Five-year risk of cardiac mortality in relation to initial severity and one-year changes in depression symptoms after myocardial infarction

[Incidence and risk factors of depression after a first coronary acute syndrome: A prospective study among 110 patients]

AIM

The purpose of this study was to estimate the incidence of post-acute coronary syndrome (ACS) depression and to identify predictive factors for the onset of this disorder.

PATIENTS AND METHODS

We conducted a prospective, multicentric study across four cardiology departments, during the period from June to December 2018. A depressive symptom screening was performed using the Hospital Anxiety and Depression Scale, in-hospital (T0) and on average 42.1±7.9 days after hospital discharge (T1).

RESULTS

A total of 110 patients were enrolled with an average age of 57±8.1 years. Sex ratio was 3.78. The incidences of depressive symptomatology at T0 and T1 were respectively 19.1% and 6.2%. Mean and cumulative incidences of depressive symptomatology were respectively 12.7% and 25.5%. According to the univariate analysis, drinking alcohol, overweight and anxiety were associated with the incidence of depressive symptomatology after SCA at T0. In binary logistic regression, drinking alcohol was the independent predictor of the incidence of depression after ACS at T0 with an odds ratio of 4.680 and CI of 95% [1.449; 15,107]; P=0.01. In univariate analysis, drinking alcohol, high risk of hospital mortality, according to the GRACE score, and non performing coronary angiography were statistically associated with the overall incidence of depressive symptomatology.

CONCLUSION

Depression screening must be a part of the evaluation of the ACS. A repeated evaluation of depression is also recommended.

Continuous Positive Airway Pressure Treatment and Depression in Adults with Coronary Artery Disease and Nonsleepy Obstructive Sleep Apnea. A Secondary Analysis of the RICCADSA Trial

RATIONALE

Obstructive sleep apnea (OSA) and depression are common among adults with coronary artery disease (CAD).

OBJECTIVES

To determine the impact of continuous positive airway pressure (CPAP) treatment on depression in adults with CAD and nonsleepy OSA.

METHODS

This was a secondary analysis of the RICCADSA (Randomized Intervention with CPAP in CAD and Sleep Apnea) trial, conducted in Sweden between 2005 and 2013. Adults with CAD and nonsleepy OSA (apnea-hypopnea index ≥15/h, and Epworth Sleepiness Scale <10 at baseline) and complete Zung Self-Rating Depression Scale (SDS) questionnaires at baseline, after 3 and 12 months, were included. Participants analyzed in their randomized arm were CPAP (n = 99) or no-CPAP (n = 104). Depression was defined as a Zung SDS score of 50 or greater. The primary outcome was the between-group difference in the absolute change in the SDS score from baseline.

RESULTS

No significant between-group differences were observed in SDS scores during follow-up in the entire study sample. Among the 56 participants with an SDS of 50 or greater at baseline (27.6%), the mean (±SD) baseline SDS was 55.0 (±5.5) in the CPAP group, and 53.9 (±4.0) in the no-CPAP group. In the CPAP group, SDS scores decreased at 3 months (47.2 ± 8.2) and 12 months (45.8 ± 7.6), but remained stable in the no-CPAP group at 3 months (53.1 ± 8.0) and 12 months (52.6 ± 8.1) (P = 0.01). The proportion with depression decreased from 30.3% at baseline to 16.2% after 3 months, and to 13.1% after 12 months in the CPAP group, from 25.0% at baseline to 23.1% after 3 months, and to 24.0% after 12 months in the no-CPAP group (P = 0.001). Moreover, there was an association between the duration of CPAP usage (h/night) and the longitudinal decline in SDS score (r = 0.46; P < 0.001). CPAP usage categories (3, 4, and 5 h/night) were significantly associated with improvement in SDS (odds ratio = 3.92, 4.45, and 4.89, respectively) in multivariate analyses adjusted for age, sex, body mass index, left ventricular ejection fraction, apnea-hypopnea index, and Epworth Sleepiness Scale at baseline.

CONCLUSIONS

Among adults with depression, nonsleepy OSA, and CAD, 3 months of CPAP treatment improved depression scores. The improvement in mood persisted up to 12 months. An on-treatment adjusted analysis confirmed these findings. Clinical trial registered with www.clinicaltrials.gov (NCT00519597).

