Cv 16: Psychiatry And Cv Disease

Front 1

What percentage of adult population has a mental disorder?

Back 1

25%

Front 2

What percentage of adult population has a medical condition?

Back 2

58%

Front 3

What percentage of adult population with a mental disorder, also has a medical condition?

Back 3

68%

Front 4

What percentage of adult population with a medical condition, also has a mental disorder?

Back 4

29%

Front 5

How does depression relate to cardiac disease?

Back 5

- Depression is associated w/ higher numbers of cardiac risk factors
- Associated w/ increased mortality post-MI

Front 6

What are some causes of increased morbidity and mortality from CVD in patients w/ depression?

Back 6

Behavioral Risk Factors:
- Treatment non-adherence
- Lifestyle factors (smoking, lack of exercise, diet, etc.)
- Personality types (A and D)

Physiologic Risk Factors:
- ANS dysfunction (loss of HR variability)
- Inflammation / platelet reactivity
- Hypothalamic Pituitary Adrenal (HPA) axis dysregulation (chronically elevated cortisol)

Front 7

How does depression compare to LVEF and prior MI as a predictor of morbidity and mortality?

Back 7

Impact of depression on prognosis was as relevant as LVEF and prior MI (3-4x adjusted relative risk)

Front 8

How does depression affect a patient without CAD?

Back 8

Presence of depression in individuals without CAD may lead to the development of CAD in the future (1.5-2x adjusted relative risk)

Front 9

What are the cause of Takotsubo CM? Outcomes?

Back 9

- Triggered by emotional or physical stress
- In absence of significant CAD
- Transient apical and mid-ventricular LV dysfunction

Front 10

What are the clinical findings of Takotsubo CM?

Back 10

- Sudden onset chest pain or shortness of breath
- ECG changes suggest MI along w/ mild to moderate elevation of cardiac biomarkers
- No evidence of obstructive CAD on cath
- "Octopus pot" morphology on echo
- Complete resolution of LV dysfunction weeks after event

Front 11

How common is Takotsubo CM? Mortality? Who is more likely to get it?

Back 11

- ~2% of suspected ACS
- In hospital mortality ranges 0-8%
- More common in women (~90%), especially post-menopausal women (>80%)
- Mean age: 58-75 years

Front 12

What are the triggers of Takotsubo CM? What does this cause?

Back 12

- Death of loved one
- Devastating financial losses
- Natural disasters
- Physical illness / ICU

- Leads to excess Catecholamines (NE elevated ~75%)
- May induce microvascular spasm or dysfunction → myocardial stunning or direct myocardial toxicity

Front 13

Which β-blockers can pass the BBB? Significance?

Back 13

- Lipophilic drugs: Carvedilol, Metoprolol, Propranolol
- May be linked to depression (although more studies fail to find an increase in rates of depression)
- Other CNS adverse events have been linked to them: drowsiness, fatigue, lethargy, and sleep disorders

Front 14

What is the concept of Metabolic Syndrome?

Back 14

Group of cardiometabolic risk factors associated with insulin resistance

Front 15

What are the criteria for diagnosis of Metabolic Syndrome?

Back 15

3 of 5 criteria:
- Waist: M > 40 inches, F >35 inches
- BP: ≥ 130/85 mmHg
- HDL: M <40 mg/dl, F <50 mg/dl
- TG: ≥ 150 mg/dl
- Glucose: ≥ 100 mg/dl

Front 16

How prevalent is Metabolic Syndrome by gender?

Back 16

- Much more common in females (50%)
- 35% of males

Front 17

How does schizophrenia relate to post-MI mortality? Why might this be?

Back 17

- 34% increased risk of mortality following MI
- Schizophrenic patients do not receive adequate treatment of dyslipidemia, HTN, DM

Front 18

What features of schizophrenia make them at increased risk for metabolic syndrome?

Back 18

- Suspicion
- Stigma
- Negative symptoms
- Executive dysfunction
- Anti-psychotic medications

- Sedentary lifestyle
- Lack of regular physical activity
- Poor food intake
- Substance use
- High rates of smoking

Front 19

Which anti-psychotics cause the greatest increase in proportion of patients meeting criteria for metabolic syndrome?

Back 19

- Olanzapine
- Clozapine

Front 20

How do anti-psychotics affect weight?

Back 20

Some (especially Olanzapine and Clozapine) tend to show weight gain that slows after first year of treatment

Front 21

What are the risk factors for anti-psychotic induced weight gain?

Back 21

- Younger age
- Lower initial BMI
- Personal or family history of obesity
- Non-white ethnic background
- Cannabis use

Front 22

What are the potential mechanisms of weight-gain due to anti-psychotics?

