Cardiac psychiatry — structured clinical viva

Interpretation

Opening moves

Core viva stations

Epidemiology and prognosis

Depression after MI predicts adverse early mortality signals (Frasure-Smith) and is recognised by AHA as a risk factor for poor prognosis after ACS.[2][3] Meta-analyses support unfavourable mortality associations in CHD with residual confounding caveats.[9]

Mechanisms

Bidirectional biological (autonomic, inflammatory, platelet) and behavioural (non-adherence, smoking, inactivity) pathways; ACS as traumatic stressor for PTSD symptoms.[8][9]

Assessment and investigations

Cardiac dossier, MSE, suicide risk, social support, PHQ/HADS if useful; ECG/QTc, Na, renal/hepatic before SSRI; bleeding risk on dual antiplatelets.[1][4]

Trial literacy

• SADHART: sertraline safe/effective for post-ACS major depression (eligible population).[4]
• CREATE: citalopram > placebo; IPT not better than clinical management alone.[6]
• ENRICHD: psychosocial gains without reduced death/recurrent MI.[5]
• SADHART-CHF (contrast): sertraline safe in HF, not superior to placebo for depression — different population/message.[7]

Prescribing

Sertraline 25–50 mg oral daily start, titrate; monitor sodium, bleeding, response. Avoid amitriptyline first-line. Protect beta-blocker unless individualised cardiology reason to change.[1][4]

ACS-PTSD and rehab

Nightmares/hypervigilance/avoidance: trauma-informed engagement, rehab graded exposure with psychology, treat comorbid depression.[8]

Takotsubo aside

Her pathway is confirmed STEMI/CAD — do not relabel as Takotsubo; reserve Takotsubo discussion for true stress cardiomyopathy cases after coronary evaluation.[9]

Closing synthesis