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Stress, Depression and Heart Disease (Dr. Pozuelo 12/8/11)

Leopoldo Pozuelo, MD

Leopoldo Pozuelo, MD
Section Head of Consultation Psychiatry

Thursday, December 8, 2011 - Noon


It is common for someone to feel sad or depressed after a heart attack, cardiac surgery or procedure, recent hospitalization, or new diagnosis of heart disease. These emotions may be the result of not knowing what to expect or not being able to do simple tasks without becoming overly tired. Early detection and treatment of depression in heart patients are crucial to improve a patient’s quality of life and possibly prevent a recurrent coronary event. Safe treatments are available to help you cope with depression and help you manage your heart disease. Cleveland Clinic Psychiatrist Leopoldo Pozuelo, MD answers your questions about stress and heart disease.

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Cleveland_Clinic_Host: Welcome to our "Stress, Depression and Cardiovascular Disease" online health chat with Leo Pozuelo, MD, FACP. He will be answering a variety of questions on the topic. We are very excited to have him here today! Thank you for joining us, let's begin with the questions.

Dr__Pozuelo: Thank you for having me today. Good afternoon. Can you tell me a little more about your heart problems?

Cardiomyopathy and Depression

melissanewc: I was diagnosed with postpartum cardiomyopathy after the birth of my son in August. I spent three weeks in the hospital, including a psychiatric admission, before doctors were able to diagnose me. Now, I am thirty-one years old, home-bound, and struggling to care for an infant, along with the typical stress, anxiety, and depression that comes with having a newborn. In addition, my husband and I were informed that future pregnancy is not an option, lending to further depression. Beyond medication and therapy, what types of treatment do you recommend? Every day is a constant struggle. I find myself crying for no apparent reason and will go days on end with no sleep because I'm not able to. Please help!

Dr__Pozuelo: We certainly empathize with how you were treated during your hospital stay. Our clinicians are always striving to incorporate emotional wellness as well as physical wellness.

One of the things to consider in conjunction with your cardiology team would be to enroll in a cardiac rehabilitation program as there are many positive outcomes to this.

Specifically for your emotional copying it is very important to see a mental health specialist in the out patient side 

  • To deal with heart disease which is challenging for ALL heart patients 
  • To make sure there are no symptoms that could be signs of post partum depression.

Finding a mental health professional who you can click with is important that you feel comfortable and that you can move on with your daily activities as best you can.

Sandy: I have been told my ejection fraction is now 25%. I was fine and had a virus and now I have heart damage. I heard that depression and stress can be bad for heart failure but how can you help but be sad when this happens to you. I started medications. Not sure if I should be exercising, not sure what my future will be.

Dr__Pozuelo: A diagnosis of cardiomyopathy is very tough for any patient to accept and deal with. Luckily today there are very good medical options and treatments that can help a patient with cardiomyopathy (heart failure) live a productive life. Emotionally coping with diagnosis can be a challenge but is doable. It is very important to have conversations with your health care team on strategies to cope. Exercise can be done in supervised fashion by patients with heart failure. You can still reap the emotional and physical benefits of exercise.

Diet and Depression

fundy: How often is insufficient magnesium in diet, partly responsible for the level of stress or depression being experienced?

Dr__Pozuelo: I am not aware of that.

Valve Surgery and Depression

tractorgirl: I had mitral valve surgery 6 months ago by "surprise sternotomy", that is, I went into the OR with a 95% chance of robotic surgery but things didn't work out and I woke up with a sternotomy. I was devastated and the depression hindered my recovery. Six months later I am still struggling with my feelings about this, and whether it was the surprise or the method that has me so bummed out. Do you have any data on whether the incidence of post-op depression differs between sternal and robotic patients?

Dr__Pozuelo: I am not aware of distinct prevalence of depression in sternotomy vs. minimally invasive/robotic surgery. This is a great question. Clearly patient's expectations with surgery and unforeseen outcomes can impact a patient's ability to recover from any medical event - including heart surgery. Physical recovery sometimes is faster than emotional recovery in any type of cardiac procedure and perhaps you are experiencing this at present.

Key wellness principles are: participation in cardiac rehab; talking to your provider about how you are coping (TELL THEM EVEN IF THEY DON'T ASK); previous history of anxiety or depression; and possible short term coaching therapy to better accept issues such as:

  • having heart disease
  • having scars
  • and - ability to move on.