Back 22

Receptors most frequently associated with weight gain:
- Serotonin 2C (5HT2C)
- Histamine 1 (H1)

Front 23

Which anti-psychotic drug is best in terms of not causing weight gain?

Back 23

- Ziprasidone
- Aripiprazole

Front 24

What modifiable risk factors should be evaluated in patients at risk of CV and metabolic diseases?

Back 24

- Weight
- BMI
- Waist circumference
- Fasting lipids
- Fasting glucose
- BP

Front 25

What is the overall incidence rate of new onset Diabetes within 3 months of anti-psychotic therapy initiation?

Back 25

4%

Front 26

What problems do anti-psychotics possibly cause with glucose regulation?

Back 26

- Diabetes Mellitus Type II: related to anti-psychotic induced weight gain and adiposity's effect on insulin secretion
- Diabetic Ketoacidosis (DKA): may be direct effect of some anti-psychotic medication on tissue insulin sensitivity or pancreatic beta-cell function

Front 27

How do anti-psychotics cause abnormal glucose regulation leading to Diabetes Mellitus type II?

Back 27

- Adiposity levels are highly predictive of level of insulin sensitivity
- ↑ Adiposity → ↓ Insulin Resistance
- Risk of diabetes during anti-psychotic tx generally follows rank order for wt gain

Front 28

How do anti-psychotics cause abnormal glucose regulation leading to Diabetic Ketoacidosis?

Back 28

- Antagonize M3 cholinergic receptors
- Muscarinic M3 cholinergic receptors are located on pancreatic beta cells
- Antagonism of M3 cholinergic receptors in pancreatic beta cells, releases insulin resistance

Front 29

How does a decrease in blood cholesterol affect CVD?

Back 29

- Reduce blood cholesterol by 10% minimum with 30% decrease in risk of CHD
- Decreased diastolic BP of 6 mmHg in patients w/ BP >90 mmHg → ↓CHD and 42%↓ in stroke

Front 30

Which phase of the myocardial AP do anti-psychotics affect?

Back 30

Phase 3: repolarization by opening of fast K+ rectifier channels (outward K+ flow)

Front 31

How do you quickly and easily determine if the QT interval is normal?

Back 31

Use rule of thumb that normal QT is less than half the RR interval

Front 32

How do you measure the QT interval? Which leads?

Back 32

- Use lead II or V5 (these give you the best T waves)
- Draw a line tangent to steepest slope of T wave so that it crosses baseline (tangent)
- Measure from first dip of Q wave to tangent = QT interval
- Corrected QT interval: QTc = QT / √RR

Front 33

What are the risks of having a prolonged QTc interval?

Back 33

- ↑ Risk of Torsades de Pointes
- Surrogate marker to predict drug-related cardiac morbidity and mortality

Front 34

What is a normal QT interval for men and women?

Back 34

- Men: <440 msec
- Women: <450 msec

Front 35

What is a "highly abnormal" QT interval?

Back 35

>500 msec for males or females

Front 36

What are some non-modifiable risk factors for prolonged QT interval?

Back 36

- Genetics (LQTS)
- Age >65 yo
- Female Gender
- Circadian Rhythm
- CV Disease

Front 37

What are some modifiable risk factors for prolonged QT interval?

Back 37

- Bradycardia (check if β-blockade is too high)
- Electrolyte Abnormalities (hypomagnesemia, hypokalemia)
- Pharmacologic (check what drugs they are that may prolong QT)

Front 38

What causes Long QT Syndrome? Risks?

Back 38

- Mutations in K+ channels (KCNQ1 and KCNH2) and others (Na+ channels too)
- Causes 3000-4000 deaths/year
- Much more susceptible to drug-induced TdP (5-20% of cases)

Front 39

What channel is most often inhibited in acquired (or drug-induced) QT prolongation? Gene? Function?

Back 39

HERG K+ channel
- KCNH2 encoded
- Mediates the rapid component of the delayed-rectifier K+ current (Ikr)

Front 40

How do drugs that bind to the HERG K+ channel affect it? Outcomes?

Back 40

- Inhibits outward K+ current (Ikr)
- Prolongs phase 3 of ventricular myocyte's AP duration
- Lengthens QT interval

Front 41

What is Torsades de Pointes? How fast is rate?

Back 41

- Polymorphic Ventricular Tachycardia
- Change in amplitude and morphology (ie, twisting) of QRS
- Ventricular rate: 160-240 bpm

Front 42

What are the symptoms of a patient with Torsades de Pointes?

Back 42

- Asymptomatic
- Self-limited dizziness, palpitations, or syncope
- Sudden cardiac death

- Usually short-lived and terminates spontaneously

Front 43

Which drugs have the greatest effect on prolonging the QT interval?

Back 43

- Thioridazine
- Ziprasidone