Coronary atherosclerotic heart disease (CHD) is one of the diseases that seriously threaten the life expectancy and quality of life of the general public. In recent years, the age of onset of CHD has gradually become younger due to the improvement of living standards and the proliferation of poor lifestyles. However, while we are constantly looking for treatment and prevention of coronary heart disease, has it ever occurred to us that coronary heart disease may be related to our long-term adverse emotions? Thirteen prospective studies of more than 4,000 healthy individuals followed for an average of 10 years showed that depression is an independent risk factor associated with cardiovascular disease prevalence and mortality, with patients with major depression having more than four times the risk of coronary heart disease than those without depression, and those with depressive symptoms that do not meet the diagnostic criteria for depression, known as “sub-syndromes”. The risk of coronary heart disease is also 1.5 C2 times higher in patients who have depressive symptoms but do not meet the diagnostic criteria for depression, so-called “sub-syndromic depression” than in those who are not depressed. As an independent risk factor in the development of cardiovascular disease, depression is comparable to risk factors such as hyperlipidemia, hypertension, and diabetes mellitus. On the other hand, epidemiological studies have shown that the prevalence of depression among patients with coronary artery disease is about 20%. Post-infarction major depression is about 15-30%, with 65% exhibiting at least mild depression. More than 30% of patients have depressive symptoms before coronary artery bypass grafting. Numerous studies have confirmed that depression can increase the incidence of cardiovascular events in coronary patients and that depression can also increase mortality due to cardiovascular events. Foreign studies have shown that six months after infarction, 16.5% of patients with depression; died, compared to only 3% of patients without depression; and at 1.5 years after infarction, the mortality rate was 20%; and 6%; for the two groups, respectively. In other words, depression increased the risk of death in patients with heart attack by more than 3-fold. Therefore, depression has a very negative impact on coronary heart disease, both before and after the disease. However, compared to the high prevalence of depression in combination with coronary artery disease, only 10% of post-infarction depressed patients are identified, let alone treated. The reasons for the low recognition rate may include: 1. atypical manifestations of depression: e.g. hostility, restlessness and withdrawal are more common than sadness; 2. depression is often perceived as a normal reaction to a serious medical event such as a heart attack – it is considered natural to feel bad after such a serious illness; 3. most uncomplicated heart attack patients have a short hospital stay and it is difficult for physicians to evaluate the patient’s mood in the limited time available. 3. Most uncomplicated heart attack patients are hospitalized for a short period of time, and it is difficult for the physician to evaluate the patient’s mood in the limited time available, and it is even more difficult for the patient to obtain consultation from a psychiatrist/psychologist. So, how can we determine early if we or our relatives are depressed? Let’s look at a real case first. Ms. Wu, 74 years old, suddenly felt short of breath, pale and cold sweat in her chest one day after getting angry with her daughter 2 years ago. Her family rushed her to Anzhen Hospital for emergency treatment, where an electrocardiogram revealed the presence of acute heart attack. After the operation, the electrocardiogram returned to normal and all biochemical indicators were normal. Ms. Wu felt that everything was normal and was discharged home on the fourth day after the operation. What she didn’t expect was that at 2:00 a.m. on the day of discharge, Ms. Wu woke up and felt her heart beating very hard and had another attack of chest tightness and shortness of breath, thinking she was going to die. She was rushed to the emergency room of Anzhen Hospital by ambulance, but the doctor’s examination results were normal in many aspects, and Ms. Wu slowly recovered herself without any substantial treatment. Since then, she woke up almost every morning and felt short of breath with chest tightness, which could improve after taking quick-acting heart pills, nitroglycerin and other drugs. Gradually, he became depressed, reluctant to talk to neighbors, and walked around as much as possible when he encountered them. Inexplicably, I wanted to cry and felt aggrieved, but I couldn’t tell why. She used to like watching Korean dramas, but now she gets annoyed when she hears the sound of TV, and her family is afraid to turn on the TV for this reason. He has a poor appetite and has lost 5kg in 3 months. He is afraid of cold and is not allowed to turn on the air conditioner at home in the three volt days. Poor sleep quality, easy to wake up and dreamy, wake up at 2~3 am, can no longer sleep, string pain around