Impact of depression at early and late phases following acute coronary syndrome on long-term cardiac outcomes

BACKGROUND

Depression has been associated with worse cardiac outcomes in patients with acute coronary syndrome, while no study has investigated trajectory of depression and ACS prognosis. This study investigated associations of depressive disorder within 2 weeks (early) and at 1 year (late) after ACS with major adverse cardiac event (MACE).

METHOD

In 757 ACS patients recruited in 2007-2012 and evaluated for depressive disorder at the two time-points, 5-12 year follow-up for MACE was conducted.

RESULTS

MACE incidence was significantly higher in patients with depressive disorder at early or late phase of ACS than those without, regardless of status at the other time point; however, highest incidence was found following depression at both time points.

LIMITATION

The follow-up for depressive disorder was made at only one point.

CONCLUSION

Depression evaluation thus needs consideration both early and late post-ACS.

Randomized Trial of Mindfulness-Based Stress Reduction in Cardiac Patients Eligible for Cardiac Rehabilitation

Currently, exercise-based cardiac rehabilitation (CR) is the only recommended secondary prevention strategy for cardiac patients that attempts to tackle stress and psychosocial wellbeing, but it is under-utilized and lacks a comprehensive curriculum for this purpose; hence there is a critical gap to address psychosocial needs of cardiac patients after an event. Mindfulness-based stress reduction (MBSR) has shown benefits in the general population but its role in cardiac patients is not clear. We conducted a pilot randomized controlled trial (RCT) of MBSR in CR-eligible cardiac patients during their initial year of recovery. Patients were allocated 2:1 (intervention:control) to an 8-week MBSR group intervention or usual care. Standard measures of depression, anxiety, perceived stress, health related quality of life (HRQOL), blood pressure, biomarkers (lipids, HbA1c, CRP) and 24-hour Holter monitoring were obtained at baseline, 3- and 9-months post-randomization. Sub-group analyses were performed for participants with at least mild depression (PHQ-9 ≥ 5). 47 patients [mean age 58.6 years; 38% female; 77% white] were enrolled in 2 cohorts. 87% of MBSR patients completed the intervention; study retention was >95% at each follow-up visit. At 3 months, compared to controls, MBSR patients showed improvements in depression [p = 0.01] and anxiety [p = 0.04] with a similar trend in HRQOL [p = 0.06]. The MBSR group showed greater improvement or less worsening of most CV risk factors, with an attenuation of treatment effects at 9 months. Participants with at PHQ-9 scores ≥5 at baseline showed greater improvement in psychosocial and CV outcomes, that persisted at 9 months. MBSR is a safe and well received secondary prevention strategy. This pilot RCT provides preliminary evidence of MBSR's potential to improve short term psychosocial well-being in cardiac patients during their first year of recovery.

Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF

Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC).

Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions.

Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA₂DS₂VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records.

Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA₂DS₂VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18–0.59) and social isolation (OR = 0.38, 95%CI 0.14–0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05–4.29) in patients aged 65–74 years.

Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.

Modifying effects of depression on the association between BDNF methylation and prognosis of acute coronary syndrome

AIMS

Brain-derived neurotrophic factor (BDNF) plays important roles in angiogenesis, inflammation, and neuronal plasticity. BDNF methylation has been extensively investigated in depression, but not in cardiac diseases. We asked whether BDNF methylation status is associated with a major adverse cardiac event (MACE), inflammation, and the association with depression comorbidity and its treatment in patients with acute coronary syndrome (ACS).

METHODS AND RESULTS

A cross-sectional baseline study and nested 24 week double-blind escitalopram placebo-controlled trial (ClinicalTrial.gov identifier NCT00419471) were performed from 2006 to 2012, with 5-12 year follow-up for MACE. Patients with recent ACS (969 total) were divided into four groups according to depression comorbidity at baseline and treatment allocation: 591, absent depression; 127, depression on escitalopram; 128, depression on placebo; 123, depression on care as usual (CAU). BDNF methylation was measured in leucocyte DNA, and multiple demographic and clinical characteristics including interleukin 6 were evaluated as covariates at baseline. The primary outcome, time to first MACE (a composite of all-cause mortality, myocardial infarction and percutaneous coronary intervention), was investigated using Cox regression models after adjustment for covariates. Interleukin 6 level was significantly higher in patients with higher BDNF methylation values. Higher BDNF methylation was associated with increased MACE independent of confounding factors [HR (95% CI) = 1.45 (1.17-1.78)]. This association was significant in patients without depression [HR (95% CI) = 1.39 (1.01-1.90)] and depressive patients on placebo [HR (95% CI) = 1.72 (1.02-3.02)] or CAU [HR (95% CI) = 1.53 (1.01-2.61)], but not in those treated with escitalopram [HR (95% CI) = 1.00 (0.51-1.95)].

