SILENT CARDIOVASCULAR THREATS: DEPRESSION AND MORBID OBESITY AMONGST DIABETIC WOMEN

Therapeutic Area

CVD Prevention – Primary and Secondary

Case Presentation

We present the case of a 72-year-old female with morbid obesity with a BMI of 37.8, uncontrolled diabetes, hypertension, and hyperlipidemia, who was seen in her primary care physician's office for a routine follow-up where she mentioned symptoms of depression, insomnia, and fatigue. The patient denied chest pain, worsening shortness of breath, or any lower extremity edema. Notably, the patient's last echocardiogram in 2021 revealed an ejection fraction of 55-60%. Additionally, no abnormalities were noted on her nuclear stress test in 2021. While managing her depressive symptoms, she presented to the emergency department with aphasia due to an acute left frontal cerebral vascular accident requiring thrombectomy. Post-procedure echocardiography revealed a left ventricular thrombus and an ejection fraction of 8%, prompting cardiac catheterization which revealed severe diffuse obstructive cardiac atherosclerotic disease. The patient developed cardiogenic shock with acute heart failure with reduced ejection fraction and ischemic cardiomyopathy stage D. This condition rendered her myocardium nonviable. Aggressive diuresis was initiated with milrinone and dobutamine therapy. Subsequently, the patient suffered from shock with severe hypotension due to vasopressor treatment, shock liver, and pre-renal azotemia, necessitating careful management of these complications.

Background

There is an intricate relationship between depression, cardiovascular disease, and silent myocardial infarctions. Failure to recognize the overlap between depression-related fatigue and cardiovascular disease can result in underdiagnosis and mismanagement. The shared symptoms coupled with inflammation as pathophysiological mechanism for these conditions, bridges the link between depression and cardiovascular health. Additionally, the prevalence of silent myocardial infarctions in morbidly obese diabetic women may obscure the presentation of a MI, leading to delayed diagnosis and increased morbidity and mortality.

Conclusions

This case emphasizes the need to raise awareness regarding two topics: the interrelation between depression and cardiovascular disease, along with the complexities of silent myocardial infarctions (MI) in morbidly obese diabetic women. Future directions should include developing targeted screening protocols with multidisciplinary approaches involving primary care physicians, endocrinologists, psychiatrists, cardiologists. Protocols that assess depression, fatigue, glycemic control, and weight management in patients with elevated cardiovascular risk factors will address the burden of depression, cardiovascular disease, diabetes, and obesity.