What is cardiac neurosis?
Many cardiologists have the experience that they can meet a few such patients every day as long as they visit outpatient clinics, with a wide range of symptoms, chattering, soft and hard to deal with. Invasive examinations, all the examinations that can be thought of have been done, but no abnormalities can be found, the patient seeks medical advice for this, the more medicine he takes, the worse his body gets, spending a lot of time, energy and money, causing the whole family no peace, pain and trouble, but from the doctor’s point of view, the patient’s symptoms have no anatomical, physiological and pathogenetic basis, and cannot be explained from a medical point of view, which is difficult to understand.
For such patients, if the diagnosis is not clear after completing the necessary differential tests, it may be necessary to consider the diagnosis of “cardiac neurosis”, referred to as “cardiac neurosis”. This is a special type of neurosis, with symptoms of the cardiovascular system, often resembling a “heart attack”, so patients often go to cardiology first for help, so from a cardiologist’s point of view, it is called cardiac neurosis. Cardiac neurosis can be combined with a variety of other systemic disorders, which are characterized by malfunctions, often without organic problems, with symptoms that are sometimes good and sometimes bad and persistent.
Cardiac neurosis is essentially a systemic disorder of the vegetative nerves due to anxiety and depression, panic attacks and other mood disorders. The vast majority of experts believe that the main symptoms of cardiac neurosis, such as chest tightness, breathlessness, panic, palpitations, and even chest and back pain, are due to dysfunction of the autonomic nerves (formerly called vegetative nerves) of the heart, and that there is no particular organic problem of the heart itself, which can often be traced back to various long-standing psychosocial problems or recent sudden psychological stress in patients upon detailed examination. Of course, such neurological disorders are not often limited to the cardiac nerves, but may affect all the vegetative nerves of the body and are very common, such as digestive neurosis, etc., and urinary neurosis.
However, based on China’s national conditions, most physicians are in a hurry to see patients, as well as the long-standing traditional medical model, there are many misconceptions about neurological disorders, and many of our clinicians are accustomed to focusing on patients with various physical symptoms or discomfort, and rarely take into account or detect the emotional and psychological changes of patients, resulting in a large number of patients with cardiac neurological disorders not being diagnosed and treated in a timely manner, which can have quite serious consequences. It is necessary to discuss this issue and draw attention to it.
One of the misconceptions: neurosis is always a minority and not common in clinical practice
The prevalence of mood disorders in the natural population of modern society is actually quite high. Data show that the prevalence of anxiety in the U.S. population is about 5%, 25% lifetime prevalence, anxiety disorders affect 26.9 million Americans; domestic scholars such as Cai Zhuoji surveyed the lifetime prevalence of depression disorder in Beijing community residents is 6.87%, while the prevalence of > 60 years of age reached 8.18%; Li Ning and other surveys of urban and rural residents in Liaoning anxiety disorders lifelong prevalence of 7.21%, while anxiety and depression in the community elderly The incidence of anxiety and depression among the elderly in the community can be 10-20%.
Due to China’s national conditions and cognitive problems, patients with mood disorders generally do not go to psychiatric hospitals, and more than 95% of them choose to seek help from various clinical departments in general hospitals. According to an epidemiological survey conducted by the Chinese Medical Association in more than a dozen large tertiary hospitals in Beijing, Shanghai and Guangzhou, depression and anxiety symptoms are prevalent among patients in neurology, cardiovascular medicine and gastroenterology, with an incidence of up to 25%; these patients were assessed by psychiatrists and found that 39-73% of them suffered from depression and anxiety, especially in patients with Parkinson’s disease, stroke, coronary heart disease, functional dyspepsia, postpartum and menopausal syndrome. Patients with Parkinson’s disease, stroke, coronary artery disease, functional dyspepsia, postpartum, and menopausal syndrome have a higher percentage of depression/anxiety than other patients, with undiagnosed rates higher than 90%, and only 1/6 of patients with depression/anxiety are treated accordingly.
