Depression and cardiac function in patients with stable coronary heart disease: findings from the Heart and Soul Study

OBJECTIVE

To determine whether depression is associated with worse cardiac disease severity in patients with stable coronary heart disease (CHD). There is considerable evidence that depression is a risk factor for adverse cardiovascular events in patients with CHD. However, a frequent criticism of this literature is that the association between depression and adverse cardiovascular outcomes may be confounded by worse baseline cardiac disease severity in depressed patients.

METHOD

In a sample of 1020 outpatients with stable CHD, we examined the association between major depression (assessed using the Computerized National Institute of Mental Health Diagnostic Interview Schedule) with measures of cardiac disease severity, including systolic dysfunction, diastolic dysfunction, exercise-induced ischemia, and cardiac wall motion abnormalities. Cross-sectional univariate and multivariate models controlling for demographic and clinical variables were computed.

RESULTS

Of the 1020 participants, 224 (22%) had current (past month) major depression. After adjustment for age, major depression was not associated with systolic dysfunction, diastolic dysfunction, inducible ischemia, or cardiac wall motion abnormalities. Similarly, multivariate models revealed no significant relationship between major depression and cardiac disease severity.

CONCLUSIONS

Overall, we found little evidence that depression is associated with worse cardiac disease severity. This suggests that greater baseline cardiac disease severity is unlikely to be responsible for the increased risk of CHD events in depressed patients.

Sensitization of emotions as a risk factor for ischemic heart disease

AIMS

Previous studies showed that sensitization could be important in cardiovascular disease subjects. The main aim of our study was to investigate further the relationship between sensitization of emotion on one side, and main risk factors for ischemic heart disease (IHD) and some psychological variables on the other.

METHODS

A total of 374 patients with (187) or without (187) ischemic heart disease took part in our study. Owing to the lower percentage of women with IHD only men were included in the study. Patients were divided into three groups: repressors (those who report low subjective disturbance but react relatively strongly objectively; psychometrically, they have a high defensiveness score - L-EPQ and low trait anxiety score - EPQ-N), sensitizers (they have the opposite results: high N and low L score) and all the remaining subjects (the remaining two combinations of the N and L scores). Altogether, 12 exploratory variables (presence of IHD and main IHD risk factors; personality traits and coping styles) were explored in relation to sensitization of emotion.

RESULTS

As predicted, sensitization of emotion was significantly more frequent in the group of patients with IHD (chi2=23.2; df=2; p<0.0001). We also showed some additional correlates of sensitization trait that could explain the association between this trait and IHD more in detail. In the group of IHD patients, the highest scores of psychoticism (F=12.14; df=2; p<0.001) and emotional coping styles (F=19.36; df=2; p<0.001) were shown in sensitizers, and the highest scores of detached emotional coping styles in the middle group of patients (F=7.58; df=2; p=0.001). Also, sensitizers were the youngest group (F=8.28; df=2; p<0.001) and had the highest frequency of smoking history (chi2=6.73; df=2; p=0.035). Some of these associations were in the same direction also significant in the group free of IHD, namely for psychoticism (F=9.15; df=2; p<0.001), emotional coping (F=11.07; df=2; p<0.001) and age (F=5.83; df=2; p=0.004).

CONCLUSION

Among some other characteristics, sensitization of emotion also relates to more emotional and less detached ways of coping with stress, and more smoking on the other, which in turn increases the overall behavioral risk of developing this chronic disease.

Depression and ischemic heart disease: what have we learned from clinical trials?

PURPOSE OF REVIEW

Discuss the interplay of depression and ischemic heart disease. Studies demonstrate high prevalence of depression and its negative impact among patients with ischemic heart disease.

RECENT FINDINGS

Results extend previous findings among men, demonstrating a significant increase in mortality and cardiovascular events among depressed women. Sertraline, citalopram and mitrazapine have been shown to be safe and well tolerated in patients with ischemic heart disease. Sertraline and citalopram have demonstrated efficacy for treating depression in such patients. Mirtazapine did not have significant efficacy on post-myocardial infarction depression. Cognitive-behavioral therapy and interpersonal therapy have not been found to have a significant treatment effect. Treating depression may have an impact on cardiovascular morbidity and mortality, but this has not yet been adequately studied. Studies to date lack sufficient statistical power to fully examine the impact of interventions for depression on cardiovascular outcomes.