CONCLUSION

BDNF methylation was significantly associated with prognosis of ACS. Escitalopram may mitigate the deleterious effect of higher BDNF methylation in depressive patients with ACS. Further research is needed to elucidate the mechanistics and to assess the generalisability of these findings.

Mediators of gender effects on depression among cardiovascular disease patients in Palestine

BACKGROUND

Among patients suffering from coronary heart disease (CHD) and comorbid depression, women experience a higher burden compared to men. Little is known on the characteristics that differentiate men and women with both diseases and whether these factors mediate gender effects on depression. This study assessed whether women are more likely to suffer from depression and which characteristics mediate gender effects on depression among a cardiac population in Palestine, specifically addressing the role of post-traumatic stress disorder (PTSD).

METHODS

Using a cross-sectional design, patients consecutively admitted with a CHD to one of the four main hospitals in Nablus, Palestine, were interviewed using a structured questionnaire with validated instruments. Data was also obtained from hospital medical records. Patients were assessed for depression using the Cardiac Depression Scale (CDS). Bivariate analysis was conducted to compare characteristics of women and men with and without depressive symptoms. Mediators (direct and indirect effects) of the association between gender and depression were evaluated using a structural equation model (SEM).

RESULTS

Women were more likely to suffer from severe depression than men (28.7% vs. 18.8%). Female gender was positively associated with higher PTSD symptoms, comorbidities, somatic symptoms and income, and with lower resilience, self-esteem, quality of life, education, prevalence of smoking and physical activity. Structural equation modeling revealed negative indirect effects of gender on depression (CDS score) through resilience, self-esteem and physical activity, whereas positive indirect effects of gender on depression were observed through PTSD, comorbidities, somatic symptoms and smoking. There was no direct effect of gender on depression.

CONCLUSION

This study found a higher prevalence of severe depression in female patients with cardiac disease compared to male cardiac patients. Our findings provide novel information on mediating factors of the association between gender and depression among cardiac patients, in particular PTSD. The results emphasize the need for further research on potential mediating factors that could account for gender differences in depression and the need to provide support programs for female patients with comorbid CHD and depression to improve their psycho-social well-being.

Psychopharmacology and Cardiovascular Disease

This review discusses common mental health disorders and their associations with cardiovascular disease risks. Commonly found mental health disorders include depression, anxiety, and personality types. The link between depression and cardiovascular disease mortality has been established. Depression is also common in patients with heart failure. In addition to discussing psychological disorders, a review of psychotropic drugs is also included. Drugs are described for therapy for depression and anxiety, as well as associations with cardiovascular drug-drug interactions. Drug-drug interactions are more common and potentially dangerous in elderly patients, in whom the conditions often coexist. The most common drug-drug interactions involve the P450 system of enzymes.

Brain Correlates of Mental Stress-Induced Myocardial Ischemia

OBJECTIVE

Coronary artery disease (CAD) is a major cause of morbidity and mortality, and despite important advances in our understanding of this disorder, the underlying mechanisms remain under investigation. Recently, increased attention has been placed on the role of behavioral factors such as emotional stress on CAD risk. Brain areas involved in memory and the stress response, including medial prefrontal cortex, insula, and parietal cortex, also have outputs to the peripheral cardiovascular system. The purpose of this study was to assess the effects of mental stress on brain and cardiac function in patients with CAD.

METHODS

CAD patients (N = 170) underwent cardiac imaging with [Tc-99m] sestamibi single-photon emission tomography at rest and during a public speaking mental stress task. On another day, they underwent imaging of the brain with [O-15] water positron emission tomography (PET) during mental stress (arithmetic and public speaking) and control conditions.

RESULTS

Patients with mental stress-induced myocardial ischemia showed increased activation with stress in anterior cingulate, inferior frontal gyrus, and parietal cortex (p < .005). This was seen with both arithmetic stress and public speaking stress. Arithmetic stress was additionally associated with left insula activation, and public speaking with right pre/postcentral gyrus and middle temporal gyrus activation (p < .005).

