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Positionspapier zur Bedeutung psychosozialer Faktoren in der Kardiologie

Update 2013

Position paper on the significance of psychosocial factors in cardiology

Update 2013

  • Positionspapier
  • Published:
Der Kardiologe Aims and scope

Zusammenfassung

Hintergrund

Die rasche Weiterentwicklung der psychokardiologischen Forschung, aber auch die wachsende Verankerung psychosozialer Fragestellungen im klinischen Alltag haben die Klinische Kommission der DGK bewogen, einer Aktualisierung und Weiterentwicklung des 2008 erstmals publizierten Positionspapiers zur Bedeutung psychosozialer Faktoren in der Kardiologie zuzustimmen.

Methoden

Der Kreis der Autoren wurde vergrößert, allgemeine Aspekte eingefügt und das Wissen in allen Abschnitten auf den heutigen Stand gebracht. Schwerpunkte der Empfehlungen sind die koronare Herzerkrankung, Herzrhythmusstörungen und die Herzinsuffizienz, da hier der Stand der empirischen Evidenz und des klinisches Wisses zu psychosozialen Fragestellungen am weitesten entwickelt ist. Berücksichtigt wurden bei den Empfehlungen Besonderheiten von Frauen und Männern, Unterschiede bzgl. der Lebensspanne, Einflüsse auf die kognitive Leistungsfähigkeit und die interaktive synergistische Bedeutung klassischer Risikofaktoren bei affektiver Komorbidität.

Ergebnisse

Eine I-A-Empfehlung (Empfehlungsgrad I, Evidenzgrad A) wurde vergeben für die Aufforderung, psychosoziale Risikofaktoren bei der Einschätzung des KHK-Risikos zu berücksichtigen, die als unabhängige ätiologische und prognostische Risikofaktoren für das Auftreten der koronaren Herzerkrankung (KHK) und für Komplikationen im Behandlungsverlauf der KHK bedeutsam sind. Ferner für die Empfehlung, Patienten mit Herzoperationen von einem interdisziplinären Team zu betreuten, in dem die Möglichkeit besteht, auf psychosoziale Aspekte einzugehen, da bei diesen Patienten komorbide psychische Störungen wie Depressivität, Angst und posttraumatische Belastungsstörung häufig und prognostisch ungünstig sind. Eine I-B-Empfehlung wurde vergeben für die Behandlung psychosozialer Risikofaktoren mit dem Ziel einer Primärprävention der KHK, wenn das Risikomerkmal an sich Krankheitswert hat (z. B. Depression) oder die Behandlung klassischer Risikofaktoren erschwert ist. Eine antidepressive Pharmakotherapie soll Patienten nach akutem Koronarsyndrom sowie in der Phase der chronischen KHK angeboten werden, die an einer mindestens mittelschweren rezidivierenden depressiven Störung leiden. Dabei sollen vorzugsweise Substanzen aus der Gruppe der selektiven Serotoninwiederaufnahmehemmer (SSRI) zum Einsatz kommen. Bei der langfristigen ärztlichen Begleitung von ICD-Patienten sollen die psychosozialen Folgen der ICD-Technologie beachtet und insbesondere relevante Affektstörungen sowie Krisen bei ICD-Patienten erkannt und fachgerecht behandelt werden.

Schlussfolgerungen

Das Positionspapier formuliert konkrete Anwendungsfelder mit hoher Priorität für die Einbeziehung psychosozialer Faktoren in die kardiologische Praxis, die eine leitlinienkonforme Evidenz aufweisen. Trotz deutlicher Fortschritte seit der Erstveröffentlichung des Positionspapiers existieren weiterhin Forschungsdefizite für die Bewertung der Wirksamkeit psychotherapeutischer und psychopharmakologischer Konzepte bei kardialen Patienten. Curricula für die Vermittlung von (psycho-)diagnostischer, kommunikativer und differenzialdiagnostischer Kompetenz müssen rasch entwickelt werden, um eine Transmission des aktuellen Wissensstands in die Alltagspraxis zu ermöglichen.

Abstract

Background

The rapid progress of psychosomatic research in cardiology and also the increasing impact of psychosocial issues in the clinical daily routine have prompted the Clinical Commission of the German Heart Society (DGK) to agree to an update of the first state of the art paper on this issue which was originally released in 2008.

Methods

The circle of experts was increased, general aspects were implemented and the state of the art was updated. Particular emphasis was dedicated to coronary heart diseases (CHD), heart rhythm diseases and heart failure because to date the evidence-based clinical knowledge is most advanced in these particular areas. Differences between men and women and over the life span were considered in the recommendations as were influences of cognitive capability and the interactive and synergistic impact of classical somatic risk factors on the affective comorbidity in heart disease patients.

