”Dual-hearted” medicine is a platform constructed by the intersection and integration of cardiovascular and psychiatry, based on which we seek to integrate the understanding of life sciences and the humanistic understanding of the individual. “Dual-hearted” medicine is to respect the individual’s feelings in medical practice, to find more diverse ways to improve prognosis and quality of life, and to avoid over-reliance on technical means that lead to medically induced diseases.
In recent years, it has been found that about 30% to 50% of patients often have very typical “angina” symptoms, but no obvious ST-T changes on static ECG, coronary angiography does not suggest the diagnosis of coronary heart disease, and most patients do not have susceptibility factors for coronary heart disease. Therefore, how to identify, diagnose and treat these patients may need to go beyond the biomedical model to the concept of psychosomatic diseases.
Patients with depression and anxiety usually have the following symptoms:
1. Self-perceived palpitations and panic, without arrhythmias.
2.Some tachycardia or arrhythmias that can be explained without etiology, such as premature beats, supraventricular tachycardia (folding type), idiopathic atrial fibrillation episodes, Ⅰ° or Ⅱ°-Ⅰ atrioventricular block, etc.
3.The chest tightness and shortness of breath often occur in quiet time unrelated to exertion, and deep breathing is preferred to relieve the ST-T changes related to heart rate.
4.Self-perceived chest pain and discomfort are not caused by coronary heart disease.
The material basis of depression and anxiety is the decrease in the level of central neurotransmitter 5-hydroxytryptamine, norepinephrine and dopamine, which in turn causes changes in cardiac autonomic function through neurohumoral and neuroendocrine mechanisms, resulting in cardiovascular system psychosomatic symptoms. In addition to cardiovascular symptoms, patients may also exhibit multisystemic somatic symptoms such as sleep disorders, headache, dizziness, foreign body sensation in the throat, functional dyspepsia, irritable bowel, nervous polyuria, increased nocturia, and chronic somatic pain and discomfort.
Patients with organic heart disease are more likely to develop new psychosomatic symptoms in combination with depression and anxiety disorders, making the manifestation of existing disease symptoms more complex and difficult to treat.
Studies have shown that depression and anxiety contribute to increased cardiac events in cardiac patients, primarily through biological and psychological mechanisms, resulting in difficulties in recovery and increased risk of readmission. In a survey of cardiologists in the United States, about half of them did not treat patients with depressive disorders. In China, it has also been shown that 2/3 of patients have a combination of varying degrees of anxiety or depression after PCI, which significantly affects the quality of life of the patients. Common emotional reactions are excessive worry, such as fear of the risks of the PCI procedure, fear of poor postoperative outcome and still sudden cardiac death. In addition to this there are somatization manifestations, such as: chest tightness, shortness of breath and other clinical symptoms.
Psychological problem identification and intervention begins with the identification of psychological problems and timely assessment. Then, reasonable interventions should be made if there are abnormalities, which can be combined with pharmacological and non-pharmacological treatments.
For patients with depressive and anxiety tendencies, the steps of “double heart” intervention are as follows.
1. Through effective communication, the patient’s medical history should be fully understood.
2, there are a variety of scales can choose to apply, the clinical is not uniform, it is not appropriate to overemphasize.
3, more serious and suicidal patients should be referred to a psychiatric specialist for intensive attention.
The main treatment tools include: medication, cognitive-behavioral therapy, aerobic exercise and cardiac rehabilitation.
Patients with cardiac neurosis can often be found to suffer from varying degrees of psychological disorders, such as depression, anxiety, hypochondriasis, and fear, after pursuing their medical history. Personality factors are usually manifested as introversion, sensitivity, impatience, emotional instability, pursuit of perfection, aggressiveness, suggestiveness, timidity, and dependence. The onset of the disease is often preceded by unpleasant psychosocial factors, such as work stress, maladjustment to environmental changes, frustration in emotional life, fear of disease, and the shock of major life events.
Among the pharmacological treatments, it has been shown that the safe and effective drug for treating depression in patients with coronary artery disease is 5-hydroxytryptamine reuptake inhibitor.
Cognitive-behavioral therapy is very important in the clinical setting, and care should be taken to keep patients informed of their condition. Studies have shown that the combination of medication and cognitive-behavioral therapy is more effective than monotherapy in patients with moderate to severe depression.
Although coronary spasm, cardiac X syndrome (functional lesions of tiny coronary branches), myocardial bridges, and even common nonspecific inflammation of the thoracic rib joints can also cause chest pain, the relationship between the symptoms of chest pain in these patients and their psychosomatic background of depression and anxiety is not exact.
It is currently believed that there are significant individual differences in pain thresholds, and adverse emotions such as depression, anxiety, suspicion, and fear can lower pain thresholds and thus make chest pain more likely to occur. Similarly, cardiac autonomic activity is also closely related to emotion, and an increase in blood catecholamine or acetylcholine concentration will not only cause contraction spasm of coronary smooth muscle, but also induce electrophysiological disturbance of myocardium or conduction system, resulting in various arrhythmias.
Therefore, in patients with non-coronary chest pain, if they have depression and anxiety disorders, simultaneous antidepressant and anxiety treatment can be beneficial. Studies suggest that cardiovascular physicians should pay attention to the presence of depression, anxiety, suspicion, fear and other psychological disorders in patients with atypical angina who do not have predisposing factors for coronary heart disease (e.g., hypertension, hypercholesterolemia, diabetes mellitus, smoking and family history of early-onset coronary heart disease).
This interface service is more urgently needed in cardiology than in any other clinical department. The cardiac patient provides a broad platform for psychiatrists to apply their knowledge of psychiatry: from depressive episodes, panic disorder, and generalized anxiety to more chronic problems such as social impairment, lack of social support, and pervasive hostility.
When there are cardiovascular physicians who are constantly aware of the psychological issues of the patients they see and how these issues may adversely affect the management of pre-existing heart disease, and while deeply appreciating the growing needs of the patient population, the visionary cardiovascular physician chooses to deal not with the heart itself, but with the person who owns that heart. The real “double heart” diagnosis and treatment model will only become a reality when the patient is treated with his own heart and treated as the main party in the treatment alliance, so that he can have a good mood and enjoy a satisfying life while getting a healthy heart.