Heart-brain medicine: Update 2008
STILL ELUSIVE: EVIDENCE THAT DEPRESSION THERAPY IMPROVES CARDIAC OUTCOMES
At the 2008 Summit there was clear enthusiasm among attendees and faculty for advances in our understanding of the pathways discussed above. Since then, as reviewed above, significant publications have furthered the link between heart and brain in the setting of atherosclerotic heart disease. That said, the missing piece—the demonstration that treating depression leads to improved outcomes in patients with coronary artery disease—remains missing.
Some advances in this regard have been made. A recent study from the Enhancing Recovery In Coronary Heart Disease (ENRICHD) clinical trial demonstrated that major depression in any patient who survived myocardial infarction decreased survival over 2.5 years.8 Interestingly, and perhaps critical for an event-driven treatment trial in the future, this analysis showed an even worse outcome in patients who experienced their initial episode of major depression after their myocardial infarction.8 The need, ethics, and design of clinical trials to determine whether treatment of depression leads to improved outcomes in patients with coronary artery disease will be a major topic of the 4th Annual Heart-Brain Summit, to be held in Chicago on October 15–16, 2009.
OTHER HIGHLIGHTS, INCLUDING ROLE OF THE HEALING ENVIRONMENT
While much of the early focus of the 2008 Heart-Brain Summit was on the interaction of depression, inflammation, and outcomes in patients with coronary artery disease, a significant portion of the Summit identified other disease states and opportunities. The disease states discussed can be divided into primary cardiac, primary psychiatric, and primary neurologic. Cardiac topics under continued investigation include the role of vagal tone on the inflammatory response that regulates left ventricular remodeling following acute myocardial infarction9 as well as the role of spinal stimulation for treatment of refractory myocardial ischemia. Psychiatric disorders of interest that have been shown to modulate vagal tone include post-traumatic stress disorder,10 which has also been shown to increase the risk for coronary heart disease.11,12 Neurologically, advances concerning the polyvagal theory of autonomic nervous system control and cardiac control were discussed.13,14
On the Summit’s final day, the discussions of neuropathways, inflammation, and cardiac control gave way to presentations on the role of the healing environment. Following discussions of how depression can have significant ramifications on systemic inflammation and acute coronary syndrome, it was interesting to review data on how the presence of family and the patient environment can improve patient outcomes.
Many of the topics touched on above are discussed in greater detail in the following pages of this proceedings of the 2008 Bakken Heart-Brain Summit. We are gratified to see the advancements in the field of heartbrain medicine over the past 5 years, and especially to see the recognition the discipline is receiving in our attempt to improve patient outcomes.
FAR MORE QUESTIONS REMAIN
Without a doubt there are more questions than answers at this time. That said, by continuing the rigorous multidisciplinary approach that has served this field well to date, many questions will be answered. We hope you will join us in Chicago on October 15–16, 2009, for the 4th Annual Heart-Brain Summit, which will be jointly hosted by the Society of Heart-Brain Medicine and the Bakken Heart-Brain Institute.