In many cardiovascular patients, the number of visits for chest pain is particularly high, and coronary angiography for unexplained chest pain is also very common at home and abroad, and clinicians prefer to take this definitive test to provide a basis for diagnosis, but in fact the negative rate of coronary angiography has gradually increased in recent years, and one important factor is that many patients with cardiac neurosis end up with coronary angiography. Yuan Chen, a domestic scholar, conducted a prospective study on 328 patients with CAG chest pain, resulting in 103 negative cases and 225 positive cases, including 25 cases of anxiety and 11 cases of major depression in the negative group, compared with 9 and 6 cases in the control group, respectively, with significant differences between them. Among all 328 patients with CAG, 31.4% had less than 50% coronary stenosis, and 86% of these negative patients still had chest pain at least once a week without psychological intervention, and 71% felt no change or even worsening of chest pain, and if psychological intervention was performed, the ratio of chest pain relief in the intervention/non-intervention group was 38:51 and 13:51, with significant differences between the two groups. Therefore, some foreign cardiovascular authorities have pointed out that 70% of chest pain is related to anxiety, but not to the heart.
In fact, for chest pain of different etiologies, clinically experienced cardiologists are able to identify one or two through careful consultation. Often, chest pain in neurosis is mostly vague, long-lasting and can be wandering, which is clearly different from the brief sharp colic of angina pectoris. But why would a mood disorder have chest pain discomfort? The reason for this phenomenon is related to the somatization of mood disorders, which is what complicates the condition. The so-called somatization refers to a tendency to experience and express somatic discomfort and somatic symptoms, which cannot be explained by pathophysiological findings, but patients attribute them to somatic diseases and seek medical help accordingly, while in fact the tendency to experience such discomfort is the expression of mood disorders in the form of somatic discomfort, a response to psychosocial stress, which are mainly caused by A variety of sudden irritating life events or situations caused by.
Misconception No. 2: White-collar workers are more likely to suffer from neurosis due to high stress, but other people are less likely
We usually think that the white-collar class, middle-level cadres work under great pressure, the proportion of emotional disorders is high, in fact, today’s society is in transition, competition is unprecedentedly increased, people’s psychosocial environment has changed rapidly, all classes, all groups of people have a great social psychological pressure, especially the “old, young, sick” people. The “old” refers to the phenomenon of empty nest in middle and old age, and the problem of loneliness and old age is increasing; the “young” refers to teenagers, and there are many problems in their hearts. However, these small patients also complain of chest tightness, chest pain and shortness of breath, making it very difficult for many clinicians, often giving a viral myocarditis; “disease” refers to major diseases, such as many patients with acute heart attack, heart failure, cerebral infarction stroke vascular accident, especially physical disability, unable to take care of themselves, the proportion of emotional disorders is very high, and Often doctors only focus on the original disease and ignore the emotional changes of the patient.
Therefore, it can be said that cardiac neurological dysfunction is not only for menopausal women and middle and senior white collar workers, but also for the old and the young.
Misconception #3: If organic heart disease is confirmed, cardiac neurosis is ruled out
According to our traditional clinical thinking, for all kinds of patients with neurological disorders suspected of heart disease, we generally exhaust all kinds of tests to exclude the possibility of organic heart disease, once it is determined that the patient has various organic problems, then the diagnosis of neurological disorders can not be established, one of the two must live. In fact, organic heart disease and functional heart disease can coexist in the same patient, i.e., there is a so-called “co-morbidity” phenomenon.
A meta-analysis of 11 prospective studies with more than 4000 patients, with a mean follow-up of 12 months and a maximum follow-up of 7.9 years, showed that the incidence of post-infarction depression: 16-20% and the incidence of depressive “symptoms”: 17-47%. Many clinicians are at their wits’ end as to whether these patients have unrelieved chest tightness, shortness of breath, and chest pain, whether the original stenosis has not been resolved or new stenosis has appeared, or whether anxiety and depression have led to somatization symptoms.