the body, suspect that she has an incurable disease. Her family took her to major hospitals for a thorough examination and found no obvious abnormalities. The patient is lethargic all day long, tired and weak, lying in bed all day long, not even washing her face or combing her hair, feeling that life is meaningless and dragging her family down, so it is better to die. At the same time, the pain in the anterior chest region was frequent, and the use of nitroglycerin and rapid-acting cardioplegia increased, but the effect was getting worse. At 4 months after surgery, the patient was hospitalized again for coronary angiography, which showed that the stent was open and all coronary arteries were normal. The resident suspected that the patient was depressed and consulted a psychiatrist, who confirmed the diagnosis of depressive episode secondary to coronary artery disease. After 2 weeks of treatment with the antidepressant sertraline hydrochloride, the patient’s symptoms began to improve, his mood was more stable and he woke up less at night. After 4 weeks of continued treatment, the patient was able to greet the neighbors on his own initiative and basically resumed his daily life, rarely using nitroglycerin and quick-acting heart pills anymore. From this example, we can see several characteristics: 1. The patient has obvious self-conscious symptoms, but there is not much evidence of objective examination. 2. Emotional symptoms were prominent and interpersonal relationships were changed. 3, Fatigue is prominent, lazy, not even doing the minimum grooming activities. 4.Interest decreases, and things that I liked before (watching Korean dramas) are no longer enjoyed. 5. Feeling useless, not having the face to see others, not willing to talk to the neighbors. I even feel that I have dragged my family down, and I have the idea of light-heartedness. 6.The medication like nitroglycerin seemed to be effective when she had chest pain, but it gradually became ineffective. A coronary angiogram again showed that her coronary arteries were patent. The cause of the chest pain was obviously not due to myocardial ischemia. 7. Antidepressants are effective. The following are the clinical manifestations of depressed patients, there are three main groups of symptoms: First, core symptoms: depressed mood – sullen all day long, wanting to cry, diminished interest, inability to enjoy – knowing that it is a very happy thing, but not interested and happy, lack of energy and excessive fatigue – feel like they always do a very heavy work, the body is tired of no strength. Second, psychological symptoms: manifested as anxiety – fidgeting, excessive worry about oneself or family members; self-blame – blaming oneself for dragging down family members; cognitive distortion – self-depreciation, believing that one Nothing is accomplished, anyone is better than them, they can’t do anything well; they think of everything in a bad way and can’t see the positive side of things; suicidal ideas and behaviors – feeling that life is meaningless, it is better to die, and even act on it; incomplete self-awareness – -Does not think he has depressive symptoms, thinks he is the somatic disease, does not accept the fact that all the objective tests are normal, thinks the doctor did not check and repeatedly asks for tests. Decreased cognitive function – lack of concentration, memory loss, reduced efficiency in doing things, inability to perform daily tasks as skillfully as before. Psychotic symptoms – Severe patients may experience psychotic symptoms such as hallucinations, hallucinations, or delusions of relationship, but most of them are related to the patient’s life reality without absurd and bizarre hallucinations. The third group is somatic concomitant symptoms: they manifest as a variety of diverse and bizarre somatic discomfort. For example, various kinds of pain, headache, back pain, etc., the pain is not fixed, wandering or series of pain, one after another; sleep disorders, insomnia or too much sleep without relief, appetite disorders, reduced eating or gluttony, loss of libido, non-specific somatic symptoms, the patient can show a variety of bizarre symptoms, such as feeling half of his brain become empty, feel a gas from the lower body up to the throat choking, etc.. The first group of core symptoms is the most dominant among the three groups of symptoms. If 1 or 2 symptoms persist for more than 2 weeks, you should seek a psychiatrist for identification and judgment in time to avoid delaying the condition. It is important to remember that depression can exist alone or secondary to somatic diseases, such as coronary heart disease, stroke, thyroid disease, Alzheimer’s disease, etc. The first onset of depression in the elderly should be especially careful to exclude somatic diseases. In addition to depression, anxiety is also a mood disorder that affects the recovery from coronary heart disease, and its incidence is even higher than that of depression, and a significant proportion of patients with depression have anxiety coexisting (psychological symptoms of depression). The most intense and extreme example is a clinical syndrome called “panic attack”, also known