Severe mental illness: cardiovascular risk assessment and management

Abstract

Patients with severe mental illness (SMI) including schizophrenia and bipolar disorder die on average 15-20 years earlier than the general population often due to sudden death that, in most cases, is caused by cardiovascular disease. This state-of-the-art review aims to address the complex association between SMI and cardiovascular risk, explore disparities in cardiovascular care pathways, describe how to adequately predict cardiovascular outcomes, and propose targeted interventions to improve cardiovascular health in patients with SMI. These patients have an adverse cardiovascular risk factor profile due to an interplay between biological factors such as chronic inflammation, patient factors such as excessive smoking, and healthcare system factors such as stigma and discrimination. Several disparities in cardiovascular care pathways have been demonstrated in patients with SMI, resulting in a 47% lower likelihood of undergoing invasive coronary procedures and substantially lower rates of prescribed standard secondary prevention medications compared with the general population. Although early cardiovascular risk prediction is important, conventional risk prediction models do not accurately predict long-term cardiovascular outcomes as cardiovascular disease and mortality are only partly driven by traditional risk factors in this patient group. As such, SMI-specific risk prediction models and clinical tools such as the electrocardiogram and echocardiogram are necessary when assessing and managing cardiovascular risk associated with SMI. In conclusion, there is a necessity for differentiated cardiovascular care in patients with SMI. By addressing factors involved in the excess cardiovascular risk, reconsidering risk stratification approaches, and implementing multidisciplinary care models, clinicians can take steps towards improving cardiovascular health and long-term outcomes in patients with SMI.

Keywords: Cardiovascular disease; Cardiovascular mortality; Risk factors; Risk stratification; Screening; Severe mental illness; Sudden cardiac death.

Graphical Abstract

The increased risk of cardiovascular disease associated with severe mental illness (SMI) is multifactorial and driven by complex pathways. Patients with SMI have a high burden of cardiovascular risk factors and disease, and a major challenge in clinical practice is that these patients tend to neglect cardiovascular symptoms, healthcare professionals often overlook and misinterpret cardiovascular signs and symptoms of patients, patients are less likely to receive timely and proper cardiovascular care, and treatment adherence is reduced in these patients. Consequently, patients with SMI develop significantly earlier atherosclerotic cardiovascular disease and therefore require intensive primary prevention strategies that include a more aggressive approach to management of cholesterol levels, blood pressure, and other cardiovascular risk factors.