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 1980s (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:

No

CAD & Anxiety ; CAD & Depression

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
AREA

PARABRACHIAL
NUCLEUS

HYPOTHALAMUS
PVN

PONTIN (CAUDAL)
NUCLEUS

COGNITIVE
DISTORTION

HYPERVENTI
LATION

ENDOCRINE
ACTIVATION

EASILY
STARTLED

STRIATUM
PERIAQUADUCT
(GREY)

HYPOTHALAMUS
(LATERAL)

VAGUS (DORSAL
MOTOR) NUCLEUS

ANXIETY BEHAVIOR

SYMPHATIC
HYPERACTIVITY

GIT
DISTURBANCES

MOTORIC
HYPERACTIVITY

next.

Mental Stress
Central and Autonomic Nervous System Activity
Catecholamine
Heart Rate
Blood Pressure
Atherosclerosis
Prior MI
LV dysfunction

Sudden
death

Plasma volume
Coronary circulation
Platelet activity
Electrical instability
Demand O2
Supply O2
VTach, VFib
Plaque rupture
Coronary thrombosis

Acute Coronary
Syndrome

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

Contd

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
Platelet function?

Autonomic
Dysfunction?
Hyper-adrenergic?

Depression or
stress

Sicker

Abnormal
Vasomotion?

Abnormal
Inflammatory
Responses

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 nondepressed 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
Psychostimulants
Trazadone
Benzodiazepines

hypotension, QT interval
Mild tachycardia and
hypertension
Postural hypotension

-------

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