CONCLUSIONS

These findings suggest that mental stress-induced myocardial ischemia is associated with activation in brain areas involved in the stress response and autonomic regulation of the cardiovascular system. Altered brain reactivity to stress could possibly represent a mechanism through which stress leads to increased risk of CAD-related morbidity and mortality.

Depression in Survivors of Acute Myocardial Infarction

INTRODUCTION

There was growing evidence of increased cardiovascular risk in patients with depressive disorders.

AIM

To determinate the percentage of depression of the three investigated groups of patients with myocardial infarction and to determinate the correlation between sociodemographic characteristic and level of depression in survivors of AMI.

METHODS

The study was designed as observation cross-section including 120 patients treated at the University Clinic of Cardiology Skopje during 2018-2019 year, observed as 3 groups: group 1 was presented with patients during hospitalization for AMI, group 2 were patients survivors after 3 months of the acute coronary event and group 3 patients survivors after 12 months of the acute coronary event, Depression status was assessed using BDI.

RESULTS

the three groups presented almost equal representation of depression according BDI (X²=1,182, df=2, p=0,913) presented with 34,1 %, 30,8% and 30% respectively. The three groups of patients did not show significant difference according distribution of gender smoking , physical activity, stress, diabetes mellitus, age, mean BDI, BMI, Systolic BP, age of education and marital status . Only group 3 presented significantly higher diastole BP comparing in group 1 and group 2 (F=9,532, df=2,p< 0,001). The depression (BDI score) in examination groups was associated with sociodemographic and clinical parameters where female gender, higher education level, decreased BMI, smoking, decreased physical activity, younger age and single status are independent predictors of depression in patients who survived acute myocardial infarction.

CONCLUSION

The results obtained in our study showed indicative representation of depression in patients survivors of AMI and significant association with sociodemographic and clinical parameters as predictors of depressive disorder. Regular screening for depression in patients survivors of AMI may improve the therapy decision, prognosis and the quality of patients' life.

Effects of continuous positive airway pressure on depression and anxiety symptoms in patients with obstructive sleep apnoea: results from the sleep apnoea cardiovascular Endpoint randomised trial and meta-analysis

BACKGROUND

Whether continuous positive airway pressure (CPAP) treatment can improve depression or anxiety symptoms in obstructive sleep apnoea (OSA) patients remains uncertain.

METHODS

Secondary analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, combined with a systematic review of randomised evidence. The SAVE secondary analyses involved 2410 patients with co-existing moderate-severe OSA and established cardiovascular disease randomly allocated to CPAP treatment plus usual care or usual care alone and followed up for 3·7 (SD 1·6) years. We evaluated the effect of CPAP treatment on depression and anxiety caseness (scores ≥ 8 on the Hospital Anxiety and Depression Scale depression and anxiety subscales [HADS-D and HADS-A]) for OSA patients.

FINDINGS

CPAP treatment was associated with reduced odds of depression caseness (adjusted odds ratio [OR] 0·80, 95% confidence interval [CI] 0·65-0·98, P = 0·031) compared to usual care in the SAVE trial and the treatment effect was greater in those with pre-existing depression symptoms. A systematic review of 20 randomised trials including 4255 participants confirmed a benefit of CPAP in reducing depression symptoms in OSA patients: the overall effect (standardised mean difference) was - 0·18 (95% CI - 0·24 to - 0·12). No effect of CPAP treatment on anxiety caseness was found both in patients of the SAVE study (adjusted OR 0·98, 95% CI 0·78-1·24, P = 0·89) and the systematic review.

INTERPRETATION

CPAP reduces depression symptoms in patients with co-existing OSA and CVD independently of improvements in sleepiness.

Qualitative Analysis of Emotional Distress in Cardiac Patients From the Perspectives of Cognitive Behavioral and Metacognitive Theories: Why Might Cognitive Behavioral Therapy Have Limited Benefit, and Might Metacognitive Therapy Be More Effective?