Overall - how is your valve working?

tractorgirl: My valve works great, no regurgitation and I am back to full activity. Cardiac rehab was disappointing; everyone else was 80 years old and ready to die. I had no one to talk to until I found Adam Pick's heart valve blog. It is helping. I think surgeons sugarcoat the process because if patients knew the truth they'd back out! But the difference in expectations probably contributes to the depression.

Dr__Pozuelo: Glad you made a good recovery. We have had young heart valve patients who actually have experienced the same things as you and some of them have led groups and been advocates about the emotional recovery with heart disease. Thank you for spreading the word.

melissanewc: @tractorgirl - I think it would be a great idea if you started a group in your area for younger patients dealing with cardiac issues. I am considering doing the same in my area. It is difficult to find support when others dealing with similar issues are older and in different stages of their life. Best of luck to you in your recovery!

Dr__Pozuelo: There are local chapters of the American Heart Assoc that may be well positioned to help you reach these goals. Contact your cardiac rehab director and see if they can be of assistance as well.

tractorgirl: Melissa, thanks for the suggestion. The nearest chapter of Mended Hearts is 100 miles away so something nearer may be needed by more than just me.

purple333: I had AVR 4 yrs ago/stenosis (age 47).I had anxiety /depression prior to that. The anxiety /depression increased substantially following OHS. Migraines have also increased, particularly after menopause. I have gone from taking OTC meds only prior to surg. to taking Coumadin, asp., Diltiaz,Topam,Wellbu,Klonop, and Hydrocod following surgery. I feel like I am poisoning myself to death and I would have been better off not having to the surg. My quality of life has deteriorated. I recently learned that OHS can increase dep. X 4. I wasn't warned about that by my doctors. I do not tolerate SSRIs (chest pains, severe Migraines, Palpitations). I am taking part in a clinical palm pilot to track my thoughts & feelings & offer suggestions. I attend counseling and a 12-Step group. Fam. and friends do not understand anxiety /depression and they are unable to offer support.

Dr__Pozuelo: Kudos to you for reaching out and using existing and new resources such as groups, monitoring of thoughts and behaviors to help you battle the depression/anxiety that you are experiencing.

We still don't know if any specific medications or coaching techniques are best suited for heart patients compared to non-cardiac depressed patients. This is a line of intensive research. But, what you are doing makes a lot of clinical sense and we hope that ultimately you will emotionally recover as you have physically recovered to this point.

fpw: Exercise helps me manage my depression (as well as medication), so I’m wondering, how soon after valve surgery can one start cardiac rehab?

Dr__Pozuelo: This is a fantastic observation that exercise is an effective weapon against depression. We love cardiac rehab. Consult with your doc but usually people are able to go to cardiac rehab within 3 - 5 weeks after surgery.

sannie: I had open heart surgery last year to replace a bicuspid aortic valve and an ascending aortic aneurysm at the Cleveland Cinic. I was in the hospital for 2 weeks with a-fib complications after surgery. The a-fib stopped about 2 months later but I'm wondering if stess and anxiety can bring it back? There are times when I feel the same sensation of a pounding heartrate after a stressful day when at rest.

Dr__Pozuelo: This is again a superb observation. We have found that experiencing afib which was short lived in your case, can leave the person sensitized to bodily sensations. This is a quite normal response. Without a doubt stress management techniques, mind body relaxation can help you better weather coping with any heart rhythms. Both stress management and exercise can favorably reset your heart rhythms so in addition to feeling well, you may also be contributing to having normal heart rhythms.

TeresaM: How do I give emotional support to my sister who is soon having a mitral valve surgery? What should I expect?

Dr__Pozuelo: It is important to be supportive as any patient that is going for surgery. in the recovery process since you know her pretty well be on the look out for how she is emotionally coping. People can have various reactions and they can all be quite normal. The key is to make sure that the patient is moving along in both physical and emotional recovery. She is lucky to have you.

Nik: One month after valve surgery I developed viral pleurisy which has sidetracked my rehab. I'm told it may take 2-3 months to get better. Meanwhile my spirits are quite low and I'm wondering how to keep a positive attitude while essentially not doing much?

Dr__Pozuelo: Sorry to hear that you are having a slow recovery but we hope this too will pass. In the meantime, keeping cognitively busy will be very important. Anything that you can do to keep you mentally engaged such as hobbies, reading - will help you to keep a mental structure during your recovery.

