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
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?
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