Introduction: Cognitive behavioral therapy (CBT) alleviates emotional distress in mental health settings, but has only modest effects in cardiac patients. Metacognitive therapy (MCT) also alleviates depression and anxiety in mental health settings and is in its initial stages of evaluation for cardiac patients. Aim: Our objective is to compare how CBT and MCT models conceptualize cardiac patients' distress, and to explore why CBT has had limited benefit for cardiac patients and whether MCT has the potential to be more efficacious. Method: Forty-nine cardiac rehabilitation patients, who screened positively for anxiety and/or depression, provided semi-structured interviews. We analyzed transcripts qualitatively to explore the "fit" of patients' accounts of their distress with the main elements of cognitive behavioral and metacognitive theories. Four illustrative cases, representative of the diverse presentations in the broader sample, were analyzed in detail and are presented here. Results: Conceptualizing patients' distress from the perspective of CBT involved applying many distinct categories to describe specific details of patients' talk, particularly the diversity of their concerns and the multiple types of cognitive distortion. It also required distinction between realistic and unrealistic thoughts, which was difficult when thoughts were associated with the risk or consequences of cardiac events. From the perspective of MCT a single category-perseverative negative thinking-was sufficient to understand all this talk, regardless of whether it indicated realistic or unrealistic thoughts, and could also be applied to some talk that did not seem relevant from a CBT perspective. Discussion: Conceptualizing distress from the perspective of CBT presents multiple, diverse therapeutic targets, not all of which a time-limited therapy would be able to address. Given the difficulty of identifying them as unrealistic or not, thoughts about disease, death or disability may not be amenable to classic CBT techniques such as reality testing. MCT proved more parsimonious and, because it did not distinguish between realistic and unrealistic thoughts, might prove a better fit to emotional distress in cardiac patients.

Models of care for populations with chronic conditions and mental/behavioral health comorbidity

Recent decades have seen increased interest in the integration of mental and physical healthcare. Healthcare reform in the US has provided an opportunity for integration of evidence-based mental health programmes. Three quarters of patients with behavioural health disorders are seen in medical settings, where behavioural problems are largely unaddressed. The human and economic toll of unaddressed mental and behavioural health needs is enormous and often hidden from view, since the behavioural or mental health implications of medical conditions like heart disease and diabetes have only recently begun to be appreciated. This paper has three goals: (1) to review models of integrated services delivery, providing a framework for making sense of strategies for integration; (2) to consider some evidence for clinical outcomes when care is integrated; and (3) to highlight some factors that enhance or impede integration in practice. The review concludes with comments on where the field is going.

Gender-Based Differences in Anxiety and Depression Following Acute Myocardial Infarction

Background

Among patients with heart disease, depression and anxiety disorders are highly prevalent and persistent. Both depression and anxiety play a significant role in cardiovascular disease progression and are acknowledged to be independent risk factors. However, there is very little gender-related analysis concerning cardiovascular diseases and emotional disorders.

Objective

We aimed to evaluate depression and anxiety levels in patients suffering from myocardial infarction [MI] within the first month after the MI and to assess the association between cardiovascular disease risk factors, demographic indicators and emotional disorders, as well as to determine whether there are gender-based differences or similarities.

Methods

This survey included demographic questions, clinical characteristics, questions about cardiovascular disease risk factors and the use of the Hospital Anxiety and Depression Scale [HADS]. All statistical tests were two-sided, and p values < 0.05 were considered statistically significant.

Results

It was determined that 71.4% of female and 60.4% of male patients had concomitant anxiety and/or depression symptomatology (p = 0.006). Using men as the reference point, women had an elevated risk of having some type of psychiatric disorder (odds ratio, 2.86, p = 0.007). The HADS-D score was notably higher in women (8.66 ± 3.717) than men (6.87 ± 4.531, p = 0.004). It was determined that male patients who developed depression were on average younger than those without depression (p = 0.005).

Conclusions

Women demonstrated an elevated risk of having anxiety and/or depression disorder compared to men. Furthermore, depression severity increased with age in men, while anxiety severity decreased. In contrast, depression and anxiety severity was similar for women of all ages after the MI. A higher depression score was associated with diabetes and physical inactivity, whereas a higher anxiety score was associated with smoking in men. Hypercholesterolemia was associated with both higher anxiety and depression scores, and a higher depression score was associated with physical inactivity in women.

Symptom patterns and clinical outcomes in women versus men with systolic heart failure and depression

BACKGROUND

Depression is more common in females than in males and is 3-5 times more prevalent in patients with heart failure (HF) than in the general population. The 9-item Patient Health Questionnaire (PHQ-9) is a validated depression screening instrument; higher sum-scores predict adverse clinical outcomes. Sex- and gender differences in PHQ-9 symptom profile, diagnostic and prognostic properties, and impact on health-related quality of life (HRQOL) have not been comprehensively studied in HF patients.

