- smoking cessation
- poor glycemic control in DM pts
- poor adherence to prescribed
medicine
Eur HJ 2004;25:3-9
Autonomic Dysfunction
Autonomic dysfunction is reflected by
decreased Heart Rate Variability (HRV)
Pts with anxiety & depression have reduced
HRV
Low HRV is a powerful predictor of sudden
cardiac death
A direct association between the severity of
depressive symptoms & modulation of
cardiovagal activity was found

Eur HJ 2004;25:3-9
Abnormal Vasomotion
Depression is independent predictor of
reactive hyperemia in brachial artery
flow-mediated dilatation (FMD) in the
absence of other conventional risk
factors
Depression is associated with
endothelial dysfunction

Eur Heart J 2004;25:3-9


Abnormal inflammatory
responses

Soluble Intercellular adhesion molecule


1 (sICAM-1) and C-reactive protein
(CRP) following Cardiac Events are
higher in depressed pts than in non-
depressed pts
CRP and sICAM are serum
inflammatory markers

Am J Psychiatry 2004;161:271-277
CARDIOVASCULAR EFFECT OF
ANXIOLYTIC & ANTIDEPRESSANTS
Agent Cardiovascular effects

SSRI
Benign bradycardia

Tachycardia, arrhythmias, Postural


Tricyclic hypotension, QT interval 

Mild tachycardia and


Psychostimulants
hypertension

Trazadone Postural hypotension

Benzodiazepines -------

Barsky AJ in Braunwald E, Zipes DP, Libby P: Heart Disease 2001


Summary

CAD & Anxiety - Depression  highly


prevalent  decrease QOL
Depression per se is an independent
risk factor of cardiac event
Several behavioral & pathophysiologic
factors link anxiety - depression & CAD
Summary
• Anxiety & Depression influence
Cardiovascular morbidity & mortality
Management of CAD + Anxiety &
Depression should includes CBT &
Medical Therapy
Short-term therapy with
Benzodiazepines and long-term therapy
with SSRI are beneficial
GOD BLESS YOU

Thank You