SUMMARY

Cardiologists encounter depression among 25-30% of their patients with ischemic heart disease. Depression is an independent risk factor for poor prognosis among ischemic heart disease patients, at a level comparable to several conventional cardiac risk factors. Adequate treatment of depression may improve the poor prognosis of depressed patients with ischemic heart disease.

Quality of life and emotional functioning in selected psychosomatic diseases

BACKGROUND

Disease and its treatment may affect a patient not only in the physical, but also in the psychological and social spheres. Quality of life (QOL) is a global concept which should include mental and social actions, physical activities, and the beneficial aspects of a good physical and mental condition as well as negative ones caused by disease and infirmity. The aim of this study was to assess the relationships between emotional functioning and QOL among people diagnosed with coronary disease, hypertension, or gastric and/or duodenal ulcer.

MATERIAL/METHODS

A group of 180 male patients hospitalized during 1999-2002 at the Military Medical Academy Hospital in Łódź was subjected to examinations. The Emotional Control Questionnaire by Brzeziński was applied together with the SF-36 Quality of Life Test. The psychometric techniques used in the examinations allowed determining statistically significant relationships between QOL level and emotional excitability, emotional expression control, and situation control.

RESULTS

1) The QOL level of the psychosomatic patients was essentially lower compared with that of healthy people. 2) QOL was strictly related to the emotional functioning of the subjects. 3) There was no essential diversity in the range of emotional functioning among the patients. 4) QOL of the patients suffering from gastric ulcer was on average a little higher than that of patients with coronary disease.

[Effects of age-related androgen deficiency on clinical and psychological characteristics of patients with ischemic heart disease]

AIM

To study prevalence of androgen deficiency and its relations with clinicopsychological disorders in males with ischemic heart disease (IHD).

MATERIAL AND METHODS

A total of 87 males aged 31-60 years (58 with stable angina of effort FCII-III, 29 with progressive angina of effort) participated in the study. Clinical symptoms of androgen deficiency, severity of anxiety and depression, quality of life were characterized with scales AMS, HADS, D. M. Aronov and V.P. Zaitsev method (2002), respectively. Left ventricular myocardial mass (L VMM) was calculated according to R. Devereux and N. Reichek formula.

RESULTS

Symptoms of male sexual hormones deficiency were seen in 67.8% examinees. In the age groups 31-40, 41-50, 51-60 years androgenic deficiency was diagnosed in 50, 85.7 and 82.9% patients, respectively. A direct correlation was found between androgenic deficiency and total cholesterol (R=0.38), prothrombin index (R=0.39), LVMM index (R=0.48), severity of depression (R=0.71), anxiety (R=0.5) and inverse correlation--between androgenic deficiency and quality of life (R = -0.69).

CONCLUSION

Young and middle-aged patients with ischemic heart disease have symptoms of androgenic deficiency in 67.8% cases. This fact necessitates screening testing of such patients with AMS questionnaire. Male sex hormones deficiency is associated with high anxiety and depression, while quality of life is subnormal.

[Cardiorehabilitation of patients with stable ischemic heart disease: compliance with treatment]

AIM

To study correlation between compliance with treatment (attendance of training sessions) and clinical symptoms in patients with ischemic heart disease (IHD) in the course of 12-week program of physical training.

MATERIAL AND METHODS

Ergospirometry before and after training was performed in 71 patients with stable IHD (21.1% females, 78.9% males, mean age 56.5 +/- 10.0 years) for estimation of exercise intensity and efficacy. A total of 36 training sessions were conducted for 12 weeks. Compliance with treatment was assessed by attendance of training sessions.

RESULTS

A direct correlation was found between the attendance and duration of IHD (r = 0.364), number of cardiovascular complications (r = 0.526), functional class of angina pectoris (r = 0.643), plasma cholesterol (r = 0.475). Negative correlation was seen between the attendance and age of the patients (r = 0.327), body mass (r = 0.311), systolic arterial pressure at rest (r = 0.756), VO+AEA-2 peak by ergospirometry before training (r = 0.543) and time of walk to the clinic (r = 0.711). No correlation was found between the attendance and gender of the patients (r = 0.107).