as “acute anxiety attack”. The patient can go from completely normal to uncontrollable within a minute, with a sudden onset of panic attacks that feel like the heart is about to jump out of the chest, reaching a peak within 10 minutes. In addition to a feeling of chest tightness and breathlessness, a sense of near-death, sweating, and weakness, the patient also has a feeling of extreme fear. Most of them resolve spontaneously within 30 minutes. Patients often call for an ambulance, but find that their symptoms have subsided by the time the ambulance arrives, and most tests at the hospital fail to reveal abnormal findings. Like the case of Ms. Wu’s first early morning chest tightness attack just described, it was actually a panic attack. During a panic attack, the level of catecholamines in the patient’s body increases, the heart rate accelerates and the blood pressure rises, which may increase the chance of coronary artery spasm and even induce myocardial infarction or induce malignant arrhythmia leading to sudden death due to a panic attack, and similar cases have been reported both at home and abroad. Hurst, a famous American cardiologist, said: “The most common cause of chest pain is not cardiovascular disease, but is related to anxiety”. Studies by foreign scholars have shown that only 23%; of those who underwent coronary angiography due to chest pain had definite coronary artery disease and 61%; of those who had normal or nearly normal coronary arteries, and most of these people had anxiety present. In a survey of chest pain patients in a ward of Anzhen Hospital, we found that among 99 patients who came for coronary angiography because of chest pain (including those who had stents to review), only 46 were finally diagnosed as having lesions in the coronary arteries, and more than half of the patients had good coronary arteries. However, a significant percentage of patients in this group had anxiety and depression, regardless of whether they had coronary artery disease or not. Among them, 13% of coronary patients had combined depression;, 37% had combined anxiety;, and 10.9% had both anxiety and depression;. It can be seen that the mood disorders of coronary heart disease should not be underestimated. The treatment rate of coronary heart disease combined with depression is even lower compared to the awareness of coronary heart disease mood disorder. Many patients think that since it is a mood problem, I can regulate and overcome it by myself, and they do not want to take antidepressants. This is actually a very big misconception. Let us first analyze the reasons why patients are reluctant to receive antidepressant treatment. First of all, Chinese people who grew up in the Eastern culture have an innate sense of shame about depression and think that having depression (or mental illness) is a matter of shame and a problem in their minds. They do not want to admit that they have this disease. Or they think that saying they are in a bad mood means that their children are not filial. Second, although admitting that they are in a bad mood, they think that they can overcome it by their own adjustment. Thirdly, they are afraid to take them because they are worried about the side effects of drugs. Fourth, they think that antidepressants add to the already heavy financial burden. In fact, depression, like other physical illnesses, is a more common disease than the flu, with a prevalence of 6% in the general population; and a higher prevalence in the elderly, with the prevalence of depression in elderly inpatients as high as 36%; – less than one in three inpatients suffer from depression. Why are older adults prone to depression after having a physical illness? Physiologically speaking, the physiological functions of all organs in the elderly are not as good as before, the most common ones are cataracts that make vision diminish, neurological deafness that makes hearing decline, and degeneration of joints that makes movement slow …… In fact, our brain functions are quietly going downhill, and memory is gradually declining. The brain’s substances in charge of emotions – monoamine neurotransmitters, such as 5-hydroxytryptamine (also known as serotonin), norepinephrine, and dopamine – have diminished function, making older people less resistant to external stress. When encountering sudden external stimuli, such as acute heart attacks, strokes and other life-threatening illnesses, the elderly’s lack of ability to cope, combined with inadequate function of mood-stabilizing neurotransmitters, can trigger depression. Obviously, these are not things we can fix with self-regulation, so hoping to make depression ease through personal adjustment is difficult. Some family members will constantly emphasize to the patient, “Think about it ……” and often advise the patient to take things easy, but this does not have much effect. Patients often say, “I understand everything in my heart, but I just can’t control it.” The reason is that depression and anxiety itself is also a disease that has a biological basis, that is, it is caused by the lack of monoamine neurotransmitters in the brain that we mentioned above, and in the long run it also