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Stress Depression&Heart Disease (Dr Pozuelo 4 21 10)

Wednesday, April 21, 2010
Leopoldo Pozuelo, MD

Leopoldo Pozuelo, MD
Section Head of Consultation Psychiatry


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 Online Health Chat with Dr. Leopoldo Pozuelo. We are thrilled to have him here today for this chat so thank you for joining us. Let’s begin with the questions.

Speaker_-_Dr__Leopoldo_Pozuelo: Thank you for having me today.

Anxiety, Stress, Depression and Heart Disease

MikeG: How good is the evidence for either depression or anxiety being a risk factor for a first cardiovascular event? How good is the evidence that treating either depression or anxiety will reduce the risk of a first cardiovascular event?

Speaker_-_Dr__Leopoldo_Pozuelo: Depression is a very strong risk factor predisposing patients for cardiac disease. Although the evidence is not as strong for anxiety of disorders, we do believe it can make the course of heart disease more difficult.

lmgaiso: How strong is the evidence that treating anxiety will prevent a first cardiovascular event or slow atherosclerosis from progressing?

Speaker_-_Dr__Leopoldo_Pozuelo: There is a lot of research going on in this arena at present - even though there is not one definitive treatment yet to show that by decreasing anxiety one's risk of heart disease will necessarily go down, we still see that treated anxiety leads to healthy benefits to the heart and mind.

Speaker_-_Dr__Leopoldo_Pozuelo: Examples would be better resting heart rate; less predisposition for flair ups of arrhythmias; and of course overall better sense of health. When one is less anxious you eat better, you exercise more; you enjoy the company of your friends and family to a much higher degree, which can all lead to better management of cardiac risk factors.

lmgaiso: Is talk therapy or medicine better for preventing a first cardiovascular event or slowing atherosclerosis progression when treating anxiety?

Speaker_-_Dr__Leopoldo_Pozuelo: We don't have a definitive answer. We try to do talk therapy first. If the patient's quality of life is significantly affected, we will recommend medication treatment for anxiety in conjunction with the therapy.

lmgaiso: Is talk therapy or medicine better for preventing a first cardiovascular event or slowing atherosclerosis progression when treating depression?

Speaker_-_Dr__Leopoldo_Pozuelo: The same applies to what I discussed earlier regarding anxiety. We have currently available very safe anti-depressants that mix very well with typical cardiac medications.

Cleveland_Clinic_Host: Dr. Pozuelo, can you please explain what exactly is Talk Therapy?

Speaker_-_Dr__Leopoldo_Pozuelo: The key focus with talk therapy in treating depression or anxiety in heart patients is to focus on the here and now - and not so much about past events. It is a dynamic, active dialog with the therapist in which the therapist takes on a coaching role in treating anxiety, depression in the setting of heart disease. To a large degree patients who encounter a major cardiac event receive the benefits of motivation, lifestyle change and group support when they successfully enroll in a cardiac rehabilitation program. Cardiac rehab has been shown to improve both the physical and the mental aspects of the cardiac patient. Here at the Cleveland Clinic we are very aggressive in making sure every eligible cardiac patient is referred to a cardiac rehabilitation program.

jerrymk1: I do not have heart disease but my dad did. I have been watching what I eat and try to exercise but I have a very stressful job. Just how much role does stress play in heart disease?

Speaker_-_Dr__Leopoldo_Pozuelo: We know that stress has negative effects on the body and emotionally affects your over all well being. It sounds like you are being very proactive in modifying your risk factors. (unfortunately we can't undo genetics), but you can modify other cardiac risk factors that benefit from healthy behaviors, good lifestyle and this is where good stress management makes a lot of sense. Keep doing what you are doing.

lmgaiso: how strong is the evidence that mediation helps prevent or slow CAD

Speaker_-_Dr__Leopoldo_Pozuelo: There is some evidence that meditation can lead toward favorable effects on cardiac tone, blood pressure, circulation. In addition to making you feel good and being a very useful form of stress management, it also has favorable effects on the heart.

lmgaiso: How important is sleep for CAD? what is the quality of the evidence?

