Evidence-Based Reviews

Acute MI risk? Protecting your patients’ heart health

Current Psychiatry. 2005 September;4(9):47-58

References

1. Holt RI, Peveler RC, Byrne CD. Schizophrenia, the metabolic syndrome and diabetes. Diabetes Med 2004;21:515-23.

2. Carney RM, Freedland KE, Miller GE, Jaffe AS. Depression as a risk factor for cardiac mortality and morbidity: a review of potential mechanisms. J Psychosom Res 2002;53:897-902.

3. Weiser M, Reichenberg A, Grotto I, et al. Higher rates of cigarette smoking in male adolescents before the onset of schizophrenia: a historical-prospective cohort study. Am J Psychiatry 2004;161:1219-23.

4. Druss B, Rosenheck R. Mental disorders and access to medical care in the United States. Am J Psychiatry 1998;155:1775-7.

5. Druss B, Rosenheck R, Desai MM, Perlin JB. Quality of preventive medical care for patients with mental disorders. Med Care 2002;40:129-36.

6. Lloyd-Jones DM, Larson MG, Beiser A, Levy D. Lifetime risk of developing coronary heart disease. Lancet 1999;353(9147):89-92.

7. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227-9.

8. Expert Panel on Detection. Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-97.

9. Frasure-Smith N, Lesperance F, Talajic M, et al. Depression and 18-month prognosis after myocardial infarction. Circulation 1995;91:999-1005.

10. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72.

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12. Panagiotakos DB, Pitsavos C, Chrysohoou C, et al. Inflammation, coagulation and depressive symptomatology in cardiovascular disease-free people: the ATTICA study. Eur Heart J 2004;25:492-9.

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15. Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Artery Heart Disease Patients (ENRICHD) randomized trial. JAMA 2003;289:3106-16.

16. Rosengren A, Hawken S, Ounpuu S, et al. Association of psychological risk factors with risk of acute myocardial infarction in 11,119 cases and 13,648 controls from 52 countries (the INTERHEART study). Lancet 2004;364:953-62.

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“Non-core” variables. Also consider certain “non-core” variables—such as pre-existing psychiatric illness—when estimating clinical risk for heart disease. Depression, anxiety, and stress are correlated with an increase in pro-inflammatory markers such as C-reactive protein and predispose patients to CAD.^11,12 Depression has repeatedly been shown to increase morbidity and mortality two- to four-fold after myocardial infarction (MI).^9,13,14 Interestingly, however, depression treatment after an acute coronary event does not clearly decrease mortality.¹⁵ Although prospective, randomized studies are lacking, mood and anxiety disorder treatment is presumed to help prevent CAD development.¹⁶

Table 2

Risk equivalents for CAD*

Established coronary artery disease
Symptomatic carotid artery disease
Peripheral vascular disease
Abdominal aortic aneurism
Diabetes mellitus
*Risk equivalent: Patient is assumed to have coronary artery disease (CAD).

Recognizing cad risk

At what point do hypertension and dyslipidemia become risk factors for CAD? When and how often should patients be screened for diabetes mellitus?

Hypertension is one of the most common and deadly CAD risk factors, affecting 50 million Americans.¹⁰ Although hypertension awareness and treatment have improved, only 35% of adults have “controlled” blood pressure (

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), normalizing blood pressure can reduce stroke incidence by 35% and MI by 25%, respectively. JNC 7, however, also found that 90% of persons who are normotensive at age 55 eventually develop hypertension.¹⁰

Based on these findings, JNC 7 in 2003 drastically changed the standard of care for diagnosing hypertension. JNC 7 defines normal blood pressure as

systolic blood pressure 120 to 139 mm Hg
diastolic blood pressure 80 to 89 mm Hg (Table 3).

A patient is considered prehypertensive if either reading falls within these ranges.

Patients with diabetes mellitus or chronic kidney disease are considered hypertensive with blood pressure >130 mm Hg systolic and/or >80 mm Hg diastolic.

As with Mr. H, a blood pressure check is imperative for patients who have rarely or never seen a primary care physician in recent years. The U.S. Preventive Services Task Force strongly recommends measuring blood pressure during a routine medical evaluation at least every 2 years. A second abnormal reading at a separate visit at any time should prompt a hypertension diagnosis. Once diagnosed with hypertension, patients should be treated and checked monthly until stable, then monitored every 3 to 6 months indefinitely.¹⁰

If you cannot measure blood pressure in the office, urge patients to use an over-the-counter blood pressure measuring device and refer them to a primary care physician. Check the patient’s self-test reading for accuracy against a clinician’s measurement.

Diabetes is now considered a risk equivalent for CAD development.⁸ Patients diagnosed with diabetes are extremely likely to have established vascular disease,⁸ which predisposes them to MI, stroke, kidney disease, blindness, and lower-extremity amputations.¹⁷ Those with type 1 diabetes usually present with acute symptoms—including polyuria, polydipsia, weight loss, malaise, dry mouth, and blurred vision—and are readily diagnosed with elevated plasma glucose.

Screening for diabetes is critical because one-third of patients with the disease are undiagnosed. Also, more than 90% of patients with diabetes are non-insulin-dependent (type 2) and are asymptomatic early in the disease course.

No data definitively show benefits from screening asymptomatic adults. Recently revised diagnostic criteria for diabetes, however, call for re-testing asymptomatic patients who were found to have normal fasting plasma glucose (FPG) levels and were considered “free” of diabetes. The American Diabetes Association recommends measuring FPG after no caloric intake for ≥ 8 hours for asymptomatic patients.

FPG measurement is cost-effective and generally more convenient than other diabetes tests.¹⁷ Expert consensus strongly suggests checking FPG every 3 years beginning at age 45:¹⁷

FPG
FPG 100 to 125 mg/dL suggests prediabetes or impaired fasting glucose
FPG ≥ 126 mg/dL demands a provisional diabetes diagnosis and a follow-up test on another day to confirm the diagnosis.

Refer for screening at an earlier age or more frequently for patients with:

comorbid cardiac risk factors
history of polycystic ovary disease
a first-degree relative with diabetes
habitual inactivity
or FPG 100 to 125 mg/dL.

Monitor persons with schizophrenia closely as their risk of diabetes is three times that of the general population.¹ Also, use of atypical antipsychotics increases the risk of developing diabetes and dyslipidemia. In addition to the above diabetes screening guidelines, check FPG before starting any atypical antipsychotic, again after 12 weeks, and annually thereafter.¹⁸

Do not base diabetes diagnosis on glycosylated hemoglobin measurements, as this test can produce false-negative results in patients with new-onset diabetes.

Dyslipidemia. Every 10% reduction in serum cholesterol reduces cardiovascular mortality by 10% to 15%.¹⁹ Data from the large, prospective Framingham heart study show a 25% increase in MIs with each 5-mg/dL decrease in high-density lipoprotein cholesterol (HDL) below the age-based median for men and women.²⁰ Serum triglycerides >150 mg/dL clearly predict future CAD and increase the likelihood of abnormally low HDL.