CONCLUSION

Some clinical features of patients with stable IHD which may indicate low compliance with treatment were identified. These features should be taken into consideration for optimization of cardiorehabilitation programs based on dose-adjusted loads.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

Mental stress hemodynamic responses and myocardial ischemia: does left ventricular dysfunction alter these relationships?

OBJECTIVE

To assess if mental stress hemodynamic responses are impaired and related to mental stress (MS) ischemia in patients with left ventricular (LV) dysfunction.

BACKGROUND

Impaired LV function is an important coronary artery disease (CAD) risk factor and hemodynamic characteristics play an important role in clinical outcomes. Patients with severe LV dysfunction (SLVD) are frequently excluded from prior studies and the effects of LV dysfunction on MS hemodynamic responses are not known.

METHODS

Fifty-eight patients with CAD, consisting of 22 patients with normal LV function (ejection fraction (EF) > or =50%), 16 patients with mild-to-moderate LV dysfunction (30% < EF < 50%), and 20 patients with severe LV dysfunction (EF < or =30) underwent bicycle exercise (EX) and MS testing with 12-lead electrocardiogram and monitoring of vital signs on consecutive days in random order. Blood pressure and heart rate (HR) measurements were obtained. Ischemia was measured using single photon emission computed tomography.

RESULTS

Both MS and EX produced significant increases in all hemodynamic measurements. HR levels were higher both at rest and during MS in SLVD patients. LV groups increased similarly from rest to stress (both MS and EX) for all measurements except HR during MS, which increased more in patients with SLVD than patients with normal LV function. Hemodynamic responses to MS were not related to myocardial ischemia or heart failure symptoms.

CONCLUSIONS

HR response during MS is increased in patients with SLVD, whereas blood pressure responses are similar to those in patients with preserved LV function. Hemodynamic reactivity is unrelated to MS-induced ischemia.

Unfairness and health: evidence from the Whitehall II Study

OBJECTIVE

To examine the effects of unfairness on incident coronary events and health functioning.

DESIGN

Prospective cohort study. Unfairness, sociodemographics, established coronary risk factors (high serum cholesterol, hypertension, obesity, exercise, smoking and alcohol consumption) and other psychosocial work characteristics (job strain, effort-reward imbalance and organisational justice) were measured at baseline. Associations between unfairness and incident coronary events and health functioning were determined over an average follow-up of 10.9 years.

PARTICIPANTS

5726 men and 2572 women from 20 civil service departments in London (the Whitehall II Study).

MAIN OUTCOME MEASURES

Incident fatal coronary heart disease, non-fatal myocardial infarction and angina (528 events) and health functioning.

RESULTS

Low employment grade is strongly associated with unfairness. Participants reporting higher levels of unfairness are more likely to experience an incident coronary event (HR 1.55, 95% CI 1.11 to 2.17), after adjustment for age, gender, employment grade, established coronary risk factors and other work-related psychosocial characteristics. Unfairness is also associated with poor physical (OR 1.46, 95% CI 1.20 to 1.77) and mental (OR 1.54, 95% CI 1.19 to 1.99) functioning at follow-up, controlling for all other factors and health functioning at baseline.

CONCLUSIONS

Unfairness is an independent predictor of increased coronary events and impaired health functioning. Further research is needed to disentangle the effects of unfairness from other psychosocial constructs and to investigate the societal, relational and biological mechanisms that may underlie its associations with health and heart disease.

Adverse clinical events in patients treated with sirolimus-eluting stents: the impact of Type D personality

BACKGROUND

Little is known about the impact of psychological risk factors on cardiac prognosis in the drug-eluting stent era. We examined whether the distressed personality (Type D) moderates the effect of percutaneous coronary intervention with sirolimus-eluting stent implantation on adverse clinical events at 2-year follow-up. Type D is an emerging risk factor in patients with cardiovascular disease.

DESIGN

Prospective follow-up study.