Speaker_-_Dr__Leopoldo_Pozuelo: There is a strong correlation with sleep disorders including sleep apnea and worse cardiac disease. More and more clinicians are screening for sleep disorders and treating it as another potential cardiac risk factor. In addition, sleep disturbances has a significant impact on mood and quality of life.

lmgaiso: setting aside sleep disorders such as sleep apnea is the length of sleep correlated to CAD. For example, my life is complicated enough that babies or business prohibits the amount of time I sleep. It seems that I often feel that I could have used 1 more hours. One or two nights a week I feel that I could have used 2 more hrs. However, at least once a week I get what feels like a full night or catch up sleep. Can you remember residency?

Speaker_-_Dr__Leopoldo_Pozuelo: Many Americans suffer from poor sleep hygiene and more and more clinicians are stressing the beneficial effects of good sleep patterns on both the body and the mind.

Arrhythmias and Anxiety

Cynthia: I have experienced panic attacks with increased heart rate due to stress in the past. (I was able to work through this). I was also diagnosed with SVT, corrected through ablation. I have now been diagnosed with occasional a-fib (doctor referred to it as a-fib, but it is not chronic type). Various tests revealed no causes. They think it may be hereditary. I only have experienced this at night or when at rest, and very rarely, but it can produce a lot of anxiety due to anticipation of an event. I am actually afraid to travel. Can it be stress induced? Or, can it be related to lack of proper vitamins/minerals or other imbalances in my system? My cardiologist pooh-poohs this theory, although he wants me to take omega-3 supplements, which I do. I also take 400 mg magnesium tablets daily. I have also been on levothyroxin for low thyroid for a few years. After adding magnesium (my plan) I seem to experience less extra beats now (which also cause anxiety). Is this my imagination? I am in general good health, do not smoke, and am not overweight. I guess I need to know if I am doing the right things, and if there is anything else I may do to prevent a-fib events in the future.

Speaker_-_Dr__Leopoldo_Pozuelo: In every type of arrhythmia - abnormal heart rhythm - it can be very common to experience anticipatory anxiety, heightened sensations from the heart and constant preoccupation or worry about ones health. Treatment for anxiety, specifically a form of talk therapy, called cognitive behavioral therapy can be very effective in decreasing overall anxiety. You should inquire about a good therapist, psychologist, counselor that does this type of therapy.

historybuff: I am a 61 year old male that was diagnosed with Symptomatic Paroxysmal Atrial Fibrillation 10 years ago. All six of my episodes required hospitalization and occurred during stressful work weeks as a middle school teacher. My AFib has no known cause and because I also had chest pain I have had all the tests and no heart disease is present. Since I retired four years ago I have been AFib free with only an occasional chest pain. I have always been an easily stressed person when under time and task pressures. Is there a connection between stress and anxiety and the onset of an AFib "attack”?

Speaker_-_Dr__Leopoldo_Pozuelo: Yes - Yes and Yes. WE are finding out more and more that levels of stress heightened anxiety can exacerbate (make worse) underlying rhythms such as atrial fibrillation. Good wellness principles, diet, exercise; relaxation techniques can be very helpful in managing one's cardiac arrhythmias.

DRJ110145: Had pulmonary ablation for psvt last June. Seems to be under control, but I am sensitive to feelings in chest and arms. Am told there is nothing wrong with heart; cholesterol little high, but HDLs are in great shape and all other markers ok. From time-to-time take .125mg of xanax. Hit the treadmill 4-5 days for 4 miles in 1 hr. Heart rate fluxgates from high of 137 when feeling anxious with recovery rate @ 110. Today peaked @ 112 w/ recovery @95. I know I worry too much, but do have bouts of anxiety/depression (?). Should I consider medication that I would take daily indefinitely, vs. when I get my bouts?

Speaker_-_Dr__Leopoldo_Pozuelo: First of all - I think you are doing well and I wish I could exercise as much as you do. As stated before, people with arrhythmias can be left more sensitive to their own heart beat and heart sensations. This is common and can predispose the patient to be more anxious about their health (checking their pulse, checking their heart rate), when the doctors tell you that everything is ok.

