Psychiatric Issues in a General Cardiology Practice Mark A. Rabinovitch MD McGill University Health Center

Panic Attacks 78 yr. old male with paroxysmal atrial fibrillation and remote angina pectoris Syncope complicated by subdural hematoma in 1998 Postoperative proximal DVT requiring IVC filter Recurrent episodes of nonexertional, apical chest "knot" with palpitations, dizziness and weakness Resting and exercise electrocardiograms were negative On Clonazepam 0.5 mg BID no further episodes SSRI (sertraline) initiated and titrated to an effective anti-panic dosage. Aim to eventually taper and stop Clonazepam

Resting and exercise electrocardiograms negative On Clonazepam 0.5 mg BID no further episodes SSRI (sertraline) initiated and titrated to an effective anti-panic dosage. Aim to eventually taper and stop Clonazepam

Discrete episodes of intense fear or discomfort lasting seconds to minutes with autonomic symptoms: cardiovascular- palpitations, SOB, chest pain (discomfort), dizziness neurohumeral activation (trembling etc.) gastrointestinal- nausea etc psychological-fear of dying

Panic Disorder Recurrent , unexpected panic attacks, worry about their meaning or consequences and a change in behavior related to the panic attacks Non-fearful sub-type of panic disorder Wide age range of presentation 15% of ER presentations of chest pain

30-60% of patients with chest pain and normal coronary arteries overlap with the cardiovascular Syndrome X ( angina pectoris , positive exercise ECG and normal coronary angiogram).

Pathogenesis of Chest Pain and Normal Coronaries Lack of myocardial ischemia in the majority Disorder of cardiac nocioception Midbrain nocioceptive signal processing Panic disorder due to amplified ANS output mediated via central processing of afferent input at the midbrain level Response to visceral analgesia

Panic disorder Also occurs in patients with CAD May present with palpitations or, less commonly, syncope Under-recognized by cardiologists ( reason for consultation-R.O.M.I. and cardiologist’s conclusion-M.I.R.O.).

No myocardial ischemia here!

Chest Pain and Normal Coronaries - Therapy Reasoned explanation for symptoms and reassurance Beta blockers if evidence for myocardial ischemia (stress echo) Estrogen therapy in postmenopausal women If no myocardial ischemia, trial of visceral analgesia(TCA). If panic disorder primary, benzodiazepine and/or SSRI and cognitive therapy

Depression and Cardiac Disease A 73 yr old male with 2 prior CABG operations- 1978 and 1991 Unstable angina in 1998 ; reoperation deemed high risk Twice daily angina despite Lopresor-SR 400 QD, Norvasc 2.5 QD and Nitropatch Depressed mood most of the time

Trial of SSRI (Sertraline) and psychotherapy 3 months later no longer depressed, not having angina and following a vegetarian regimen

Increased rate of sudden CV death Higher rate of ischemic heart disease (symptomatic and fatal) Common post MI (18% major and 27% minor depression) Increased 6-month post MI mortality Decreased parasympathetic activity;SA hyperactivity; increased platelet activation,hypercortisolemia.

Cumulative Mortality for depressed and nondepressed patients after myocardial infarction (MI) REF:Lesperance F; Frasure-Smith N; Juneau M; Theroux P. Depression and 1-year prognosis in unstable angina. Arch Intern Med 2000 May 8;160(9):1354-60

Tricyclic antidepressants side effects: postural hypotension, heart block if preexisting conduction block, and as type 1A antiarrhythmics may increase mortality in ischemic heart disease. SSRIs have benign cardiovascular profile and possibly beneficial antithrombotic effect. Sertraline well tolerated post MI (SADHAT trial)

Drug Interactions in the Cardiac Patient A 55-year old female with highly symptomatic recurrent atrial fibrillation Refractory to Propafenone (type1C) and Sotalol (type 3) Finally controlled with Amiodarone and Coumadin in1997-1998 In 1999 incapacitated by headache, morning nausea, and fatigue, inability to concentrate and chest pain. Great mental stress at work

Private psychiatrist proposed a TCA (though she denied depression). Cardiologist opposed to TCA due to possible interaction with amiodarone QT Hospital psychiatrist treated her for GAD with Clonazepam and cognitive-behavior therapy Improving slowly; still off work

Cardiac patients often elderly and on combinations of antiarrhythmics, beta blockers, Ca blockers, ACE’s, Arb’s, Diuretics, Lipid lowering agents, oral hypoglycemics, Allopurinol, drugs for BPH and antithrombotics. Concern regarding interactions with a new psychotropic agent

Drug Interactions -Cytochrome P450 Enzymatic System Oxidation of large amount of meds 6 cytochromes responsible for vast majority (CYP 1A2, CYP 2C19, CYP 2E1, CYP 2C9 CYP 2D6, CYP 3A4) Competition between 2 meds leading to accumulation of 1 Appreciate possibility of competition- adjust dosages and give at 12-hour interval

Potential Interactions Examples of possible competitive interactions: Paroxetine and Antiarrhythmics- CYP2D6 Sertraline and Calcium blockers- CYP3A4 Fluvoxamine and Coumadin- CYP2C9 Fluoxetine and Beta Blockers- CYP2D6

But think of this, you are a reportable case!

Psychosocial Factors and Coronary Artery Disease Personality traits - hostility Social isolation Chronic life stressors - contribute to atherosclerosis cause maintenance of poor lifestyle discourage successful lifestyle modification Acute life stressors

Psychosocial Factors in CAD Therapeutic Implications Psychosocial interventions - should be patient specific benefit deduced from surrogate end-points must be cost-effective Need to elucidate mechanisms by which psychosocial interventions modify development of CAD at the molecular level

Reference: Lesperance F; Frasure-Smith N; Juneau M; Theroux P. Depression and 1-year prognosis in unstable angina. Arch Intern Med 2000 May 8;160(9):1354-60