There is growing evidence that psychological problems and cardiovascular disease can be causal and affect each other, jointly leading to deterioration in patient prognosis, and the co-morbidity of the two has become one of the most serious health problems, and a survey of 3,260 consecutive patients in cardiovascular medicine clinics in Beijing in 2005 showed that the incidence of anxiety was 42.5% and depression was 7.1%. The incidence of anxiety was 42.5% and depression was 7.1%. However, the traditional biomedical model does not pay attention to the psychological problems that coexist with physical diseases, and the cardiologists do not have psychological knowledge, which leads to misdiagnosis and omission of a large number of patients, resulting in low identification rate, low diagnosis rate and even lower treatment rate of psychological disorders. Therefore, it is very important to improve the recognition ability of psychological disorders among cardiologists. Ni Weibing, Department of Cardiovascular Medicine, Nantong Hospital of Traditional Chinese Medicine Patients with psychological disorders in cardiology can be divided into two categories: (1) Patients without organic cardiovascular disease, with physical manifestations such as chest tightness and chest pain, panic and shortness of breath, headache, nausea and stomach distension, insomnia and weakness, and so on. It often involves organs innervated by the autonomic nervous system, such as heart rate, blood pressure, respiration, digestion, sweating, sphincter, skin, etc. Cardiovascular manifestations include chest tightness and chest pain, panic and shortness of breath, tachycardia, arrhythmia, hypertension, Raynaud’s sign; digestive manifestations include esophageal blockage, “plum pneumonia”, esophageal reflux, “pneumonia”, and “pneumonia”. “Respiratory system manifests hyperventilation, chest congestion, cardiac asthma, cough, laryngeal spasm, chest pain; Neurological system manifests insomnia, tremor, headache; Endocrine system manifests obesity, hyperglycemia, hypoglycemia, hyperthyroidism, hypothyroidism, menopause and menopausal syndrome; Skin manifests neurogenic hyperhidrosis, itching, rash. The genitourinary system shows urinary frequency and urgency, genital pain, menstrual irregularities, and hypogonadism. (2) Cardiovascular disease combined with psychological disorders, the so-called “co-morbidities”. The incidence is 15%-30% in outpatients and further increases in inpatients, especially for patients hospitalized for cardiac emergencies, the incidence of co-morbidity can be 60%-75%. The relative risk of primary and recurrent cardiovascular events is significantly higher in patients with concomitant psychological disorders and is comparable to well-defined risk factors for coronary heart disease. With the exception of typical clinical depression and anxiety disorders, many of the symptoms associated with psychological disorders that occur in cardiology patients are atypical but significantly increase the incidence of cardiovascular events. In the case of coronary revascularization with psychological disorders, the patient has a clear diagnosis of cardiovascular disease, has undergone coronary intervention or bypass revascularization, and has objective evidence of good physical recovery, but has frequent clinical episodes where the patient is in a state of panic and anxiety, or suspects that his or her disease is not being properly treated, notably with increasing medical anxiety or depression. Due to economic pressure or to avoid medical disputes, many doctors give too heavy an account of the patient’s condition, clinical over-examinations, patients more doctors give too heavy an account of the patient’s condition, the patient’s mind is overburdened, lack of reasonable guidance, resulting in new diseases added before the old ones go. For this category of patients, it is difficult to rely solely on the corresponding means of treatment of cardiovascular disease, requiring clinicians to be able to accurately identify timely, psychological intervention. 2 Identification of psychological disorders Somatization and somatization disorder Somatization (Somatization) is a clinical phenomenon, but not a diagnostic name, is a psychological disorder in which the patient’s somatic discomfort is the main complaint; Somatization disorder (Somatization) is a diagnostic name that includes symptoms of multiple systems and organs. 