METHODS AND RESULTS

This post hoc analysis from the Interdisciplinary Network Heart Failure program enrolled 852/1022 participants (67 ± 13 years, 28% female) who completed the PHQ-9 at hospital discharge after cardiac decompensation. All had a left ventricular ejection fraction ≤ 40%. Women had a higher mean PHQ-9 sum-score than men (8.4 ± 5.6 vs. 7.4 ± 5.5; p = 0.027), and higher proportions rated the following items ≥ 2 (i.e., present on ≥ 50% of days): 'feeling down, hopeless' (25.8 vs. 18.0%; p = 0.011); 'fatigue' (51.9 vs. 37.2%; p < 0.001); and 'trouble concentrating' (21.6 vs. 15.4%; p = 0.032). A PHQ-9 sum-score ≥ 10 predicted increased mortality in women [hazard ratio 1.91 (95% confidence interval 1.06-3.43); p = 0.030] and men [2.10 (1.43-3.09); p < 0.001] and was associated with worse HRQOL (p < 0.001 for all comparisons). Sum-scores ≥ 10 predicted higher re-hospitalization rates in men only [1.35 (1.08-1.69); p = 0.008].

CONCLUSIONS

Differences in several PHQ-9 items indicated sex- or gender-specific depression symptomatology in HF. For both sexes, HRQOL and survival were worse when PHQ-9 sum-score was ≥ 10, but higher sum-scores predicted higher re-hospitalization rates in men only. Considering these specific aspects might help optimize care strategies in HF.

Effect of Escitalopram vs Placebo Treatment for Depression on Long-term Cardiac Outcomes in Patients With Acute Coronary Syndrome: A Randomized Clinical Trial

IMPORTANCE

Depression has been associated with poorer medical outcomes in acute coronary syndrome (ACS), but there are few data on the effects of antidepressant treatment on long-term prognosis.

OBJECTIVE

To investigate the effect on long-term major adverse cardiac events (MACE) of escitalopram treatment of depression in patients with recent ACS.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled trial conducted among 300 patients with recent ACS and depression enrolled from May 2007 to March 2013, with follow-up completed in June 2017, at Chonnam National University Hospital, Gwangju, South Korea.

INTERVENTIONS

Patients were randomly assigned to receive either escitalopram in flexible dosages of 5, 10, 15, or 20 mg/d (n = 149) or matched placebo (n = 151) for 24 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome was MACE, a composite of all-cause mortality, myocardial infarction (MI), and percutaneous coronary intervention (PCI). Four secondary outcomes were the individual MACE components of all-cause mortality, cardiac death, MI, and PCI. Cox proportional hazards models were used to compare the escitalopram and placebo groups by time to first MACE.

RESULTS

Among 300 randomized patients (mean age, 60 years; 119 women [39.3%]), 100% completed a median of 8.1 (interquartile range, 7.5-9.0) years of follow-up. MACE occurred in 61 patients (40.9%) receiving escitalopram and in 81 (53.6%) receiving placebo (hazard ratio [HR], 0.69; 95% CI, 0.49-0.96; P = .03). Comparing individual MACE outcomes between the escitalopram and placebo groups, respectively, incidences for all-cause mortality were 20.8% vs 24.5% (HR, 0.82; 95% CI, 0.51-1.33; P = .43), for cardiac death, 10.7% vs 13.2% (HR, 0.79; 95% CI, 0.41-1.52; P = .48); for MI, 8.7% vs 15.2% (HR, 0.54; 95% CI, 0.27-0.96; P = .04), and for PCI, 12.8% vs 19.9% (HR, 0.58; 95% CI, 0.33-1.04; P = .07).

CONCLUSIONS AND RELEVANCE

Among patients with depression following recent acute coronary syndrome, 24-week treatment with escitalopram compared with placebo resulted in a lower risk of major adverse cardiac events after a median of 8.1 years. Further research is needed to assess the generalizability of these findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00419471.

Changes in quality of life and health status in patients with extracorporeal life support: A prospective longitudinal study

Background

Extracorporeal life support (ECLS) provides emergency pulmonary and cardiac assistance for patients in respiratory or cardiac failure. Most studies evaluate the success of ECLS based on patients’ survival rate. However, the trajectory of health status and quality of life (QOL) should also be important considerations. The study’s aim was to explore changes in health status and QOL in adult patients weaned from ECLS who survived to hospital discharge over a one-year period.

