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AD's and Heart Disease In Women

Posted by Phillipa on May 7, 2009, at 20:42:29

Darned if you do darned if you don't Phillipa

Clinical Context

In patients with CHD, depression may predict cardiac events and mortality, possibly from arrhythmia. Potential mediators of this increased risk may include abnormalities in heart rate variability, levels of inflammatory biomarkers, platelet activation, omega-3 fatty acid levels, and plasma norepinephrine levels.

It is still undetermined whether depression is an independent risk factor for adverse prognosis after MI, or whether treatment of depression lowers this risk. In the Enhancing Recovery in Coronary Heart Disease Patients trial, post-MI patients treated with cognitive behavior therapy and SSRIs did not have improvements in survival rates or prevention of recurrent MI.


Study Highlights

The goal of this analysis from the Nurses' Health Study was to evaluate the association between depression and SCD and cardiac events in individuals without CHD at baseline.
The study cohort consisted of a relatively healthy group of mostly white women.
The investigators looked at depressive symptoms and a proxy variable for clinical depression consisting of severe symptoms and/or antidepressant medication use.
Questionnaires administered in 1992, 1996, and 2000 included the MHI-5 to assess depressive symptoms. MHI-5 scores of less than 53 were previously found to predict clinical depression.
Antidepressant use was evaluated in 1996 and 2000.
The main outcomes of the study included SCD, fatal CHD, and nonfatal MI and their relationship to depression.
Among 63,469 women without a history of CHD or stroke in 1992, 7.9% had MHI-5 scores of less than 53.
Depressive symptoms were directly associated with the risk for CHD events in age-adjusted and multivariable models excluding potential biologic intermediates.
The relationship between depressive symptoms and CHD events was strongest for fatal CHD.
This association remained significant even after controlling for CHD risk factors (HR, 1.49; 95% confidence interval [CI], 1.11 - 2.00 for MHI-5 score < 53).
Depressive symptoms were also associated with multiple risk factors for CHD.
The relationships between depressive symptoms and all 3 endpoints, including fatal CHD, were attenuated in multivariable analyses that adjusted for updated CHD risk factor status.
Models from 1996 onward showed that the proxy variable for clinical depression was most associated with SCD in multivariable models (HR, 2.33; 95% CI, 1.47 - 3.70).
This risk was mainly attributed to a specific relationship between antidepressant use and SCD (HR, 3.34; 95% CI, 2.03 - 5.50).
In multivariable models, neither depression score nor antidepressant use was significantly associated with nonfatal events.
The investigators concluded that in this cohort of women without baseline CHD, depressive symptoms were associated with fatal CHD, and a proxy marker of clinical depression that included antidepressant use was specifically associated with SCD.
They suggested that antidepressant use might be a marker of worse depression but that its specific association with SCD should be studied further.
Limitations of this study include reverse causality possibly accounting for at least part of the association seen between depression and cardiovascular disease; inability to measure adherence to medications; lack of data on other comorbid psychologic factors, such as anxiety; relatively small number of SCD events; and limited generalizability to other populations.

Pearls for Practice

In a cohort of women without baseline CHD in the Nurses' Health Study, depressive symptoms were associated with the risk for CHD events in age-adjusted and multivariable models excluding potential biologic intermediates. The relationship between depressive symptoms and CHD events was strongest for fatal CHD. This association remained significant even after controlling for CHD risk factors.
A proxy marker of clinical depression that included antidepressant use was specifically associated with SCD. This risk was mainly attributed to a specific relationship between antidepressant use and SCD. Although antidepressant use might be a marker of worse depression, its specific association with SCD should be studied further.

CME/CE Test

Questions answered incorrectly will be highlighted.


According to the analysis of Nurses' Health Study data by Whang and colleagues, which of the following statements about the association of depressive symptoms with CHD is not correct?
The relationship between depressive symptoms and CHD events was strongest for fatal CHD
Depressive symptoms were directly associated with the risk for CHD events
After controlling for CHD risk factors, the relationship between depressive symptoms and fatal CHD was no longer significant
Depressive symptoms were also associated with multiple risk factors for CHD

According to the analysis of Nurses' Health Study data by Whang and colleagues, which of the following statements about the association with SCD of a proxy marker of clinical depression that included antidepressant use is correct?
In multivariable models, depression score was significantly associated with nonfatal events
In multivariable models, antidepressant use was significantly associated with nonfatal events
The proxy variable for clinical depression was most associated with SCD in multivariable models
Findings from this study can be generalized to black men

[CLOSE WINDOW]
Authors and Disclosures
As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Author(s)
Lisa Nainggolan
Lisa Nainggolan is a journalist for theheart.org, part of the WebMD Professional Network. She has been with theheart.org since 2000. Previously, she was science editor of Scrip World Pharmaceutical News, covering news about research and development in the pharmaceutical industry, and a consultant editor of Scrip Magazine. Graduating in physiology from Sheffield University, UK, she began her career as a poisons information specialist at Guy's Hospital before becoming a medical journalist in 1995. She can be reached at LNainggolan@webmd.net.

Disclosure: Lisa Nainggolan has disclosed no relevant financial relationships.

Editor(s)
Brande Nicole Martin
Brande Nicole Martin is the News CME editor for Medscape Medical News.

Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Reviewer(s)
Laurie E. Scudder, MS, NP
Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland

Disclosure: Laurie Scudder, MS, NP, has disclosed no relevant financial information.

CME Author(s)
Laurie Barclay, MD
Laurie Barclay, MD, is a freelance reviewer and writer for Medscape LLC.

Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
[ CLOSE WINDOW ]
CME/CE Information
Target Audience
This article is intended for primary care clinicians, psychiatrists, cardiologists, and other specialists who care for women with depression and/or antidepressant use who may be at risk for sudden cardiac death.