Myth #4: Functional disease is not clinically significant compared to organic heart disease
We are used to thinking that cardiovascular medicine is a high-risk department, and we often face a variety of high-risk patients with myocardial infarction, malignant arrhythmias, and other sudden cardiovascular events are very common. In contrast, cardiac neurosis may be difficult for patients, but it is not clinically dangerous. In reality, however, the dangers of cardiac neuropathy should not be underestimated. The dangers are as follows
1.Seriously occupy medical resources, duplication of diagnosis and treatment causes inefficiency, and social medical costs rise.
The clinical chest pain not caused by the heart is called non-cardiac chest pain (NCCP), a study shows that NCCP patients with anxiety and depression significantly higher than normal 43.8%, due to the chronic process of recurrent attacks, although the clinical healing is good but social rehabilitation psychological reduction, seriously affecting the quality of life, and constantly repeat medical treatment caused by the United States a year due to NCCP attacks resulting in medical losses of $8 billion, and The entire anxiety treatment-related treatment costs $42.3 billion/year (1990), accounting for more than 1/3 of all psychiatric medical expenditures, and only 1/4 of these direct medical expenditures, indirect expenditures (affecting the loss of social functioning of patients) more, accounting for more than 3/4!
Domestic scholars study inpatients, if there is no emotional disorder average hospitalization of 10 days, with disorder with treatment average hospitalization of 13.8 days, but with disorder without treatment average hospitalization of 45.6 days!
2, severe neurosis can lead to reduced emotional and social functioning, decreased compliance, decreased physical fitness, impaired immune function, exacerbate the difficulty of treatment of the original disease, and even induce new diseases such as cancer, heart attack, hypertension, seriously lead to suicide, poor prognosis! In addition, more and more cardiologists have observed that mood disorders themselves are independent risk factors for cardiovascular disease.
Available clinical studies confirm depression as an independent risk factor for the development of cardiovascular disease process. A meta-analysis of 13 studies prospectively with >40,00 healthy individuals followed for a mean of 10 years, duration: 4-37 years, found depression to be an independent risk factor associated with cardiovascular disease prevalence and mortality, corrected for relative risk, major depression: 4-4.5 times, mild to moderate depression: 1.5-2 times!
The latest study is that the University of Washington School of Medicine
Professor led a 12 expert panel of 53 independent prospectively designed studies for Meta-analysis, which included all-cause mortality studies of 22 cohorts in 9 countries in North America, Europe and Asia, with a minimum sample size of 100 and a maximum sample size of 21,745, with follow-up periods spanning 1 month to 10 years. Pooling these studies noted that the results showed that 17 studies identified a significant association between depression and an elevated risk of all-cause mortality after corrected ACS, and 4 suggested an uncorrected significant association. Another 12 studies explored cardiac-caused mortality in 8 separate cohorts in 5 countries with sample sizes ranging from 222-1042. 7 of these studies suggested a significant corrected association and 1 suggested a significant uncorrected association. 3 Meta-analyses showed an overall uncorrected effect of depression of 1.8-2.6 for all-cause mortality; for cardiac-caused death, this range was 2.3-2.9 for cardiac death.
Given that depression is associated with multiple negative prognoses in patients with acute coronary syndrome (ACS), including all-cause and cardiac death, the American Heart Association (AHA) panel noted that depression should be the fifth “official” risk factor for heart disease, after obesity, diabetes, hypertension and smoking. The study was published online Feb. 24 in the journal Circulation.
3. It is very easy to cause confrontation between doctors and patients, intensify the conflict between doctors and patients, and even lead to serious untoward consequences!
Many patients with cardiac neurosis find doctors with hope to get help to relieve physical pain, but they do not know that this pain and discomfort does not come from their heart organs, and many clinicians also lack knowledge of mental illness, often starting from physical disease to solve the problem, of course, is the opposite, chicken and duck talk, unclear diagnosis, ineffective treatment often cause patient dissatisfaction, trust, and decreased compliance. If you encounter individual personality disorder patients, doctor-patient conflict can be more intense, and even terrible consequences, such as the Wenling murder case, Qiqihar murder case, etc., blood lessons need to be awakened and attention of colleagues!
