Authors

• Muhamed Zuko — J.U. Psihijatrijska bolnica Kantona Sarajevo, Sarajevo, Bosna i Hercegovina — ORCID: 0000-0002-7373-3761
• Alina Fazlić — Farmaceutsko-zdravstveni fakultet Travnik, Travnik, Bosna i Hercegovina — ORCID: 0000-0001-7588-2958
• Elma Sokić Begović — Federalno ministarstvo zdravstva, Sarajevo, Bosna i Hercegovina — ORCID: 0000-0003-4548-9500
• Enida Halvadžić — Klinički centar Univerziteta u Sarajevu, Sarajevo, Bosna i Hercegovina — ORCID: 0000-0003-3666-4864
• Sanela Halilović Šuškić — J.U. Bolnica Travnik, Travnik, Bosna i Hercegovina — ORCID: 0000-0003-4689-0566

Abstract

About 0.5% of the population have schizophrenia and are thus at increased risk of death. The consequences of disordered physiological processes in the body lead to a reduction in life span of up to twenty years. Poor eating habits and lifestyles lead to more frequent occurrence of metabolic syndrome, and antipsychotics are one of the main causes of diabetes and hyperlipidemia. Psychiatric patients are often exposed to discrimination, resulting in poorer social acceptance and poorer health care. These people often have low or no income and are unemployed and socially excluded. The aim of our study was to determine the incidence of unrecognized myocardial infarction in patients with schizophrenia and whether the patients have been treated with appropriate medication such as acetylsalicylic acid, beta-blockers, ace inhibitors, statins, etc. The study included patients diagnosed with schizophrenia hospitalized at the Psychiatric Hospital of Canton Sarajevo. A total of 605 patients were treated. Scarring was indicated on electrocardiogram examination in 11.85% patients, 56.25% of whom were men and 43.75% women. The youngest patient with ECG-indicated scarring was a man aged 37, while the oldest was also a man aged 67. The average life expectancy of patients with scarring indicated on the electrocardiogram was 53 years. In order to prevent cardiac incidents, it is necessary to raise awareness in patients with schizophrenia regarding to lifestyle and dietary habits and to perform regular health examinations in this population.