What we do in these cases, is encourage patients in part with the coaching therapy called Cognitive Behavioral Therapy (CBT) to actually check your pulse and your blood pressure allot less. The goal is to slowly but firmly free yourself from these checking behaviors. Sometimes in addition to the CBT, medications short term such as xanax can help achieve these goals. Other times - and I would discuss with your primary care physician - one of the safe anti-depressants called SSRIs can be very helpful in decreasing the anxiety if despite all the above it still remains high.

jk_miller: I have palpitations and irregular beats but they are not serious and I don't want to go on medications. My friend told me to check out biofeedback. What is that? Do you need a prescription for it?

Speaker_-_Dr__Leopoldo_Pozuelo: Biofeedback is a type of relaxation therapy where you learn to modulate your body's responses to stress. Decreased heart rate, decreased blood pressure, better circulation can be achieved by using this type of therapy in addition to deep breathing exercises. Certain therapists practice biofeedback and you should inquire. You do not need a prescription for it.

Heart Failure, Anxiety and Depression

Paula: Dear Doctor, I have both v-tach and a-fib problems and have a pacemaker and defibrillator. My ejection fraction was at 30 following surgery so they put me with the "heart failure" support group. They said 50% of the patients with that diagnosis don't live beyond 5 years. After 2 months of low sodium diet and the new pacemaker, my ejection fraction is 60 and they took me out of the "heart failure" range as that is normal heart muscle. I can't help feeling anxious whenever I feel ill that I am getting sicker again. I am even taking the occasional valium lately (I do not drink or smoke). This seems to help. Any other ideas would be welcome! Thanks Paula1948

Speaker_-_Dr__Leopoldo_Pozuelo: Thank you for this very genuine comment and patient experience. It has to be frightening to be told you have significant heart failure which carries a higher risk of death. However, your cardiology team and organizations such as the American Heart Association are very aggressive about treating heart failure with medications and exercise. And - people can get good results - like you have. One of the things to focus on is not what can happen to you but that you strive and succeed in achieving a good quality of life.

maryb: I have been told my ejection fraction is now 25%. I was fine and had a virus and now I have heart damage. When reading on the internet it said that depression and stress can be bad for heart failure but how can you help but be sad when this happens to you. I am at a loss for what to do. I started medications. Not sure if I should be exercising, not sure what my future will be. frankly I am depressed I think.

Speaker_-_Dr__Leopoldo_Pozuelo: There is about a 30% incidence of clinical depression in patients with heart failure. You are not alone. More and more cardiology clinicians are screening for and treating depression with patients that have CHF. Encourage you to talk to your clinicians about how you are feeling and how you are coping.

Mitral Valve Prolapse and Anxiety

Smithb: I have mitral valve prolapse and it is not severe - the doctors are keeping an eye on it but there is really no treatment at this time. I often have feelings that my heart rate is running away - are there any relaxation exercises or calming medications that would help?

Speaker_-_Dr__Leopoldo_Pozuelo: It is not unusual to have some anxiety symptoms with mitral valve prolapse. Good to hear that it is not severe. Exercise, time for yourself, relaxation techniques, yoga, and socialization are all non-pharmacological approaches in treating or optimizing anxiety.

Speaker_-_Dr__Leopoldo_Pozuelo: If despite this, you need more assistance, would not hesitate to see a therapist for CBT. Medications for anxiety would be another option but would discuss with your physician first.

Heart Surgery and Depression

cc83: My dad had heart surgery about 4 weeks ago and he has been very depressed. I can't motivate him to get up and walk. He says he is tired and I know he needs to walk. What did he go through all that for if he is just going to sit around all the time? How long does depression after heart surgery take to go away?

Speaker_-_Dr__Leopoldo_Pozuelo: This is the type of depression post CABG that you want diagnosed and treated. My recommendation is to talk directly to your dad's doctor. Have him seen and assessed for depression - and treated aggressively for it.

wandwe: as a caregiver, is there something that I can look out for? after heart surgery my husband seems depressed, but he keeps brushing it off.