Goal
The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Learning Objectives
Upon completion of this activity, participants will be able to:

Describe the association of depressive symptoms with coronary heart disease in a cohort of women without baseline coronary heart disease who were enrolled in the Nurses' Health Study.
Describe the association of a proxy marker of clinical depression that included antidepressant use with sudden cardiac death in the Nurses' Health Study.
Authors and Disclosures
Lisa Nainggolan
Lisa Nainggolan is a journalist for theheart.org, part of the WebMD Professional Network. She has been with theheart.org since 2000. Previously, she was science editor of Scrip World Pharmaceutical News, covering news about research and development in the pharmaceutical industry, and a consultant editor of Scrip Magazine. Graduating in physiology from Sheffield University, UK, she began her career as a poisons information specialist at Guy's Hospital before becoming a medical journalist in 1995. She can be reached at LNainggolan@webmd.net.
Disclosure: Lisa Nainggolan has disclosed no relevant financial relationships.

Brande Nicole Martin
Brande Nicole Martin is the News CME editor for Medscape Medical News.
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Laurie E. Scudder, MS, NP
Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland
Disclosure: Laurie Scudder, MS, NP, has disclosed no relevant financial information.

Laurie Barclay, MD
Laurie Barclay, MD, is a freelance reviewer and writer for Medscape LLC.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)

Family Physicians - maximum of 0.25 AAFP Prescribed credit(s)

Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

Pharmacists - 0.25 knowledge-based ACPE (0.025 CEUs)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

Physicians should only claim credit commensurate with the extent of their participation in the activity.

Accreditation Statements
For Physicians
Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Medscape, LLC designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credit(s) . Physicians should only claim credit commensurate with the extent of their participation in the activity. Medscape Medical News has been reviewed and is acceptable for up to 350 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 09/01/08. Term of approval is for 1 year from this date. This activity is approved for 0.25 Prescribed credits. Credit may be claimed for 1 year from the date of this activity.

Note: Total credit is subject to change based on topic selection and article length.

AAFP Accreditation Questions

Contact This Provider

For Nurses
This Activity is sponsored by Medscape Continuing Education Provider Unit.

Medscape is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

Contact This Provider

For Pharmacists

Medscape is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Medscape is accredited by the American Council on Pharmacy Education as a provider of continuing pharmacy education. Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) of the American Council on Pharmacy Education (Universal Program Number 461-000-09-027-H01-P).

Contact this provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact CME@medscape.net

CME/CE Released: 03/13/2009; Valid for credit through 03/13/2010


Instructions for Participation and Credit
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

Read the target audience, learning objectives, and author disclosures.
Study the educational content online or printed out.
Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape encourages you to complete the Activity Evaluation to provide feedback for future programming.
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 5 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.

Hardware/Software Requirements
Medscape requires version 4.x browsers or higher from Microsoft or Netscape. Certain educational activities may require additional software to view multimedia, presentation or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Macromedia Flash, Apple Quicktime, Adobe Acrobat, Microsoft Powerpoint, Windows Media Player, and Real Networks Real One Player.
[ CLOSE WINDOW ]
CME/CE Information
CME/CE Released: 03/13/2009; Valid for credit through 03/13/2010

Target Audience
This article is intended for primary care clinicians, psychiatrists, cardiologists, and other specialists who care for women with depression and/or antidepressant use who may be at risk for sudden cardiac death.

Goal
The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Learning Objectives
Upon completion of this activity, participants will be able to:

Describe the association of depressive symptoms with coronary heart disease in a cohort of women without baseline coronary heart disease who were enrolled in the Nurses' Health Study.
Describe the association of a proxy marker of clinical depression that included antidepressant use with sudden cardiac death in the Nurses' Health Study.
Credits Available
Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)

Family Physicians - maximum of 0.25 AAFP Prescribed credit(s)

Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

Pharmacists - 0.25 knowledge-based ACPE (0.025 CEUs)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

Physicians should only claim credit commensurate with the extent of their participation in the activity.

Accreditation Statements
For Physicians
Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Medscape, LLC designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credit(s) . Physicians should only claim credit commensurate with the extent of their participation in the activity. Medscape Medical News has been reviewed and is acceptable for up to 350 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 09/01/08. Term of approval is for 1 year from this date. This activity is approved for 0.25 Prescribed credits. Credit may be claimed for 1 year from the date of this activity.

Note: Total credit is subject to change based on topic selection and article length.

AAFP Accreditation Questions

Contact This Provider

For Nurses
This Activity is sponsored by Medscape Continuing Education Provider Unit.

Medscape is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; 0.25 contact hours are in the area of pharmacology.

Contact This Provider

For Pharmacists

Medscape is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Medscape is accredited by the American Council on Pharmacy Education as a provider of continuing pharmacy education. Medscape designates this continuing education activity for 0.25 contact hour(s) (0.025 CEUs) of the American Council on Pharmacy Education (Universal Program Number 461-000-09-027-H01-P).

Contact this provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact CME@medscape.net

Instructions for Participation and Credit
There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

Read the target audience, learning objectives, and author disclosures.
Study the educational content online or printed out.
Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape encourages you to complete the Activity Evaluation to provide feedback for future programming.
You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 5 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.

Hardware/Software Requirements
Medscape requires version 4.x browsers or higher from Microsoft or Netscape. Certain educational activities may require additional software to view multimedia, presentation or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Macromedia Flash, Apple Quicktime, Adobe Acrobat, Microsoft Powerpoint, Windows Media Player, and Real Networks Real One Player.

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Medscape Medical News © 2009 Medscape, LLC
The material presented here does not necessarily reflect the views of Medscape or companies that support educational programming on www.medscape.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.

 

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