Myth #5: Cardiac neuropathy is a typical functional problem with a good prognosis and no possibility of organic transformation
There is a lot of clinical evidence that cardiac neurosis, or the presence of anxiety and depression symptoms, can raise blood pressure and induce atrial fibrillation, arrest, ventricular premature, ventricular tachycardia and other serious arrhythmias, which have serious consequences and require the attention of our clinicians and in-depth research. Dr. Angelos Halaris, an American cardiologist, suggested that “psychocardiology” should be a subspecialty of cardiology to explore the relationship between depression and heart disease.
Here are some recent studies from abroad, which we hope will enlighten us.
1. Studies on the association between depression and ventricular arrest.
The Washington State Out-of-Hospital Arrest (n=2228, 40-79y) registry study, compared with controls, showed that both less severe depression (OR 1.30
) or more severely depressed (OR 1.77, 95% CI 1.28C2.45) patients, the rate of cardiac arrest was significantly higher in the depressed group!
2. on sudden cardiac death and depression correlation studies.
In
, 671 post-MI patients with frequent ventricular premature beats and a Beck Depression Inventory (BDI) score ≥10 were associated with SCD at 2 years of follow-up (RR 2.45
), which was significantly different from the control group.
3, Regarding the study of the correlation between depressive symptoms and the occurrence of electroshock in ICD patients.
, depressive symptoms (assessed with the depression CES-D scale) were associated with
correlation (hazard ratio 3.2, 95% CI 1.1 to 9.9) in a multivariate model including left ventricular ejection fraction, heart failure, and prior ICD shocks.23 The number of
et al. studied 277 patients with ICDs in whom ventricular arrhythmias were triggered by angry emotions. It was found that anger occurred more frequently in the first 15 minutes of the shock compared with the control period (odds ratio 1.8, 95% CI 1.04 C3.16; p < 0.04). A further multivariate analysis of the same patients also revealed high Speilberger Trait Anger measure scores in the 17 patients with anger 15 minutes before shock.
4. Multivariate analysis on depression and the occurrence of SCD in the elderly.
et al. A flow-modulated study for northern Finland (n=915, y>70) with multivariate analysis, including hypertension, diabetes, and congestive heart failure, at 8 years of follow-up, asked questionnaires with high scores were associated with an increased risk of SCD according to baseline depressive symptoms (HR 2.74, 95% CI 1.37C5.50), whereas non-SCD was not significantly increased!
To explain the above arrhythmogenesis and mechanisms.
1, arrhythmic events require sensitive myocardial substrates with trigger mechanisms such as infarction (MI) leading to ventricular tachycardia (VT) mechanisms, mixed intertwining of scarred fibrous tissue and surviving myocardial fibers leading to delayed impulse conduction and reduced cardiomyocyte coupling, these for their sensitive substrates sensitive substrates under some trigger factor, such as anger occurrence, leading to a sharp rise in blood catecholamine secretion and stimulation of electrically unstable myocardium that leading to the occurrence of arrhythmias.
2, The other most common hypothesized mechanism for the relationship between arrhythmias and psychological disorders is cardiac autonomic dysfunction. grippo and his colleagues studied a depressive phenotype in a rat model induced by stress, including exposure, such as continuous overnight lighting, paired housing, and white noise. Random exposure to stress induced an increase in heart rate, a decrease in heart rate variability, and a higher risk of arrhythmias in rats.
and colleagues showed that heart rate variability was reduced in depressed patients in a low-frequency frequency domain analysis of 24-hour ambulatory ECG monitoring. 311 depressed and 367 non-depressed post-MI patients in the ENRICHD clinical trial demonstrated that reduced heart rate variability partially bridges the relationship between depression and mortality.
In summary
Cardiac neurosis is very common in clinical practice, but most of our clinicians do not know enough about it and there are many misconceptions, which will surely bring us a lot of confusion in diagnosis and treatment, and we need to update our knowledge structure in time, take the modern medical model of bio-social-psychological as the guide, and establish the concept of double “heart” treatment, that is, pay attention to The diagnosis and treatment of heart disease, but also pay attention to the identification and prevention of psychological diseases, the two complement each other, one is indispensable, in order to better relieve the suffering of patients!