Results

A IA recommendation (recommendation grade I and evidence grade A) was given for the need to consider psychosocial risk factors in the estimation of coronary risks as etiological and prognostic risk factors. Furthermore, for the recommendation to routinely integrate psychosocial patient management into the care of heart surgery patients because in these patients, comorbid affective disorders (e.g. depression, anxiety and post-traumatic stress disorder) are highly prevalent and often have a malignant prognosis. A IB recommendation was given for the treatment of psychosocial risk factors aiming to prevent the onset of CHD, particularly if the psychosocial risk factor is harmful in itself (e.g. depression) or constrains the treatment of the somatic risk factors. Patients with acute and chronic CHD should be offered anti-depressive medication if these patients suffer from medium to severe states of depression and in this case medication with selective reuptake inhibitors should be given. In the long-term course of treatment with implanted cardioverter defibrillators (ICDs) a subjective health technology assessment is warranted. In particular, the likelihood of affective comorbidities and the onset of psychological crises should be carefully considered.

Conclusions

The present state of the art paper presents an update of current empirical evidence in psychocardiology. The paper provides evidence-based recommendations for the integration of psychosocial factors into cardiological practice and highlights areas of high priority. The evidence for estimating the efficiency for psychotherapeutic and psychopharmacological interventions has increased substantially since the first release of the policy document but is, however, still weak. There remains an urgent need to establish curricula for physician competence in psychodiagnosis, communication and referral to ensure that current psychocardiac knowledge is translated into the daily routine.

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Authors and Affiliations

  1. Deutsches Forschungszentrum für Gesundheit und Umwelt, Institut für Epidemiologie-2, Helmholtz-Zentrum München, Ingolstädter Landstr. 1, 85764, Neuherberg, Deutschland

    K.-H. Ladwig

  2. Klinik und Poliklinik für Psychosomatische Medizin und Psychotherapie, Klinikum Rechts der Isar der TU München, München, Deutschland

    K.-H. Ladwig

  3. Zentralinstitut für Seelische Gesundheit, Universität Heidelberg, Medizinische Fakultät Mannheim, Mannheim, Deutschland

    F. Lederbogen

  4. Klinik und Poliklinik für Psychosomatik und Psychotherapie, Universitätsklinikum Köln , Köln, Deutschland

    C. Albus

  5. Deutsches Zentrum für Herzinsuffizienz, Universitätsklinikum Würzburg , Würzburg, Deutschland

    C. Angermann

  6. I. Medizinische Klinik für Kardiologie, Angiologie, Pneumologie, Internistische Intensivmedizin und Hämostaseologie, Universitätsmedizin Mannheim, Mannheim, Deutschland

    M. Borggrefe

  7. Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Homburg/Saar, Deutschland

    D. Fischer

  8. Abteilung für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland

    K. Fritzsche

  9. Innere Medizin II: Kardiologie, Angiologie und Internistische Intensivmedizin, Theresienkrankenhaus und St. Hedwig-Klinik, Mannheim, Mannheim, Deutschland

    M. Haass

  10. Herz-, Thorax- und Rheumazentrum, Abteilung für Psychokardiologie , Kerckhoff Klinik, Bad Nauheim, Bad Nauheim, Deutschland

    J. Jordan

  11. Klinik für Allgemeine Innere Medizin und Psychosomatik, Universität Heidelberg, Heidelberg, Deutschland

    J. Jünger

  12. Innere Medizin III (Kardiologie/Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Homburg/Saar, Homburg/Saar, Deutschland

    I. Kindermann

  13. Medizinische Fakultät, Universität des Saarlandes, Blieskastel, Blieskastel, Deutschland

    V. Köllner

  14. Fachpraxis für Innere Medizin, Kardiologie, Angiologie und Notfallmedizin, Heidelberg, Heidelberg, Deutschland

    B. Kuhn

  15. Institut für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf , Hamburg, Deutschland

    M. Scherer

  16. Medizinische Klinik 3 (Kardiologie), Helios-Klinikum Wuppertal-Herzzentrum, Universität Witten/Herdecke, Wuppertal, Deutschland

    M. Seyfarth

  17. Fachklinik für Innere Medizin, Abteilung Kardiologie, Klinik am See, Rüdersdorf , Rüdersdorf, Deutschland

    H. Völler

  18. Abteilung Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Ulm, Ulm, Deutschland

    C. Waller

  19. Klinik für Psychosomatische Medizin und Psychotherapie, Universitätsmedizin Göttingen, Göttingen, Deutschland

    C. Herrmann-Lingen

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  1. K.-H. Ladwig
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  2. F. Lederbogen
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  3. C. Albus
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  15. M. Seyfarth
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  16. H. Völler
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  17. C. Waller
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  18. C. Herrmann-Lingen
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Correspondence to K.-H. Ladwig.

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Die Autoren K.-H. Ladwig und F. Lederbogen haben zu gleichen Teilen zu der Arbeit beigetragen.

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Ladwig, KH., Lederbogen, F., Albus, C. et al. Positionspapier zur Bedeutung psychosozialer Faktoren in der Kardiologie. Kardiologe 7, 7–27 (2013). https://doi.org/10.1007/s12181-012-0478-8

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