Psychokardiologie: praxisrelevante Erkenntnisse und Handlungsempfehlungen

 

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Zusammenfassung

Psychosoziale Risikofaktoren (Arbeitsstress, niedrige Sozialschicht, mangelnde soziale Unterstützung, Ärger, Angst, Depressivität), überdauernde Persönlichkeitsmuster (z. B. Feindseligkeit) sowie die posttraumatische Belastungsstörung können die Entwicklung und den Verlauf zahlreicher Herz-Kreislauf-Erkrankungen negativ beeinflussen. Eine systematische Erfassung dieser Faktoren hilft, das Risiko angemessen einzuschätzen und bei der Behandlung zu berücksichtigen. Die vorgestellten Behandlungsempfehlungen stützen sich auf aktuelle Positionspapiere und Leitlinien.

Der Arzt-Patienten-Kontakt sollte grundsätzlich nach den Prinzipien einer patientenzentrierten Kommunikation erfolgen und alters- sowie geschlechtsspezifische Besonderheiten berücksichtigen. Die psychosomatische Grundversorgung ist eine wirksame, niedrigschwellige Option zur Behandlung psychosozialer Risikofaktoren und sollte regelmäßig angeboten werden.

Bluthochdruckpatienten können (allerdings mit mäßigem Effekt) von Entspannungsverfahren oder Biofeedback profitieren. Patienten mit koronarer Herzerkrankung, Herzinsuffizienz oder nach Herzoperationen soll ein individuell angepasstes, multimodales Behandlungskonzept angeboten werden, das Wissensvermittlung, Sport- und Bewegungstherapie, Motivationsförderung, Entspannungsverfahren und Stressmanagement umfasst. Bei einer psychischen Komorbidität ist oft zusätzlich eine psychotherapeutische Behandlung indiziert. Eine antidepressive Pharmakotherapie sollte bei einer mindestens mittelschweren depressiven Störung angeboten werden, wobei bevorzugt selektiven Serotonin-Wiederaufnahme-Hemmer (SSRI) eingesetzt werden sollten. Psychotherapie und SSRI, insbesondere Sertralin, sind bei bestimmungsgemäßem Gebrauch sicher und wirksam hinsichtlich einer Verbesserung der Lebensqualität. Eine Prognoseverbesserung ist nicht eindeutig belegt. Patienten mit implantiertem Defibrillator sollten im Rahmen der psychosomatischen Grundversorgung, bei psychischer Komorbidität mit Psychotherapie und ggf. auch SSRI, behandelt werden. Trizyklische Antidepressiva sollten wegen unerwünschter kardialer Wirkungen bei Herzpatienten möglichst vermieden werden.

Abstract

Psychosocial risk factors (work stress, low socioeconomic status, impaired social support, anger, anxiety and depression), certain personality traits (e. g. hostility) and post-traumatic stress disorders may negatively influence the incidence and course of multiple cardiovascular disease conditions. Systematic screening for these factors may help to adequately assess the psychosocial risk pattern of a given patient and may also contribute to the treatment of these patients. Recommendations for treatment are based on current guidelines.

The physician-patient interaction should basically follow the principle of a patient centered communication and should gender and age specific aspects into consideration. Integrated biopsychosocial care is an effective, low threshold option to treat psycho-social risk factors and should be offered on a regular basis.

Patients with high blood pressure may profit from relaxation programs and biofeedback procedures (however with moderate success). An individually adjusted multimodal treatment strategy should be offered to patients with coronary heart disease, heart failure and after heart surgery. It may incorporate educational tools, exercise therapy, motivational modules, relaxation and stress management programs. In case of affective comorbidity, psychotherapy may be indicated. Anti-depressant pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) in the first line should only be offered to patients with at least moderate severe depressive episodes. Psychotherapy and SSRIs, particularly sertraline, have been proven to be safe and effective with regard to improvements of the patient’s quality of life. A prognostic benefit has not been clearly proven so far. Patients with an implanted cardioverter/defibrillator (ICD) should receive psychosocial support on a regular basis. Concomitant psychotherapy and/or psychopharmacotherapy (SSRIs) should be offered in case of a severe mental comorbidity. Generally, tricyclic antidepressants should be avoided in cardiac patients because of adverse side effects.

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