Speaker_-_Dr__Leopoldo_Pozuelo: This is always a challenge to caregivers. I would encourage your husband to begin an exercise regimen which of itself can lift mood. If your husband qualifies, a referral to cardiac rehabilitation is a must and can help your husband get through the slump.

JJazzely: Going into major 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?

Speaker_-_Dr__Leopoldo_Pozuelo: Having a good mental attitude surrounding yourself with good support and committing yourself to a good rehabilitation program are all key ingredients of a successful recovery.

Speaker_-_Dr__Leopoldo_Pozuelo: Educating yourself about the surgery, hospital stay and recovery always help to know what to expect and how your family, friends can be of help.

Speaker_-_Dr__Leopoldo_Pozuelo: You can visit our website or go to the American Heart Association for resources.

Panic Attacks

123io: I was having 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?

Speaker_-_Dr__Leopoldo_Pozuelo: Get the panic attacks treated! Talk to your primary care physician first. Many good family doctors know how to treat panic disorder and panic attacks.

leeJ: I keep having panic attacks - chest pain, shortness of breath, difficulty breathing and my blood pressure goes up. I am having a fast heart rate. I can't sleep. What do you think it is? I have taken some xanax and it isn't helping - could it be my heart?

Speaker_-_Dr__Leopoldo_Pozuelo: Important as always to get it checked out medically - but if your doctor determines the heart is fine, there is a strong possibility this could be an anxiety disorder. At times xanax (pure anti-anxiety medications) are not enough and you should talk to your doctor about other forms of treatment, whether medication or the coaching therapy CBT discussed previously.

Procedures and Anxiety

sarah12: I have to go in for a TEE next week and I am scared out of my mind. Is there anything you can suggest to do to help me relax prior to the test?

Speaker_-_Dr__Leopoldo_Pozuelo: You are not the only patient that this happens to. Listening to relaxation tapes, soothing music a couple days before and even the morning of the procedure can be very helpful. Many clinicians welcome patients having their own IPOD or mp3 players to play relaxation music or guided imagery prior to procedures.

Stress and the Heart

hjkl_0987: How much stress is bad stress - where its bad for your health?

Speaker_-_Dr__Leopoldo_Pozuelo: We all function with some level of stress and for some of us it motivates us and helps us accomplish our goals. The tipping point is different for all of us. When the level of stress significantly starts to affect your overall quality of life, this is usually a good rule of thumb that you have to institute some changes.

historybuff: I know from experience that meditation and other relaxation techniques help reduce my anxiety and stress but I still don't do them enough even if I have time. It seems as if I'm addicted to stress or at least it seems my normal state. Can you be addicted to stress and even create it to feel normal?

Speaker_-_Dr__Leopoldo_Pozuelo: The tolerance for stress varies from individual to individual and as stated earlier a certain amount of stress is beneficial to help one achieve their goals and aspirations.

Speaker_-_Dr__Leopoldo_Pozuelo: Striking the balance is the key.

What is Depression?

lynch007: How can you tell if you are depressed? What is the difference between being sad and being depressed?

Speaker_-_Dr__Leopoldo_Pozuelo: Great question. Sadness describes your mood which could be low and all of us experience some of this at some time or another.

Speaker_-_Dr__Leopoldo_Pozuelo: Depression is more than just sadness. It is accompanied by lack of interest in activities, lack of pleasure, poor concentration. poor appetite and low energy among other symptoms.

Speaker_-_Dr__Leopoldo_Pozuelo: Talk to your doctor, spouse, family, friends to see where your level of sadness is at. If necessary get treatment.

tttrwe: What is the connection between depression and the heart? What does it do?

Speaker_-_Dr__Leopoldo_Pozuelo: We believe depression can affect heart disease by altering heart tone, increasing platelet activity, increasing cortisol levels as well as increasing inflammation.