Study design

A prospective longitudinal study was conducted from April 2012 to September 2014. A convenience sample of patients who had undergone ECLS was followed for one-year after hospital discharge. Heath status was measured with a physical activity scale, the Centre for Epidemiologic Studies Depression scale, and a social support scale; we assessed quality of life with the physical and mental component summary scales of the Short-Form 36 Health Survey. Changes in depression, social support, physical activity and QOL were analysed with generalized estimating equations at 3-month intervals; participants’ QOL at 12 months after discharge was compared with the general population.

Results

A total of 231 patients received ECLS during the study period. Sixty-five patients survived to hospital discharge (28% survival rate); 32 participants completed the study. Data showed scores for physical activity increased significantly over time (p < .001), while depression and social support significantly decreased (p < .05 and p < .001, respectively). Participants with veno-venous ECLS had higher scores for depression than participants with veno-arterial ECLS (p < .05). PCS scores significantly increased at 9, and 12 months after discharge (p < .05 and p < .001, respectively). There was no significant change in MCS scores.

Conclusions

This was a preliminary study of patients with ECLS following hospital discharge over a one-year period. One year following hospital discharge survivors of ECLS continued to experience physical complications and some continued to have depressive symptoms; the level of social support was significantly lower after hospital discharge. Healthcare professionals should understand the trajectory of health status and QOL after discharge, which can help developing evidence-based interventions and improve QOL for survivors of ECLS.

Residual Symptoms After Treatment for Depression in Patients With Coronary Heart Disease

OBJECTIVE

Depression is associated with an increased risk of mortality in patients with coronary heart disease (CHD). The risk may be reduced in patients who remit with adequate treatment, but few patients achieve complete remission. The purpose of this study was to identify the symptoms that persist despite aggressive treatment for depression in patients with CHD.

METHODS

One hundred twenty-five patients with stable CHD who met the DSM-IV criteria for a moderate-to-severe major depressive episode completed treatment with cognitive behavior therapy, either alone or combined with an antidepressant, for up to 16 weeks. Depression symptoms were assessed at baseline and after 16 weeks of treatment.

RESULTS

The M (SD) Beck Depression Inventory scores were 30.0 (8.6) at baseline and 8.3 (7.5) at 16 weeks. Seventy seven (61%) of the participants who completed treatment met remission criteria (Hamilton Rating Scale for Depression ≤7) at 16 weeks. Loss of energy and fatigue were the most common posttreatment symptoms both in remitters (n = 44, 57%; n = 34, 44.2%) and nonremitters (n = 42, 87.5%; n = 35, 72.9%). These symptoms were not predicted by baseline depression severity, anxiety, demographic, or medical variables including inflammatory markers or cardiac functioning or by medical events during depression treatment.

CONCLUSIONS

Fatigue and loss of energy often persist in patients with CHD even after otherwise successful treatment for major depression. These residual symptoms may increase the risks of relapse and mortality. Development of effective interventions for these persistent symptoms is a priority for future research.

Abnormal Repolarization Duration During Everyday Emotional Arousal in Long QT Syndrome and Coronary Artery Disease

BACKGROUND

Rare, high-arousal negative emotions are known triggers of sudden death in individuals with preexisting heart disease. Whether everyday fluctuations in emotional arousal influence arrhythmia risk is unknown.

METHODS

We studied 160 patients with the congenital long QT syndrome, 199 patients with coronary artery disease, and 2 groups of matched healthy volunteers (n = 52 and 50, respectively). Three-day home visits including a 12-hour Holter recording each day were completed. Subjects engaged in typical daily activities and were paged 10 times per day. On each occasion, subjects rated the intensity of 16 different emotions during the 5 minutes preceding the page. Holter data over those 5-minute epochs were analyzed for heart rate and QT interval corrected for heart rate (QTc). Analyses focused on within-subject covariation of momentary emotion and QTc.

RESULTS

In patients with long QT syndrome, activated positive affect and activated negative affect were associated with QTc shortening, whereas low arousal positive affect (calm and relaxed) was associated with QTc lengthening, which at times exceeded 500 msec. Findings were not affected by beta-blocker status or observed in younger healthy subjects. Findings were 3 to 8 times stronger in the LQT2 genotype, known to be prone to emotion-induced events, relative to the LQT1 genotype. Findings in patients with long QT syndrome for activated positive affect and low arousal positive affect were replicated in patients with coronary artery disease relative to older healthy subjects.

