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New Guidelines For Diagnosis, Management Of Post-Heart-Attack Infarction Depression

Ruzanna Harutyunyan's picture

The American Academy of Family Physicians today released new clinical practice guidelines for the diagnosis and management of depression in patients who have suffered a heart attack, also known as a myocardial infarction.

The guidelines call for patients who have experienced a heart attack to be screened for depression regularly, and for patients diagnosed with depression to be treated with antidepressant medication, psychotherapeutic counseling or both.

The guidelines are published in the January/February 2009 issue of the Annals of Family Medicine, the AAFP's peer-reviewed research journal, which is available online at www.annfammed.org.

Cardiovascular disease remains the leading cause of death and disability among both men and women of all ethnic groups in the United States. Depression is an important predictor of future cardiac problems for patients with coronary heart disease, particularly after a heart attack.

Depression has been shown to correlate with increased morbidity and mortality among patients who have suffered a heart attack, independent of the patients' previous cardiac history or the severity of their coronary artery disease.

As many as 65 percent of patients with acute myocardial infarction report experiencing symptoms of depression, and major depression is present in 15 to 22 percent of these patients. Depression is common during hospitalization and often persists for several months if left untreated.

"Depression is relatively common among patients recovering from heart attacks, and causes significant suffering. Fortunately, it can readily be diagnosed and treated, helping patients to feel better," said Lee A. Green, M.D., MPH, lead author of the guideline panel.

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Many studies have shown depression to be associated with an increase in subsequent coronary events and with coronary-related mortality. The correlation of depression with adverse cardiac outcomes has led to a number of trials examining the effect of depression treatment on coronary outcomes as well as depression outcomes.

Controlled trials using antidepressants, specifically selective serotonin reuptake inhibitors, and psychotherapy have shown reductions in the symptoms of depression among post-myocardial infarction patients.

Selective serotonin reuptake inhibitors have been shown to be safe in patients who have experienced a heart attack and are preferred over tricyclic antidepressants because of the heart rate and conduction effects of tricyclic antidepressants.

The AAFP's clinical practice guidelines are designed to assist the clinician and patients in making decisions about appropriate health care for specific clinical circumstances.

In 2003, the AAFP Commission on Public Health and Science determined there was a need for an evidence-based review on the effect of depression on post-myocardial infarction patients and successfully nominated the topic to federal Agency for Healthcare Research and Quality. The AHRQ published an evidence report on this topic in May 2005, which was used as the basis for the AAFP guidelines:

1. Patients having a myocardial infarction should be screened for depression using a standardized depression symptom checklist at regular intervals during the post-myocardial infarction period, including during hospitalization.

2. Post-myocardial infarction patients with a diagnosis of depression should be treated to improve their depression symptoms, with systems in place to ensure regular follow up and monitoring of their treatment response and adherence to treatment.

3. Selective serotonin reuptake inhibitors are preferred to tricyclic antidepressants for treatment of depression in post-myocardial infarction patients.

4. Psychotherapy may be beneficial for treatment of depression in post-myocardial infarction patients. The existing evidence base does not establish what form of psychotherapy is preferred.