METHODS

Three hundred and fifty-eight patients with ischemic heart disease, who consecutively underwent percutaneous coronary intervention with sirolimus-eluting stent as part of the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital registry, completed the Type D Scale (DS14) post-percutaneous coronary intervention (PCI). The end-point was a composite of death and non-fatal myocardial infarction 2 years after PCI.

RESULTS

At follow-up, there were 22 events (12 deaths and 11 myocardial infarctions). Type D patients had a greater than two-fold risk of an event at follow-up compared with non-Type D patients (10.4 vs. 4.4%, P=0.031). In multivariable analysis, Type D remained an independent predictor of adverse outcome (hazard ratio: 2.61; 95% confidence interval: 1.12-6.09; P=0.027) adjusting for sex, age, and history of coronary artery disease, multivessel disease, diabetes, hypercholesterolemia, hypertension, renal impairment and smoking. Previous cardiac history was also an independent predictor of death or myocardial infarction (hazard ratio: 2.83; 95% confidence interval: 1.00-7.96; P=0.049).

CONCLUSIONS

Type D personality moderated the effect of percutaneous coronary intervention on hard clinical events despite treatment with the latest innovation in interventional cardiology. The inclusion of psychological risk factors in general and personality factors in particular may optimize risk stratification in the drug-eluting stent era.

Mental stress–induced myocardial ischemia in coronary artery disease patients with left ventricular dysfunction

BACKGROUND

Reduced left ventricular ejection fraction (LVEF) is a risk factor for poor outcomes in patients with coronary artery disease (CAD). Mental stress-induced myocardial ischemia (MSIMI) also identifies a subset of CAD patients at increased risk for future cardiovascular events. Susceptibility to MSIMI in patients with CAD and reduced LVEF is unknown.

METHODS AND RESULTS

We enrolled 182 patients (67 women) with a mean age of 64 years and a documented history of CAD in this study. Baseline resting ejection fraction was determined by use of technetium 99m sestamibi gated single photon emission computed tomography. Abnormal LVEF was defined as less than 45% for men and less than 50% for women (based on published norms for our software [Cedars-Sinai Medical Center]). All participants underwent mental stress testing with a public speaking task. Rest/stress myocardial perfusion single photon emission computed tomography was performed via conventional methodology. Images were visually compared for number and severity of perfusion defects by use of a scoring method from 0 to 4. A summed difference score was calculated as the difference between summed stress and rest scores. A score of greater than 3 was considered abnormal. MSIMI developed in 19% of patients with normal LVEF and 31% of those with reduced LVEF. There is no statistically significant difference between the two groups (P = .11).

CONCLUSIONS

CAD patients with left ventricular dysfunction are equally susceptible to MSIMI as those with normal LVEF.

[Depression and ischemic heart disease]

Depression is an independent risk factor for ischemic heart disease and is related to increased cardiovascular mortality. Post myocardial infarction depression is related to less compliance with medical treatment, less participation in cardiac rehabilitation, less modification of life style factors and increased mortality. So far, routine treatment with selective serotonin re-uptake inhibitors is not warranted as the evidence is insufficient. Improved cooperation between general practice, cardiologists and psychiatrists is necessary in order to identify and treat this group of patients.

C-reactive protein and vulnerability to mental stress-induced myocardial ischemia

Myocardial ischemia provoked in the laboratory during mental stress (MSI) in patients with stable coronary artery disease (CAD) predicts subsequent clinical events. The pathophysiology of MSI differs from that of exercise ischemia, and the mechanisms tying MSI to poor prognosis are not known. C-reactive protein (CRP) is a risk marker for cardiovascular events in patients with CAD, but little is known regarding the relationship of CRP to MSI. The purpose of this study was to examine the association of CRP to risk of MSI in CAD patients. Eighty-three patients with stable CAD underwent simultaneous single-photon emission computed tomography (SPECT) imaging with technetium-99m tetrofosmin myocardial perfusion imaging (MPI) and transthoracic echocardiography (TTE), at rest and during MS induced by laboratory mental stress. Serum CRP levels were measured 24 h after MS. MSI was defined by the presence of a new perfusion defect on SPECT and/or new regional wall motion abnormality on TTE during MS. Of the 83 patients, 30 (36%) developed MSI. There was no difference in gender, sex, BMI, histories of diabetes, hypertension, smoking, lipid profile, medications used (including statins, beta-blockers, ACE inhibitors, and aspirin), or hemodynamic response during MS between those with and without MSI. In univariate logistic regression analysis, each unit (1 mg/L) increase in CRP level was associated with 20% higher risk of MSI (OR 1.2, 95% CI 1.01-1.39, P=.04). This relationship remained in multivariate models. These data suggest that levels of CRP may be a risk marker for MSI in patients with CAD.

