Case study in heart-brain interplay: A 53-year-old woman recovering from mitral valve repair

PSYCHIATRIC CASE PRESENTATION

At the time of the first psychiatric consult, postoperative day 6, the patient’s chart was reviewed, detailing her presentation and hospital course as described above. The chart confirmed one episode of “panic” following surgery while the patient was on telemetry, showing only sinus tachycardia. This episode was successfully treated with 1 mg of lorazepam. She expressed a fear of “losing it,” which is how she characterized her panicky state during the hospital stay, punctuated by the feeling that she was not in control. The nursing staff reported that she was distressed and irritable. Her husband also confirmed that the patient “was not herself.”

Her baseline functioning was high; she is a partner in a law firm and is customarily “in control.” Before the interview began, the patient had several questions ready, including how quickly she would heal, how soon she could return to work and resume her normal activities, the reason for her low ejection fraction despite having mitral valve surgery, and whether or not she would be able to attend her son’s graduation. Even though she knew the psychiatry consult had been ordered, she was not very receptive to it at first and was more focused on her physical symptoms.

Psychiatric history

Her psychiatric history was significant for fear of heights and panic attacks, but she had been able to conquer each. She overcame performance anxiety in high school and was able to be a successful malpractice attorney, deliberating cases in court. She had never seen a psychiatrist or mental health professional, and had never been on psychotropic medications, although for the past couple of years she had been using 0.5 mg of alprazolam to treat flight anxiety. She admitted to postpartum depression that lasted about 2 months; no treatment was sought at the time, and the depression resolved.

Family and personal history

Her mother was a teacher and a “professional worrier,” and her father is a retired lawyer. She reported resolving to “suck it up” during times of adversity during childhood, but her childhood was otherwise unremarkable. She is an only child and finished at the top of her class at law school.

Review of symptoms

An assessment of depressive symptoms using the mnemonic SIGECAPS (disturbance of sleep; disturbance of interest; presence of guilt; disturbance of energy, concentration, or appetite; increased or decreased psychomotor activity; ideas of suicide) elicited low energy levels, decreased concentration, and a “slowed down” feeling. The WART (withdrawal, anhedonia, rumination, tearfulness) scale, used to assess depressive symptoms in the medically ill, showed the patient to be withdrawn and tearful at times.

Mental status examination

The patient was polite, professionally courteous, and sitting up in bed. Her vital signs were stable (heart rate, 70 beats per minute; blood pressure, 122/72 mm Hg) and her mood was “fine,” although she had many concerns about her physical health. Her affect was serious, constricted, and controlling. Her thought process was linear and organized, and her thought content revealed no psychosis, suicidal ideations, or overt hopelessness. She admitted that she was slightly anxious and overwhelmed, and that this anxiety precipitated her “panic” on telemetry and tearfulness, but she believed (and asked for assurance) that this level of anxiety was normal following surgery.

Diagnosis and recommendations

By the end of the consultation, we were able to make a series of recommendations. We arrived at a diagnosis of adjustment disorder with anxious features, and we agreed to treat her with alprazolam at a dose of 0.5 mg twice daily as needed. We provided education about mood and anxiety disorders in cardiac patients. We explained that her postpartum depression was a risk factor for future depression. We discussed coping strategies and relaxation techniques, and scheduled a follow-up appointment with her primary care physician for further monitoring of her mood and anxiety.

One week postdischarge

The cardiology team communicated with us after her wound check at postdischarge week 1. At this time, she was still having pain and was concerned about excessive wound drainage even though it was found to be minimal. The cardiology team was concerned because her progress was slow and she appeared anxious and tense. A follow-up psychiatry consultation was arranged for the patient’s next postoperative visit.

Follow-up at postoperative week 4

At her scheduled psychiatric visit at postoperative week 4, the patient was a little surprised to see the fellow, as she expected to see the staff psychiatrist. She appeared tense and frustrated, was fixated on her echocardiogram and her physical symptoms, and reported that she was not yet back to work. She was preoccupied with her son’s graduation that was coming up and wondered if she would be able to attend and celebrate it.

We administered the Patient Health Questionnaire depression scale, and the patient’s score of 11 indicated moderate depression. Treatment options, including psychotherapy and pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI), were reviewed with the patient. A call to the cardiology team revealed that her ejection fraction was fairly typical for a patient who has had a mitral valve repair but that the continued fatigue was not normal, leading us to suspect that depression may be the actual cause of her fatigue. She remarked, “Let’s see how the cardiac rehabilitation program goes and then we’ll talk about medications for depression.”

Cardiac rehabilitation at postoperative week 6

The patient was entered into the cardiac rehabilitation program, and she was administered a Short Form–36 (SF-36) health survey, which showed a low mental summary score and a low physical component summary score (low scores connote worse health and/or more disability). She was referred to the psychiatrist at the cardiovascular behavioral health clinic for further assessment of her mood as she commenced the cardiac rehabilitation program.