2001 CCMD-3, reference The 2001 CCMD-3, with reference to the ICD-10, lists the following subtypes: (1) somatization disorder: recurrent and frequently changing somatic symptoms in multiple systems; (2) somatoform pain disorder: pain in the trunk, head and neck, and extremities; (3) hypochondrical disorder: suspicion of serious illness, terminal illness, and lack of explanation by doctors. (3) hypochondrical disorder: suspicion of serious illness, terminal illness, doctors’ explanations do not listen, various tests are not abnormal, often accompanied by anxiety and depression; (4) somatoform automatic dysfunction: symptoms of vegetative excitation: worry, redness, panic, sweating, shivering, etc., burning sensation in a part of the body, tightness and swelling; somatization disorder is a common type of cardiovascular patients Psychological disorder type, often misdiagnosed as somatic diseases, these patients often find several doctors or go to multiple hospitals, while also taking a variety of drugs for coronary heart disease, but the effect is not obvious; some patients also underwent coronary angiography to rule out coronary heart disease, and in the end, it is not settled, or continue to use some anti-angina drugs. Because the patient’s painful experience is not relieved, he or she is always in constant search for medical help. Anxiety disorders The common symptom of anxiety disorders is chest pain, chest pain is mostly pinprick-like, occurring in quiet, not related to exertion, some are relieved after activity, nitrate drugs do not relieve obvious, the electrocardiogram does not have obvious ischemic changes, or non-specific ST-T changes, at the same time there is excessive worry, nervous anxiety, often accompanied by sleep disorders, autonomic They often have excessive worry and nervous anxiety, often accompanied by sleep disturbance, autonomic nervous system hyperfunction such as sweating, flushing, panic, shortness of breath, dizziness, hand tremors, nausea, bowel movements, urinary frequency, pain and other anxiety manifestations in various systems. Patients’ complaints are very diverse and involve multiple systems and organs. Psychology is divided into two types: (1) generalized anxiety: the patient is chronically nervous and irritable, but there is no actual objective threat, fearful, fidgety, shaking and flesh jumping, symptoms for at least 6 months; (2) panic attack (Panic Attack): sudden onset of intense irritability and anxiety without a cause, panic as if death is imminent, no obvious symptoms during the interval, at least 3 attacks in a month. Patients with panic attacks may have cardiopulmonary, digestive, neurological and other systemic symptoms, accompanied by depersonalization, loss of reality and near-death experience, etc. They can be spontaneous or induced by special scenarios, more women than men, and the attacks are accompanied by tachycardia, and patients are often seen as cardiovascular emergencies, which are easily misdiagnosed as acute coronary syndrome or acute left heart failure. Depressive disorders Most patients with depressive disorders present to the cardiology department with physical complaints of chest tightness, panic attacks, shortness of breath, and relief of symptoms after prolonged expiration. Patients are depressed, depressed, lack of interest, fatigue, and inattentiveness. Patients with depressive disorders associated with cardiovascular disease have painful expressions and low mood that vary with the condition of the physical disease and with changes in the way the physician talks and treats them. The diagnosis of depression is based on depressed mood and at least four of the following: (1) loss of interest and unpleasantness; (2) decreased vitality and fatigue; (3) self-blame and guilt; (4) decreased thinking ability; (5) sluggishness or irritability; (6) desire to die; (7) sleep disturbance; (8) loss of appetite; (9) decreased sexual function; and symptoms for at least 3 months. Patients with depressive disorders can be accompanied by significant anxiety, and depressive disorders should be diagnosed when both anxiety and depressive symptoms are present, especially in the elderly, where depressive disorders are easily masked by anxiety manifestations. Non-pharmacological treatment Non-pharmacological treatment includes psychological intervention, cognitive-behavioral therapy, biofeedback therapy, and exercise rehabilitation therapy. Psychological intervention is to apply psychological theories and methods to influence patients’ psychology to make them change towards predetermined goals. Psychological support is the basis of the whole psychological treatment, through the use of appropriate medical knowledge and psychotherapy, to help patients obtain positive cognitive responses and positive behavioral responses as much as possible, encourage patients to face the reality, establish confidence in overcoming the disease, adopt