Outcomes of cardiac rehabilitation with versus without a follow-up intervention rendered by telephone (Luebeck follow-up trial): overall and gender-specific effects

The effects of a nurse-managed secondary prevention program for patients after acute cardiac events were examined. Special interest was given to gender-specific results. The design was a prospective, randomized, controlled trial involving 343 patients following 3 weeks of inpatient cardiac rehabilitation, randomly assigned to either of two study groups. Patients in the treatment group were contacted monthly by phone over 1 year. The main goals of the intervention were the reduction of behavioural coronary risk factors and enhancing quality of life. The program was conducted by specially trained nurses. The control group received written information only. Primary outcome was the Framingham risk score. Follow-up examination after 12 months was completed by 297 patients. Patients in the intervention group showed lower Framingham risk scores as compared to controls. Separate analyses by sex revealed that this was mostly due to the men in the sample. Women, on the other hand, showed a significant rise of clinically relevant anxiety/depressiveness in the control but not in the intervention group; in males there were no differences between study conditions. In conclusion, telephone counselling by specially trained nurses seems a cost-effective way to achieve a lasting reduction in cardiac risk factors and to maintain the effects of cardiac rehabilitation.

[Silent ischemia and noisy stunning: a perspective of the cause and hints of associations]

The significance of ST-segment changes in an electrocardiogram need not be always as clear-cut as we used to think. Minor problems usually represent only the ST-segment depressions in the presence of typically manifested problems and established coronary artery disease. The same holds true for ST-segment elevations: in addition, they definitively superior to ST-segment depressions. Among other categories, silent ischemia denotes only a part of what is or can be seen. This article deals with other conditions associated with changes in ST segments and variable symptoms with changeable clinical implications.

[The level of approval in selected chronic diseases]

Every somatic disease causes difficulties and negative emotions. It makes people limit or change their social roles. Approval of the disease is a significant factor in the process of adaptation to it. Approving the disease significantly influences the reduction of negative emotional reactions it causes. The paper attempts to define the degree of disease approval among the patients with the following illnesses: diabetes, bronchial asthma, cardiac ischaemia, chronic renal insufficiency.

MATERIAL AND METHODS

The study was carried out on 121 subjects, the patients of the district hospital in the Lublin Region. The study applied Approval Illness Scale (AIS)--B.J. Felton, T.A. Revenson, C.A. Hinrichsen, adapted in Poland by Z. Juczyński. It consists of 8 statements describing consequences of bad health condition.

RESULTS

The analysis of the obtained results confirmed a similar approval level in comparable illnesses. However a correlation was confirmed between the level of illness approval and the sex, age and place of living.

[Association of temperament, character and depressive symptoms with clinical features of the ischaemic heart disease]

The aim of this study was to assess the associations between temperament and character, depressive symptoms and the intensity and the course of ischaemic heart disease.

MATERIAL AND METHODS

42 patients with ischaemic heart disease, aged 37-65 years, meeting the ICD-10 diagnostic criteria, participated in this study. The evaluation of temperament and character was performed using Cloninger's Temperament and Character Inventory (TCI), and the intensity of depressive symptoms was assessed with Beck Depression Index (BDI). The clinical features of the illness were evaluated by structuralized interview.

RESULTS

Subjects with ischaemic heart disease presented significant severity of depresive symptoms on BDI (mean 19.9 points). Patients with higher intensity of ischaemic heart disease symptoms (with myocardial infraction, treated with interventional treatment) presented significantly greater severity of depression. Moreover these subjects were characterized with the specific features of temperament and character: higher level of harm avoidance and lower level of reward dependence. The longer duration of the illness was associated with the lower scores of the character trait--the ability to self-transcendence.