leads to the atrophy of a structure called “hippocampus” in the medial temporal lobe of the brain, which is not only related to mood but also has a close relationship with our memory. The hippocampus is not only related to emotions but also has a close relationship with our memory, therefore, it is often seen that depressed patients also have a deteriorating memory. The sensible thing to do is to be diagnosed by a doctor and prescribed with an appropriate antidepressant, and to follow the doctor’s orders for regular treatment, just like for other physical diseases such as hypertension and coronary heart disease. Interestingly, after the efficacy of medication, patients will realize many philosophies of life by themselves, and I often have patients tell me, “Doctor, after this illness, I feel that I have grown a lot inside, and I don’t see things so drastically as before.” As we all know, “medicine is poisonous in three parts”. Therefore, it makes sense to worry about adverse drug reactions. The first thing people do when they get a doctor’s prescription is to read the instructions carefully, this sense of self-protection is right, but the key is that depressed patients have a distorted perception, tend to overstate the side effects of drugs rather than pay attention to the therapeutic effects of drugs, especially when they see adverse reactions in the current symptoms of their own resistance, “I was already dizzy, you I’m already dizzy, and the medicine you gave me will cause dizziness, so I can’t take this medicine!” Instead of paying attention to the fact that the least that can happen when a drug is approved for marketing to patients is that the incidence of adverse reactions should be very low, perhaps one in a thousand or one in ten thousand, and not all people who take the drug will experience them. It is also forgotten that if depression is not treated, the incidence of coronary angina or heart attack will increase many times and will lead to serious consequences. There is also the thought that you are already taking a lot of medication, and that adding antidepressants will increase drug interactions and toxicity? This is a very important question, some drugs do interact with each other, so when prescribing drugs, you must find an experienced doctor, tell your doctor which drugs you are taking, what chronic diseases you have, and let your doctor help you choose the most suitable drugs for you, and choose those drugs that have fewer interactions and have evidence-based medical evidence showing that they are safer for cardiovascular patients, and not blindly listen to your neighbors who say which drug is good or which drug is advertised as good. You can’t just listen to the neighborhood or advertisements about which drug is better. How do you know who is an experienced physician? Each senior physician (or specialist) has his or her own specialty, which can be found in each hospital’s own specialist profile or on the Good Doctor website, and can help you find a doctor experienced in treating somatic disorders combined with depression. Finally, some patients think that the medication for coronary heart disease is already very expensive, and adding antidepressants to it makes it financially unaffordable. This is true on the surface, but when you think about it, if depression is not treated, it will increase the chance of angina pectoris and heart attack in coronary patients, and increase the risk of death. In fact, numerous studies have shown that antidepressant treatment can reduce the cost of treatment for coronary heart patients, such that patients no longer have to undergo repeated expensive tests and take or drip unnecessary medications after their depression subsides. Anti-anxiety antidepressants can reduce the number of times patients take medications such as nitroglycerin. Foreign studies have shown that patients who received antidepressant treatment had 31.5 days shorter hospital stays than those who did not receive treatment, which is conceivably a lot of money. Domestic studies have shown that patients with depression and untreated coronary heart cost $3400 more for a single hospital stay than those without depression, and the length of stay was 4 days longer. This shows that not using antidepressants does not save the total cost of treatment. Finally, it should be emphasized that while paying attention to the mood disorders of coronary heart disease, we should not forget the medications for secondary prevention of coronary heart disease itself, such as anti-platelet aggregation drugs, statin lipid-lowering drugs, drugs to control blood pressure and blood sugar, etc., and review the heart condition at the cardiologist on time. In conclusion, depression in patients with coronary artery disease is a common state that seriously affects the quality of life and prognosis of coronary artery disease. Active attention to the emotional changes of coronary heart patients, early identification and regular treatment of depression and anxiety is directly related to the treatment of coronary heart disease this disease, only after lifting the psychological depression, we can make our engine, the heart, beat healthier!