Keywords

unrecognized myocardial infarction, schizophrenia, metabolic syndrome

DOI

Full Text

## Introduction As a psychiatric illness, schizophrenia affects approximately 0.5% of the population and is associated with increased mortality. The lifespan of a patient with schizophrenia is thus reduced by twenty years. (1) The most common risk factor for the development of myocardial infarction (MI) in patients with schizophrenia is metabolic syndrome, which is present in more than 60% of patients. Furthermore, poor dietary habits and lacking or practically absent physical activity are the basis for the development of cardiac events. Heart rhythm disorders such as torsades de pointes develop as a consequence of prolonged QT-interval caused by antipsychotics. Antipsychotics can also exert a negative influence on the individual’s metabolic profile, leading to frequent morbidity from diabetes and hyperlipidemia. (2) Due to the nature of the illness, persons with schizophrenia, especially if they are not supervised by family or professionals, are more prone to disease since they are not under appropriate healthcare. Over the past few decades, mortality from MI has increased in these patients due to ignored symptoms, inadequate provision of medical assistance, and especially due to reperfusion therapy. (3-6) Diabetes is an entity that represents an additional hazard in these patients since it reduces the pain threshold. (7) Increased risk of MI can also be associated with arterial hypertension, which is more prevalent in patients with schizophrenia. (4, 7) There is still a distinction between psychiatric and somatic illnesses, which has negative consequences in the context of stigma and discrimination of patients with mental illnesses. (8-10) Emotions, fear, and other external factors have an important role in the development of cardiological diseases such as MI and arterial hypertension. The presence of somatic and mental conditions greatly reduces the quality of life and ultimately leads to poorer prognosis and outcomes. (8-11) Unhealthy lifestyle habits are often present, such as an overly sedentary lifestyle, lack of physical activity, and consumption of alcohol or narcotics. Such persons often have low or no income and are unemployed as well as socially isolated. (10, 12) The aim of this study was to describe the prevalence of unrecognized MI in patients suffering from schizophrenia as well as the prevalence of the application of appropriate pharmacological treatment (acetylsalicylic acid, beta-blockers, ACE inhibitors, and statins). ## Patients and methods This study included patients with the diagnosis of schizophrenia hospitalized at Psychiatric Hospital of Canton Sarajevo. The inclusion criterion for this study were diagnosis of schizophrenia. Exclusion criteria for this study were: patients who knew they had already suffered from MI and those with other psychiatric illnesses. All patients underwent an internal medicine exam, an electrocardiogram (ECG) test, routine laboratory diagnostics, and anthropometric measurements. The authors of the study personally interpreted the ECG results. The following values were considered pathological: Q-wave duration above 0.04 seconds, an amplitude less than 1/3 of the R wave in the same QRS complex, triglyceride values above 1.7 mmol/L, LDL cholesterol above 3.4 mmol/L, glycemia above 6.2 mmol/L, arterial pressure above 140/90 mmHg, and body-mass index (BMI) above 25. (13) ## Results The study included a total of 605 patients, of which 46.66% were men and 53.33% were women. Smoking was reported by 83% patients. Elevated arterial pressure values were found in 55.55% patients, diabetes was present in 23.70%, LDL cholesterol was elevated in 49.62%, and BMI was increased in 65.92%. **Figure 1** shows the prevalence of risk factors based on gender. FIGURE 1. Prevalence of risk factors based on gender. LDL = low-density lipoprotein; BMI = body mass index. ECG changes indicating scarring were observed in 11.85% patients, of whom 56.25% were men and 43.75% were women. The youngest patient with ECG-indicated scarring was a man aged 37, while the oldest was another man aged 67. Average age among those in whom scarring-related changes were detected by ECG was 53 years of age. In patients with ECG changes indicating scarring (**Figure 2**), elevated values of LDL cholesterol as a risk factor for the development of MI were found in 43.80% men and 56.30% of women. BMI values were elevated in 37.50% men and 50% of women, whereas smoking was equally prevalent in both genders. Hypertension was found in 12.50% men and 31.30% women, and 12.50% of men and 31.30% of women had diabetes mellitus. Metabolic syndrome was present in 43.75% of all patients, of which 28.57% were men and 71.42% were women. FIGURE 2. Prevalence of risk factors in patients with ECG results indicating myocardial scarring. LDL = low-density lipoprotein; BMI = body mass index. The greatest number of ECG changes indicating scarring in women was found in patients aged between 50 and 59, while for men the changes were most prevalent in those aged between 60 and 69 (**Figure 3**). In 50% of patients, the ECG changes indicating scarring were present on the inferior leads, 25% of changes were in the anterior myocardial wall, and the septum was affected in 25% of cases (**Figure 4**). FIGURE 3. The prevalence of scarring-related ECG characteristics in different age groups. FIGURE 4. The localization of scars based on ECG results. Medical history of patients with changes indicating scarring showed that 60% of these patients had felt a strong pain in their chests in the last two years, but did not seek medical assistance. Only one patient was undergoing treatment with acetylsalicylic acid, which was prescribed by the family physician as preventive treatment due to advanced age. None of the patients were being treated by statins. Two patients were receiving beta-blockers, and five patients were prescribed antihypertensive