CONCLUSIONS

The obtained results may indicate, that the worse course of ischaemic heart disease and intensity of the illness are associated with the higher severity of depressive symptoms and with specific traits of temperament and character.

Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction

OBJECTIVES

We tested the hypothesis that perception of control moderates any relationship between anxiety and in-hospital complications (i.e., recurrent ischemia, reinfarction, sustained ventricular tachycardia or fibrillation, and cardiac death) in patients with acute myocardial infarction (AMI).

BACKGROUND

Anxiety is common among patients with AMI, but whether it is associated with poorer outcomes is controversial. Conflicting findings about the relationship of anxiety with cardiac morbidity and mortality may result from failure to consider the moderating effect of perceived control.

METHODS

This was a prospective examination of the association among anxiety, perceived control, and subsequent in-hospital complications among patients (N = 536) hospitalized for AMI.

RESULTS

Patients' mean anxiety level was double that of the published mean norm. Patients with higher levels of perceived control had substantially lower anxiety (p = .001). A total of 145 (27%) patients experienced one or more in-hospital complications. Patients with higher levels of anxiety had significantly more episodes of ventricular tachycardia, ventricular fibrillation, and reinfarction and ischemia (p < .01 for all). In a multivariate hierarchical logistic regression model, left ventricular ejection fraction, history of myocardial infarction, anxiety score, and the interaction of anxiety and perceived control were significant predictors of complications.

CONCLUSION

Anxiety during the in-hospital phase of AMI is associated with increased risk for in-hospital arrhythmic and ischemic complications that is independent of traditional sociodemographic and clinical risk factors. This relationship is moderated by level of perceived control such that the combination of high anxiety and low perceived control is associated with the highest risk of complications.

[Clinico-epidemiological program of the study of depression in cardiological practice in patients with arterial hypertension and ischemic heart disease (COORDINATA)]

COORDINATA - first Russian multicenter prospective (3 year long) study having the aim to elucidate prevalence of symptoms of anxiety and depression among patients with arterial hypertension (AH) and ischemic heart disease (IHD) and their influence on cardiovascular (CV) prognosis. Results of baseline epidemiological part of the study are presented. Results of prospective phase will be published in 2008.

MATERIAL AND METHODS

Symptoms of depression and anxiety were assessed by validated in Russia Hospital Anxiety and Depression Scale (HDS) in 5038 patients with AH and/or IHD aged 55 years and older. Prevalence of CV risk factors was also studied and their association with anxiety/depressive symptoms were evaluated in a framework of multivariate regression analysis.

RESULTS

Clinically significant symptoms of anxiety (HADS score >or=11) took place in 33 and 38%, symptoms of depression - in 30 and 38% of patients with AH and IHD, respectively. Relationship of symptoms of anxiety and depression was established with a number of psychosocial and biological risk factors of CV diseases (D) specifically low levels of education and income, insufficient level of physical activity, high level of chronic psychoemotional stress, exposition to acute stresses of great power, lack of social support, social isolation, elevated blood pressure level. It was shown that CVD comorbid anxiety and depressive states might cause excessive use of health care resources by patients.

Neighborhood socioeconomic deprivation and residential instability: effects on incidence of ischemic heart disease and survival after myocardial infarction

BACKGROUND

Previous literature has shown that neighborhood socioeconomic position influences the risk of ischemic heart disease, but little is known about the mechanisms linking the residential context to ischemic heart disease incidence and mortality. We examined whether neighborhood socioeconomic position and neighborhood residential stability (as a determinant of social interaction patterns) have an influence on ischemic heart disease risk. Moreover, we investigated whether dissimilar contextual influences operate at different stages of the disease process, ie, on incidence, 1-day case-fatality, and long-term survival after acute myocardial infarction (MI).

METHODS

Using a large 27-year longitudinal cohort (baseline: 1 January 1996) defined in the Scania region, Sweden, we estimated multilevel survival models adjusted for individual sociodemographic factors and previous diseases of the persons.