an upward attitude, and create good psychological conditions for treatment. Cognitive-behavioral therapy is a form of psychotherapy. Cognitive-behavioral therapy is a psychotherapeutic orientation, a kind of talk therapy, with goal-oriented and systematic procedures to address behavioral and cognitive problems. Cognitive-perceptual and behavioral therapies are divided into two categories: cognitive-perceptual and behavioral. Cognitive-perceptual therapy is used to reduce or eliminate symptoms by explaining the patient’s perceptions and gaining understanding. Behavioral therapy focuses on observable external behaviors or specifically described mental states, using experimentally established principles and methods of learning to overcome maladaptive behavioral habits. Biofeedback therapy is the application of biofeedback principle in clinical work, using the instrument to process the body information related to the process of mental and physiological activities (such as electromyographic activity, skin temperature, heart rate, blood pressure, brain waves, etc.) and display it to people in a visual or auditory way (i.e. information feedback), and train people to learn to consciously control their own psychophysiological activities through the awareness of these information, in order to adjust the function of the body, prevent and cure diseases. Non-pharmacological treatment therapy can improve patients’ quality of life and relieve anxiety and depression, and can be the preferred treatment. However, for patients with moderate or severe anxiety and depression disorders, anti-anxiety and antidepressant medication should be selected. Evaluation of therapeutic drugs (1) benzodiazepines: diazepam, eszopiclone, alprazolam, clonidine tabs, lorazepam tabs, and doxorubicin. Anxiolytic effect is rapid and reliable, and relatively inexpensive. However, it lacks antidepressant effect and has addictive properties. (2) TCAs (tricyclics): chlorpromazine, amitriptyline, doxepin; tetracyclics: maprotiline. Antidepressant and anxiolytic efficacy is indeed, cheaper, but inhibits hepatic cytochrome CYP isoenzyme, should not be used simultaneously with Ic class antiarrhythmic drugs, cardiovascular disease caution, risk of upright hypotension, QTc prolongation, cardiogenic syncope. (3) Mixed preparations: Dextran (containing the new tricyclic tetracycline 10mg and the psychotropic drug trifloxithiazole 0.5mg) has a rapid onset of action, with greater anxiolytic efficacy than antidepressant, but with poor efficacy in major depression and anxiety. (4) Trazodone SARI, 5-HT reuptake inhibition + receptor antagonist: Meprobamate, persuaderm. (5) SSRI: fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine. Antidepressants and anxiolytics are effective, non-addictive and safe for cardiovascular disease. However, slow onset of action, expensive, with side effects such as dry mouth, nausea and fatigue. (6) SSRA, 5-HT reuptake enhancer: tianeptine (Daptilan) has obvious antidepressant and anxiolytic efficacy and is safe for use in patients with heart failure; however, gastrointestinal reactions are more pronounced and drowsiness. (7) SNRI, 5-HT and noradrenal dual channel reuptake inhibitors: venlafaxine (Enox), duloxetine. Antidepressant and anxiolytic efficacy is obvious, the onset of action is faster than SSRI (about a week) part of the OCD effective, gastrointestinal side effects are less. (8) NaSSA is also a 5-HT and noradrenal dual channel reuptake inhibitor; but unlike SNRI, excites 5-HT and blocks 5-HT2 and 5-HT3 receptors: Mirtazapine (Remeron) has strong antidepressant and anxiolytic effects and improves sleep and appetite. However, it has side effects of drowsiness and weight gain. The lack of mental health knowledge among many cardiologists has led to misdiagnosis and mistreatment of patients with psychological disorders manifesting as somatic symptoms, wasting medical resources. In addition, cardiovascular disease as a life event produces a psychological stress response in patients, and psychological disorders have a high prevalence in the cardiovascular disease population. Psychological disorders, especially depression, increase sympathetic excitability in patients; platelet activity is enhanced; rhythm variability is reduced; patients have poor compliance with treatment, and patients with cardiovascular disease combined with psychological disorders have a poor prognosis and high mortality. Therefore, early identification and intervention of cardiovascular disease patients with combined psychological disorders can really improve the treatment effect of cardiovascular patients.
(Tianjin First Central Hospital_|Xia Dasheng|Lu Chengzhi)