خطر بیماریهای قلبی عروقی در نمونه روان پریشی اپیزود اول : دوره بحرانی برای پیشگیری؟

Objective Studies in first episode psychosis samples about status of cardiovascular risk factors have shown discordant results. We aimed to determine the 10-year risk of developing coronary heart disease in a sample of first episode psychosis patients referred to an early intervention clinic and compared the same with age, gender, and race matched controls from the U.S. National Health and Nutrition Examination Survey (NHANES). Method We conducted a cross-sectional analysis of baseline data of 56 subjects enrolled in first episode psychosis clinic from April 2006 to January 2010. This sample was compared with age, gender, and race matched 145 individuals drawn from NHANES 2005–2006 database. Sociodemographic and clinical variables were collected. Physical examination including laboratory evaluation was used to screen for common medical illnesses. The 10-year risk of developing coronary heart disease was calculated by using a tool developed by the National Cholesterol Education Program (NCEP-ATP III). Results There were elevated rates of smoking (46%) and hypertension (11%) albeit statistically significant differences from the control could not be demonstrated for these measures or weight, body mass index, or total or HDL cholesterol, fasting plasma glucose, status of diabetes and impaired fasting plasma glucose, HbA1C level. The 10-year median (range) risk of developing coronary heart disease in patients and controls was 1 (0–5)% and 0 (0–9)% respectively. The difference was not statistically significant. Conclusions First episode psychosis patients do not present with significantly higher cardiovascular risk than age and race-matched controls despite clinically significant prevalence of individual risk factors. This sample presents an opportunity for early intervention for the primary prevention of cardiovascular morbidity and mortality.

Individuals with serious mental illness (SMI) die, on average, 25 years earlier than their peers (Colton and Manderscheid, 2006 and Parks et al., 2006). While 30–40% of this premature mortality is attributable to suicide and accidental injury, cardiovascular disease accounts for the majority of early death. The single most common cause of death in patients with schizophrenia is cardiovascular disease (Osby et al., 2000, Capasso et al., 2008 and Tiihonen et al., 2009). Patients with schizophrenia, relative to peers without SMI, experience a 3-fold increase in cardiovascular mortality between the ages of 18 and 49 and almost a 2-fold increase in mortality between the ages of 50 and 75 years (Osborn et al., 2007). They have a greater incidence of myocardial infarction than demographically similar persons without schizophrenia (Brown et al., 2000 and Enger et al., 2004). The causes of this increased cardiovascular burden in patients with schizophrenia are likely multi-factorial. Modifiable risk factors for cardiovascular disease include smoking, obesity, diabetes, dyslipidemia, and hypertension (Yusuf et al., 2004). When compared to age- and gender-matched controls, persons with chronic psychosis have higher rates of nicotine dependence (70–80% vs 25–30%) (de Leon and Diaz, 2005), obesity (45–55% vs 31–39%) (De Hert et al., 2009 and Meigs et al., 2003), diabetes (13% vs 3%) (Goff et al., 2005), dyslipidemia (25–69% vs 24–48%) (De Hert et al., 2009 and Meigs et al., 2003) and hypertension (27% vs 17%) (Goff et al., 2005). The largest study comparing cardiovascular risk factors in chronic schizophrenia patients, drawn from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Schizophrenia Trial, with age-, gender-, and race-matched controls from the U.S. National Health and Nutrition Examination Survey (NHANES) showed that patients had significantly higher 10-year coronary heart disease risk. This was due to higher rates of smoking, diabetes, and hypertension. Also, the mean (SD) duration of antipsychotic use in the CATIE study was 14.4 (10.7) years (Lieberman et al., 2005) and long-term use of antipsychotic medications may play an important role in the increased risk for cardiovascular diseases (Goff et al., 2005 and Newcomer, 2009). Antipsychotic medication use is associated with significant weight gain, dyslipidemia, and insulin resistance (Stahl et al., 2009). In contrast to the consistent evidence across all measures of cardiovascular risk in chronic schizophrenia, studies of ‘first episode’ psychosis samples have been inconsistent. The first study comparing cardiovascular risk factors in drug-naïve first-episode schizophrenia patients with matched controls found that patients had significantly higher fasting plasma glucose levels. HDL cholesterol was not different, but total cholesterol was lower in patients (Ryan et al., 2003). These authors were unable to replicate these findings with a different sample, and, in a second study, reported that first-episode schizophrenia patients, their first degree relatives, and matched controls did not differ with respect to fasting plasma glucose levels (Spelman et al., 2007). Another study of drug-naïve first-episode psychosis patients compared to age, gender, and race matched controls showed that patients had a significantly higher prevalence of diabetes but lower frequencies of obesity and total and LDL cholesterol (Verma et al., 2009). A study of 38 first-episode psychosis patients compared to age, gender, and race matched controls did not find significant differences in fasting plasma glucose levels, glucose tolerance, body mass index, waist circumference and pulse pressure (Sengupta et al., 2008). Another study of antipsychotic-naïve, first-episode schizophrenia patients compared to healthy controls did not show significant differences in fasting glucose and insulin resistance (Arranz et al., 2004). The use of specialized early intervention services (EI) to reduce long term psychosocial morbidity in psychotic disorders has been substantiated by several high quality studies (Marshall and Rathbone, 2006). The traditional focus of EI has been to deliver best available treatments during a putative ‘critical period’ for psychosocial development wherein intensive early intervention is hypothesized to achieve disproportionately positive results on long term outcomes. We propose an analogous formulation for reducing cardiovascular morbidity and mortality. The existence of EI clinics around the world, which are redefining care for early psychosis patients, presents an opportunity for the study and development of primary and secondary preventions of cardiovascular disease in schizophrenia. Given the discrepancies in the reported prevalence of cardiovascular risk factors in early psychosis samples, the current study aimed to measure these risks again in a carefully characterized sample of patients referred to an early intervention clinic. Also, we used the best available risk calculator to formulate a 10 year risk estimate of developing coronary heart disease. We report a cross sectional comparison of these first-episode psychosis patients with age, gender, and race matched controls from the U. S. National Health and Nutrition Examination Survey (NHANES) (Centers for Disease Control and Prevention, 2005–2006).