RESULTS

After adjustment, multilevel survival models indicated that the incidence of ischemic heart disease increased with neighborhood socioeconomic deprivation but was only weakly associated with neighborhood residential instability (for high vs low residential instability, hazard ratio = 1.2; 95% credible interval = 1.0-1.4). Conversely, beyond effects of individual and contextual socioeconomic circumstances and distance to the hospital, we saw a markedly higher 1-day case-fatality (4.9; 1.8-15) and shorter survival time after MI among individuals still alive 28 days after MI (4.3; 1.2-17) in neighborhoods with a high versus low residential instability.

CONCLUSIONS

Effects of residential instability on post-MI survival may be mediated by the lower availability of social support in residentially unstable neighborhoods, suggesting a new class of intermediate processes that should be taken into account when investigating contextual influences on ischemic heart disease. Moreover, dissimilar contextual effects may operate at various stages of the disease process (ie, on incidence, case-fatality, and survival after MI).

Panic attacks, daily life ischemia, and chest pain in postmenopausal women

BACKGROUND

Chest pain is a common symptom of panic attacks, but little is known about the relationship in older women among panic attacks, chest pain, and daily life ischemia.

METHODS

The authors conducted a cross-sectional survey of 3063 community-dwelling, generally healthy postmenopausal women enrolled between 1997 and 2000 in the Myocardial Ischemia and Migraine Study in 10 clinical centers of the 40-center Women's Health Initiative. Participants, ages 50 to 79 years, completed a questionnaire about occurrence of panic attacks in the previous 6 months and underwent 24-hour ambulatory electrocardiogram monitoring (AECG); 2705 women had valid AECG recordings and panic attack questionnaires. ST depression on AECG, heart rate variability (HRV), and chest pain episodes were compared among women with and without a 6-month history of panic attack.

RESULTS

There was no difference in overall prevalence of ischemic episodes during AECG between women with and without panic attacks. Women with a recent history of panic were more likely to experience chest pain during AECG after controlling for potential confounders (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.40-2.88), including both nonischemic (OR = 1.83; 95% CI = 1.26-2.65) and ischemic chest pain (OR = 4.94; 95% CI = 1.41-17.30). Although mean HRV was lower in those with panic attacks (p = .017), this was not significant after controlling for confounders.

CONCLUSIONS

Postmenopausal women with a recent history of panic attacks do not appear to have more daily life ischemia as measured by occurrence of ST depression during 24-hour monitoring, but do have more chest pain and possibly lower HRV, suggesting that even sporadic panic attacks may be related to cardiovascular risk.

Cognitive-behavioural stress management does not improve biological cardiovascular risk indicators in women with ischaemic heart disease: a randomized-controlled trial

OBJECTIVES

Psychosocial factors, such as stress and vital exhaustion, are associated with an increased risk of cardiovascular events, and women report more psychosocial ill-being after an acute myocardial infarction than men. We have earlier shown that a cognitive-behavioural intervention in women with ischaemic heart disease (IHD) improved psychosocial well-being. In the present study, we tested the hypothesis that the improvement in psychosocial well-being is associated with an improvement in biochemical indicators of cardiovascular risk.

DESIGN

Randomized-controlled trial in northern Sweden.

SETTING

Outpatient care.

SUBJECTS

Women with IHD were randomized to either a 1-year cognitive-behavioural stress management programme or usual care. Of the 159 women who completed the study, 77 were in the intervention group, and 82 in the control group.

INTERVENTIONS

A 1-year cognitive-behavioural stress management programme versus conventional care.

RESULTS

Group assignment was not found to be a determinant of waist circumference, high sensitive C-reactive protein (hs-CRP), fibrinogen, von Willebrand factor (vWF), plasminogen activator inhibitor type 1 (PAI-1) activity, tissue plasminogen activator (tPA) activity, tPA antigen, tPA-PAI-1 complex, leptin, or HOMA2 insulin resistance index (HOMA2-IR) at follow up. Changes in psychosocial variables were not associated with changes in any of the biological risk indicators.

CONCLUSIONS

Even if our cognitive-behavioural stress management programme had effects on proximal targets, such as stress behaviour and vital exhaustion, we found no improvement in intermediate biochemical targets related to the metabolic syndrome and IHD. Our results challenge the proposition that the relationship between psychological well-being and biological cardiovascular risk indicators is a direct cause-effect phenomenon.