therapy but were not taking the medication regularly. ## Discussion Due to the nature of their illness, psychiatric patients are highly susceptible to the development of somatic conditions. (14, 15) The present study confirms that patients suffering from schizophrenia represent a population group at high risk for the development of MI. Poor socioeconomic circumstances, social stigma, and the association between realistic cardiac symptomatology with the psychiatric condition of the patient are the reason for the large number of cardiac events in this population. (14, 15) A large number of risk factors present in patients with schizophrenia are the reason for the growing incidence of acute MI. As many as 83% of patients were smokers, and more than half of the study participants, i.e. 55.55%, had unregulated hypertension that was diagnosed for the first time during the internal medicine examination either in the course of this study or at an earlier examination, but without the patient taking regular therapy. As a consequence of poor lifestyle and dietary habits, obesity and increased BMI were present in 65% of the patients, and abdominal obesity and peripheral insulin resistance are considered the most important factor for the development of metabolic syndrome. As opposed to subcutaneous fatty tissue, abdominal fatty tissue is a metabolically active organ that when excessively large releases increased quantities of free fatty acids and inflammatory factors such as TNF alpha and IL 6, which interfere with the insulin transduction pathway, ultimately leading to reduced muscle glucose uptake, overproduction of triglycerides, and increased gluconeogenesis in the liver. Atherosclerotic changes in the blood vessels are more pronounced in these patients. Our study demonstrated that LDL cholesterol values were elevated in half the participants. Attar et al (16) found elevated cholesterol in 35.7% and elevated BMI in 6.7% of patients with schizophrenia. That study reported a smoking prevalence of 73.8%, hypertension in 36.6% of patients, and 11.6% patients with diabetes. Non-significant Q-wave peaks were not considered during ECG analysis in our study. Although the specificity for discovering previous MI is between 64% and 99%, most studies reported a precision of over 95%. (15) Scarring indicated by ECG was found in 11.85% of patients, of which 56.25% were men and 43.75% women. In a study by different authors, (16) the prevalence of MI in patients suffering from schizophrenia was between 25% and 33%, up to 75%. (17) Cardiac events in the psychiatric patient population happen at a younger age, and these patients do not receive adequate care according to the healthcare protocols for acute MI. In patients with schizophrenia and ECG-indicated scarring, clinical cardiologists suggest exercise stress test and echocardiography as additional diagnostic tests. Coronary angiography was not considered for these patients. We found similar data in other studies. (18-21) The results of the present study indicated inadequate treatment in patients with schizophrenia. Many studies have shown that these patients have elevate blood glucose levels and higher prevalence of type 2 diabetes (22, 23) and hypercholesterolemia (24) in comparison with the general population. Discrimination and stigmatization of mentally ill patients is present not only in society in general but in the healthcare system as well. (25) It can be intentional and unintentional and can result in failure to adequately diagnose and treat these patients. (26) Other authors have reported the case of three patients with schizophrenia who presented at the hospital complaining of typical angina-related chest pain, but they were not taken seriously and were returned home without any examination. Furthermore, studies by the same authors have shown that these patients receive medical care only when their symptoms become life-threatening, (27) and that physicians do not take chest pain-related symptoms seriously in this group of patients. (28) In a study on secondary prevention in patients with schizophrenia and previous MI, (29) the authors found that every sixth patient suffering from schizophrenia was not under cardiovascular protection and that the mortality rate for this group was extremely high in comparison with the general population. In line with this study, other authors (30-32) found reduced use of antiaggregation medication, beta-blockers, ACE inhibitors, and statins in patients with schizophrenia in comparison with the general population. Kugathasan et al (29, 33) showed that poor quality of medical care can result in increased cardiovascular mortality in the general population. Using the National Registry in Denmark, the authors examined the prescription of medication and mortality records for all patients hospitalized for MI in Denmark between 1995 and 2015. The mortality rate in the study period was alarmingly high for patients with schizophrenia. As many as 45% of patients with a prior diagnosis of schizophrenia died during the study period, in comparison with only 27% of the other patients. Two thirds of total deaths in both groups were due to cardiovascular diseases. It is important to perform a careful examination of psychiatric patients and take their reports of somatic symptoms seriously without immediately assuming they are due to the patient’s mental condition. The patients themselves can also be the source of the problem, however, if they associate their symptoms with their current mental condition and perceive them in their own idiosyncratic way as part of their clinical picture. ## Conclusion In order to prevent cardiac events, it is necessary to raise awareness in patients with schizophrenia regarding lifestyle and dietary habits, perform periodic examinations that include laboratory diagnostics and ECG tests, and prescribe adequate medication therapy based on the somatic condition of the patient.

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