Coronary Artery Disease and Depression

Hatchetman: In the beginning of November I went ambulatory to our local hospital and they quickly determined that I must have a blockage and I was having a heart attack.. Stent was put in in the LAD artery. About 4 days later I am home and I got depressed and I was thinking just how close I came to death. (One half hour earlier unbeknownst to me my best friend had a HA and died. We are only 50 years old. I felt guilty he died and I didn't. I was very depressed for about 3 solid weeks. Was this normal. I also still have side effects and problems and I saw my Card yesterday. He didn't address any of them. What to do?

Dr__Pozuelo: Sorry to hear about your friend's death. The emotional experience you described is quite normal. As, none of us are prepared for the unexpected.

Many times the challenge and the opportunity in recovering from heart disease is to reset one's lifestyle which includes: 

  • diet
  • exercise
  • and at times, looking where one is at their stage of life.

It is natural to take stock or inventory of life events when you are faced with an unexpected stent. It is a wake up call for many and it is normal to go through a varied scope of emotions. Key thing is to talk about those with your provider and make them listen.

Anxiety , Stress and Risk for Heart Disease

Mark: Is there evidence that either depression or anxiety is a risk factor for a first cardiovascular event? Does treating either depression or anxiety reduce the risk of a first cardiovascular event?

Dr__Pozuelo: This is an excellent excellent question. There is clear evidence that having both anxiety and depression can increase the chance of new heart disease. We are not sure yet if treating the depression or anxiety will make a dent in the heart disease (course of heart disease, readmission, medical outcomes). However, it is very clear that treating the depression and anxiety in someone who has heart disease makes a very positive impact on quality of life.

AngeaLI: I have a very stressful job, but I eat well and exercise regularly. What role does stress play in cardiovascular disease? Is there anything additional I can do to reduce my risk

Dr__Pozuelo: The key in stress management is knowing what things you can change and knowing what things you can not. It sounds like you are doing some very productive wellness principles. If at work, you are able to have the healthiest routine possible such as ability to take time off, practice breathing techniques, having good co-workers to bounce things off, and employ good coping techniques such as humor - then you are probably doing the best you can with the current work environment.

Ask your self how is your overall quality of life (we all need to do this periodically) and see how your current work fits into the equation.

897fjos: How important is sleep for heart disease prevention?

Dr__Pozuelo: Very important. There have been robust studies looking at the incidence of sleep disorders with depression, sleep disorders with heart disease and the two are quite possibly linked. In addition to having regular sleep hygiene habits, which make you feel good, there is good evidence it is also physically advantageous for heart disease and overall health.

Anxiety and Arrhythmias

CinMal: I have panic attacks with increased heart rate due to stress. I have now been diagnosed with occasional a-fib, but he couldn't find the reason behind them. Can it be stress induced? Should I be taking vitamins or something else to help with this? I just need to know if there is anything else I may do to prevent a-fib events in the future.

Dr__Pozuelo: This is a really cutting edge field right now: Looking at the effects of anxiety on arrhythmias. We are not sure yet if having high levels of anxiety or depression can influence the start of atrial fib or make patients go back into atrial fib from sinus rhythm. What is clear is that patients with atrial fib can experience anxiety about having afib even if they were never anxious before.

Key principles here are: striving for best quality of life. So - absolutely stress management can be of help in patients with afib for improved quality of life and it may help the underlying arrhythmia.

Lsure: I sometimes have chest pains and fast heart rate. I went to the cardiologist but he said there is nothing wrong with me - it is panic or anxiety attacks. I am not sure what to do now. what do you suggest?

Dr__Pozuelo: Talk to your cardiologist about wearing a holter monitor that can record these events when you are at home. In addition to physically recording these events, it is helpful to note emotionally any major feelings, stressors, or events that are occurring when you feel these heart sensations.

Depression and Heart Disease

tractorgirl: I note your advice to tell your health care provider about your depression, even if they don't ask. I had never experienced depression and didn't realize what was wrong for over 4 weeks postop. My primary care doc has recommended short term antidepressants, but how is that going to help me understand why I feel this way? Seems like that would just cover it up.

Dr__Pozuelo: Anti depressants can treat certain symptoms of depression and many times they are helpful to lift the weight of depression and help patients then understand better how they are coping. You should follow your primary care physician's recommendations but still leave the door open to seek some psychotherapy to better understand possible triggers; improved coping mechanisms; and relapse prevention.

There are some patients who have never experienced depression and for reasons we do not fully understand have their first bout of depression in the setting of heart disease.

fpw: If someone has a history of depression, what it the best way to prevent a reoccurrence post-heart surgery? Meds? Therapy? Other?