Speaker_-_Dr__Leopoldo_Pozuelo: Either by the above or in combination with poor wellness behaviors seen in depression (increased smoking, decreased exercise, and decreased socialization) cardiac patients that are depressed do worse.

sar32: I read from a study that women are more prone to developing depression than men - is this true? if so why?

Speaker_-_Dr__Leopoldo_Pozuelo: We don't know exactly why, but there is a higher incidence of depression in women than in men.

Medications, Herbals for Stress, Anxiety, Depression

historybuff: Since I retired I have less stress and more time for exercise, relaxation and other positive things to reduce my stress and anxiety. I still have periods of mild anxiety and depression. Besides doing more meditation, are there any foods, supplements, etc. to help with mild anxiety and depression.

Speaker_-_Dr__Leopoldo_Pozuelo: We don't have great trials of herbal medications that are affective in treating moderate depression or anxiety. There is a lack of safety data with these herbal medications and traditional medications that you may be taking for other reasons. Some data suggest that fish oil exerts antidepressant effects as well as checking your vitamin D level, especially if you live in Cleveland.

luvbug120: There are many anti anxiety medications - it seems that from the commercials that some may be bad if you are on some heart pills or if you have blood pressure. Are there certain medications that are safer than others?

Speaker_-_Dr__Leopoldo_Pozuelo: Yes. In general the SSRIs are very safe in heart disease. Many studies have been done in cardiac patients and they are well tolerated.

lmgaiso: Which of the SSRIs interact with Lipitor or Crestor? Which if the SSRIs interact with ACE inhibitors?

Speaker_-_Dr__Leopoldo_Pozuelo: In general, the SSRIs that have the least drug interactions with heart medications are sertraline (zoloft); citalopram (celexa); escitalopram (lexapro).

Stress Testing

buyejl8: I have heard a lot about the different type of stress tests. What are their differences? and does it matter which one you get?

Speaker_-_Dr__Leopoldo_Pozuelo: There are stress tests that can be done for patients with limited mobility. Best to consult with your cardiologist or family physician as to what is the ideal stress test in your case or of your significant other.

Heart Tone

lmgaiso: can you explain what is "tone" in the context of laterel tone

Speaker_-_Dr__Leopoldo_Pozuelo: Heart tone also known as autonomic heart balance is mediated by the nervous system we have in our bodies. There are two components to the heart tone - both sympathetic (can raise heart rate) and parasympathetic (which can lower heart rate).

Speaker_-_Dr__Leopoldo_Pozuelo: As it turns out, patients with depression have impairment in this autonomic tone or balance. However, exercise, meditation, yoga has been proven to be effective in regulating a healthy cardiac tone.

Cardiac Rehabilitation

yrte34: You mentioned, cleveland clinic's rehabilitation program - what exactly does it entail?

Speaker_-_Dr__Leopoldo_Pozuelo: Cardiac rehabilitation programs are approved 12 week multidisciplinary exercise programs that most insurance will cover for patients recovering from major cardiac events or surgery. It usually starts 4 - 6 weeks after the heart surgery. The cardiac rehab program is multidisciplinary where you meet 3 times a week and receive guidance from an exercise specialist, nutritionist, and cardiologist. The goal is to modify and enhance any exercise, nutrition, and wellness behaviors as you recover from heart surgery.

Speaker_-_Dr__Leopoldo_Pozuelo: Our cardiology clinicians are very assertive in screening for depression and anxiety while the patients are enrolled in cardiac rehabilitation. While in the program we offer psychiatric and psychological services on site for those cardiac patients that are also suffering from depression or significant anxiety.

Cleveland_Clinic_Host: I'm sorry to say that our time with Leopoldo Pozuelo, MD is now over. Thank you again Dr. Pozuelo for taking the time to answer our questions about Stress and Heart Disease.

Speaker_-_Dr__Leopoldo_Pozuelo: It has been a pleasure to talk to you today. I encourage you all to talk to your clinicians about how you are coping overall and don't be bashful to bring up depression, anxiety or stress in the context of one's medical problems.

Technology for webchats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 04/10

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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