“Doctor, I feel like I have no energy ever since I had my bypass surgery.” I hear this in my practice often within a few months after a heart disease-related event. A big part of being a cardiologist is taking care of people after coronary artery bypass surgery, heart attack (myocardial infarction) or near-heart attack, or a diagnosis of congestive heart failure.
Of course, as with any complaint in my office, my first instinct is to consider a medical cause for a lack of energy. This starts with a better description of the problem. “What do you mean exactly?” I will ask. “Are you short of breath after small tasks? Are you dizzy? Sleepy? Running of out steam at three o’clock in the afternoon?” To rule out residual blood flow problems and heart muscle-pumping disorders, tests like electrocardiogram, echocardiogram, and stress test are at my disposal. I also need to consider that a class of medications that is a cornerstone in the treatment of most heart disease can cause this feeling. Beta-blockers like metoprolol (Lopressor and other brands), carvedilol (Coreg), atenolol (Tenormin) and propranolol (Inderal and InnoPran XL) are known to cause a feeling of lack of energy. After carefully considering these causes, I also have to ask myself, could it be something more?
Mental-health issues following heart disease-related events are, sadly often not the focus of follow-up care by the health practitioner. But, in fact, these issues are common and treatable. For my bypass patient, after ruling out medical conditions and adverse drug reactions, it should be known that 30-40 percent of individuals undergoing coronary artery bypass surgery will experience depression, 11 percent will report generalized anxiety and panic attacks and some will report symptoms of post-traumatic stress disorder. And those experiencing depression following coronary artery bypass surgery have a worse prognosis than those who don’t. It is also known that the depressed will have more pain, fatigue, insomnia, and loss of appetite following their surgery. So with my patient’s complaint of excessive fatigue, depression has to be under consideration as a cause.
A certain degree of sad and anxious feelings will naturally accompany a stressful event like a diagnosis of heart disease, but if a reaction is excessive and completely overwhelming, it could be adjustment disorder. In addition to depression and anxiety, a staggering three-fourths of people can have adjustment disorder with depressed mood following bypass surgery. Compare this to the rates of 20-30 percent seen in those with a cancer diagnosis, and you can begin to see the scope of the problem in heart disease.
Depression is all too common following heart attack (myocardial infarction) as well. Major clinical depression is thought to occur in 15-22 percent of those who have had a heart attack, with as many as 65 percent reporting depressive symptoms. Even mild to moderate depressive symptoms have been found to increase the risk of dying from heart disease after a heart attack. Because of this, the American Academy of Family Physicians recommends early and periodic screening tests for depression following a heart attack.
Heart failure (abnormal heart muscle pumping action) can either follow a heart attack or occur in the absence of a heart attack. Whatever the cause, depression is something that should be on your doctor’s radar if you are diagnosed with this condition. Of those with heart failure, 14 percent have major clinical depression. And while it seems like common sense that depression could be a barrier to treatment and prognosis, studies have shown that individuals with heart failure who experience depression have a poorer prognosis and more hospital admissions for heart failure than those who don’t.
The statistics are gloomy but the outlook doesn’t have to be. In addition to recommending screening for depression in those with heart disease, the American Academy of Family Physicians made a statement that selective serotonin reuptake inhibitors (for example fluoxetine (Prozac and other brands), escitalopram (Lexapro and Cipralex), paroxetine (Paxil and Pexeva), and others) are effective and considered the initial drugs of choice for the treatment of depression after heart attack. Mediations that should be avoided in those with heart disease include tricyclic antidepressants (amitriptyline (Elavil), nortriptyline (Pamelor), and others) because of a potential for causing rapid or irregular heartbeats. Nonmedication treatments like psychotherapy, cognitive behavioral therapy, and supportive stress management are also thought to be helpful.
Mental health problems commonly accompany heart disease, especially following events like bypass surgery, heart attack, or a diagnosis of heart failure, and are treatable. More cardiologists and other health care practitioners should be paying attention not only to your blood pressure and heart rate but also to measures of your mood. Left untreated, mental health problems that accompany heart disease can lead to future heart disease-related events, preventable hospitalizations, and even death. And if your doctor doesn’t bring it up, don’t keep it to yourself, have an honest conversation about how you are feeling physically and emotionally. To arm yourself with knowledge, a good place to start would be an excellent article from the American Heart Association on this topic.
Tully PJ, Baker RA. Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review. Journal of Geriatric Cardiology : JGC. 2012;9(2):197-208.
Freedland KE, Skala JA, Carney RM, et al. Treatment of Depression After Coronary Artery Bypass Surgery: A Randomized Controlled Trial. Archives of general psychiatry. 2009;66(4):387-396. doi:10.1001/archgenpsychiatry.2009.7.
Trede AK, Kramer RS. Depression and Cardiac Surgery: Underrecognized and Undertreated. The Journal of Extra-corporeal Technology. 2012;44(4):233-234.
Post–Myocardial Infarction Depression Clinical Practice Guideline PanelMembers of the Post Myocardial Infarction Depression Clinical Practice Guideline Panel are Lee A. Green, MD, MPH, Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; W. Perry Dickinson, MD, University of Colorado Health Sciences Center, Denver, Colorado; Donald E. Nease, Jr, MD, Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; Kenneth G. Schellhase, MD, MPH, Department of Family & Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Doug Campos-Outcalt, MD, MPA, American Academy of Family Physicians, Leawood, Kansas; Bellinda K. Schoof, MHA, CPHQ, American Academy of Family Physicians, Leawood, Kansas; Michelle Jeffcott-Pera, MA, American Academy of Family Physicians, Leawood, Kansas. AAFP Guideline for the Detection and Management of Post–Myocardial Infarction Depression. Annals of Family Medicine. 2009;7(1):71-79.
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James Vitarius MD, PhD, is a cardiologist, medical writer, and novelist based in the New York City area. He is a Fellow in the American College of Cardiology and a member of the American Medical Writers Association. James enjoys following the latest developments in cardiology and medicine, both high and low tech, and sifting through the evidence to provide the best advice to his patients and readers. Follow James on Twitter @JamesVitarius and Facebook @DrJamesVitarius.