Dr__Pozuelo:When a patient has a previous history of depression or anxiety, the key is to be vigilant that none of those previous symptoms recur in the cardiac recovery process. Screening, monitoring and early intervention for depression are helpful strategies. your health care team of the past medical history of depression is very important.

purple333: Any suggestions for medications for depression when SSRI's cannot be used?

Dr__Pozuelo:There are other categories of anti depressants such as SNRIs; remeron; and wellbutrin that have been used safely in cardiac disease. The key here is to talk to your health care provider of the options.

KitKat: Are men or women more at risk for experience heart disease related to depression?

Dr__Pozuelo: Great question. We don't know but it affects both sexes. There have been some differences between men and women as to how they respond to certain psychotherapy techniques. Research is being done to this regard.

tractorgirl: You have mentioned coaching techniques a couple of times, can you elaborate on that?

Dr__Pozuelo: Thanks tractorgirl. Great observation. What we mean by coaching techniques is having a therapist (could be PhD; masters therapist; social worker) who takes inventory of where you are in life, how you are coping and provides treatment (coaching) as to how you can better cope emotionally and behaviorally. In contrast to types of therapy that focus on growing up experiences and things that happened in the past, coaching therapy (also known as cognitive behavioral therapy) focuses on the here and now.

purple333: Exercise sounds great but is impossible for me by the time I work and complete my regular routines - laundry, housework, etc...

Dr__Pozuelo: I am as guilty as you but it is very easy to pencil out exercise from our daily chores and routine. Because of its tremendous beneficial affects, physical and mental, we have to pencil it back into our schedule. Exercising 20 minutes a day can do it

minnie: Can you talk a little more about depression and its effect on heart disease? Why would it cause problems?

Dr__Pozuelo: Another excellent question. We don't know the exact mechanism by which depression can be toxic on the heart. However, various pathways have been implicated such as depression affecting cortisol levels (stress hormone); affecting platelets (making them more sticky); affecting overall heart rhythm.

There is also evidence that depression can increase inflammation which can contribute to heart disease.

tractorgirl: @Nik, if you haven't visited Adam Pick's heart valve blog you should do so. You can journal there with other valve patients who are having similar experiences. I live in a very isolated area and this connection with other patients has helped me.

Dr__Pozuelo: Great. Tractorgirl rocks!

Nik: Thanks tractorgirl! Will do

ThomsonK: When talking about depression and cardiovascular disease, do you mean depression in the clinical terms? How would one determine if they are depressed or just having a rough time? Is there anything I can be doing, such as eating certain foods that would be good for the heart and also for my well being?

Dr__Pozuelo: Terrific question. As far as screening and diagnosing for depression, one can ask two simple questions:1) Over the last two weeks, has your mood been down and 2)Over the last two weeks have you had difficulty in enjoying things. If you answered yes to these questions on most days and these emotions and experiences are affecting your quality of life, there is a strong possibility that a clinical depression is onboard.

The general principle of a balanced diet still applies to being favorable for mind and body; heart and brain. There is some research being done with fish oil being beneficial for both heart disease and depression even though the jury is still out.

ALk98y6: When preparing for heart surgery what would you suggest patients can do to be mentally prepared, and once out of surgery how they can maintain good mental health?

Dr__Pozuelo: It is a great idea to have a walk through of what to expect during your hospital stay. Many centers offer the patients the ability to see where they are going to be and better understand what the recovery process will be. Some patients find that guided imagery, relaxation techniques, bringing their favorite music can help before and after the surgery. You will meet cardiac rehabilitation folks prior to discharge that will also clue you in on how to best recover.

Windy: My father had heart surgery a few months ago and has been really depressed. He doesn't want to get up and get out of the house or do any activity. How long does it take for depression to "go away" after surgery?

Dr__Pozuelo: These signs and symptoms are worrisome as they have persisted for more than 2 weeks and are clearly affecting his quality of life. If you can, please have your dad contact his health care team even if it means his primary care physician and alert them as to how your dad is doing.

Cleveland_Clinic_Host: Thank you for joining us for the chat today. Dr. Pozuelo, thank you again for taking the time to answer our questions about stress, depression and cardiovascular disease.

Dr__Pozuelo: I want to thank you for some superb questions. This great dialogue that we had, I hope that you can continue with your health care team and your support system. Both patients and clinicians need to do their part in keeping the right heart brain balance of dealing with heart disease. Thanks very much.

Reviewed: 12/11

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