Anxiety also can portend worse outcomes from CAD,13 including higher all-cause mortality.14 There is some hope, but limited evidence, that treating depression and anxiety, whether with antidepressant medication or behavioral therapy, can improve CAD outcomes.10,15
Making a diagnosis of CAD
CAD can present in a variety of ways, ranging from unrecognized or so-called silent CAD (there is an association between T2DM and unrecognized CAD and between hypertension and unrecognized CAD) to stable angina, unstable angina, acute coronary syndrome, MI, and sudden cardiac death. A variety of abnormalities on resting and exercise electrocardiogram (ECG), including ST segment depression, ST elevation, Q waves, and other morphological changes are indicative of CAD.
Other modalities, including coronary calcification score on computed tomography and coronary angiography can confirm the presence of CAD. Some clinicians recommend periodic ECG treadmill testing in patients who have:
• a total cholesterol level is >240 mg/dL
• systolic blood pressure >140 mm Hg, diastolic blood pressure >90 mm Hg, or both
• a family history of MI or sudden cardiac death in young (age <60) first-degree relatives
• a history of smoking
Risk stratification. A low (<10%), moderate (10% to 20%), or high (>20%) 10-year risk of CAD can be ascertained using a risk calculator, such as one that is available through the Framingham Heart Study (Figure) and the National Heart, Lung, and Blood Institute (http://cvdrisk.nhlbi. nih.gov). Because patients with risk factors for CAD should be offered interventions— including smoking cessation therapy, diet and exercise, aspirin, lipid-lowering therapy, and blood pressure modification strategies—whether or not they have evidence of CAD, the United States Preventive Services Task Force does not recommend for or against diagnostic screening in patients at moderate or elevated risk of CAD.16
There are guidelines in the literature recommending specific screening strategies for patients with mental illness, although the vetting and update process has been ill defined. Among patients with schizophrenia, though, regardless of antipsychotic prescription status, baseline and then regular monitoring of metabolic risk parameters is recommended.17
Primary prevention. Lifestyle modification and attention to modifiable coronary risk factors are important primary prevention strategies. Dietary modifications, exercise, not smoking, and maintenance of a normal BMI (<25 kg/m2) are associated with a lower risk of CAD.18,19
Lifestyle modifications can be challenging for patients with persistent mental illness, however: For example, patients with schizophrenia smoke more, eat less healthfully, and participate less in behavioral modification that targets risk factors than patients who do not have schizophrenia.20,21
According to 2012 evidence-based practice guidelines established by a collaboration that included the American College of Physicians and several cardiology and thoracic medicine societies, persons age >50 who do not have symptomatic CAD should take low-dose (75 to 100 mg/d) aspirin; the benefit of low-dose aspirin in persons at moderate or high risk of CAD is even greater. Other medications, including statins and fixed-dose combinations of antihypertensive medications in combination with a statin are not clearly beneficial as primary prevention strategies across the board, although selected high-risk populations might benefit.
Regrettably, the high-risk population of persons with mental illness and whose primary care is suboptimal has not been studied. It stands to reason that these patients would especially benefit from more attentive monitoring and intervention.
Collaborative care? Although many psychiatrists do not practice in such a model, a comprehensive approach to the care of their patients, using a collaborative care strategy that includes attention to the mental health diagnosis along with medical health, can result in improved health in both domains.22 However, enlisting patients with paranoia or an inherent distrust of medications and health care providers to adhere to either a medication regimen or lifestyle modification can be challenging.
Common-sense strategies, such as creating a multidisciplinary team with the psychiatrist coordinating care and optimizing antipsychotic treatment, might provide benefit.1 Data demonstrate that patients with severe mental illness who experience acute coronary events undergo revascularization at a lower rate than their mentally heathy counterparts, despite the fact that patients with severe mental illness die at a higher rate from their CAD than patients who do not have mental illness. An important role for the psychiatrist, even in the absence of a collaborative care program, is to be an advocate for appropriate guideline-based care.23
Secondary prevention. Once a patient develops CAD, ongoing risk factor modification is important. Adherence to a therapeutic regimen that variously combines a platelet inhibitor, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor is associated with improved outcomes in patients with CAD.24 Specific antiplatelet recommendations and a recommendation for single vs combination antiplatelet therapy depends on chronicity and type of revascularization in a setting of CAD.25