CONCLUSION

These findings suggest that even subtle changes in emotional arousal may alter repolarization reserve and contribute to sudden death risk in vulnerable individuals.

Augmented neutrophil extracellular traps formation promotes atherosclerosis development in socially defeated apoE-/- mice

Depression is an independent risk factor of cardiovascular disease (CVD); however, the causal association remains undefined. We exposed mice to repeated social defeat (RSD) to precipitate depressive-like behaviors, and investigated the effects on atherosclerosis. Eight-week-old male apoE^-/- mice were exposed to RSD by housing with a larger CD-1 mouse in a shared home cage. They were subjected to vigorous physical contact daily for 10 consecutive days and fed a high-cholesterol diet (HCD) for 6 weeks. The social interaction ratio and immobility time showed dramatic social avoidance before and after HCD feeding. Defeated mice showed higher increase in atherosclerotic lesion areas in the aortic root and entire aorta than control mice. Mean blood pressure and lipid profile were equivalent in both groups. While Ly-6G- and Mac3-positive areas in the aortic root were comparable between the groups, citrullinated histone H3 (Cit-H3)- and myeloperoxidase (MPO)-positive areas, markers of neutrophil extracellular traps (NETs), were significantly increased in the defeated mice. Treatment with DNase I completely diminished the exaggerated atherosclerosis. The proportion of peripheral blood polymorphonuclear myeloid-derived suppressor cells (PMN-MDSC), but not of inflammatory monocytes, was markedly increased. Moreover, in vitro NETs formation from bone marrow (BM) PMN-MDSC was markedly augmented, accompanied by higher expression of Nox2 gene and reactive oxygen species. Our findings demonstrate that exposure to RSD promotes atherosclerosis by augmenting NETs formation within the plaque. This provides new insight into the underlying mechanism of depression-related CVD.

The relationship of depressive symptoms and functional and structural markers of subclinical atherosclerosis: A systematic review and meta-analysis

Objectives

The relationship of depressive symptoms and subclinical atherosclerosis remains controversial. We performed a systematic review and meta-analysis to evaluate the effect of depressive symptoms on the functional and structural markers of subclinical atherosclerosis as measured by carotid intima-media thickness (IMT), pulse wave velocity (PWV) and flow-mediated vasodilation (FMD).

Methods

A systematic literature search was performed electronically. Studies relating IMT, PWV or FMD to depressive symptoms were included. Standard/weighted mean differences (SMD/WMD) and corresponding 95% confidence intervals (95% CIs) were pooled in overall and subgroup analyses (age, sex, depression diagnosis, region, study design, site measured and sample size). Sensitivity analysis and publication bias were also conducted.

Results

Thirty-eight articles involving 5947 patients with depressive symptoms and 34,423 controls without depressive symptoms were included. Compared with controls without depressive symptoms, patients with depressive symptoms showed a significantly thicker IMT (SMD (95% CI) = 0.137 (0.047–0.227), p = 0.003), a higher PWV (SMD (95% CI) = 0.216 (0.139–0.293), p < 0.001) and a lower FMD (WMD (95% CI) = –2.554 (–3.709 to –1.399), p < 0.001). When analyzing subgroups with age and female ratio, all results were still significant ( p < 0.05) except IMT and FMD in age < 50 years subgroups ( p > 0.05). There was no statistical significance in sensitivity analysis and publication bias ( p > 0.05).

Conclusions

Depressive symptoms contributed toward subclinical atherosclerosis, and resulted in impaired functional and structural markers of subclinical atherosclerosis, which holds great promise in early prevention of cardiovascular disease.

Pre-admission quality of life as predictor of outcome after acute care: the role of emotional well-being

PURPOSE

We sought to investigate whether pre-admission quality of life could act as a predictor of mortality among acutely ill patients, and which dimension of QOL has the greater impact on outcomes.

METHODS

Prospective cohort study including patients admitted to an acute medical unit of Rabat Ibn Sina University Hospital, Morocco, between June and September 2014. Characteristics of patients were recorded at admission. The primary exposure was pre-admission quality of life recorded using Euroqol five dimensions three level (EQ-5 D-3 L) and the primary outcome was 90-day mortality. We fit a Cox proportional hazards model to assess their association. We constructed six prediction models; each model included either EQ5D index or one of the five dimensions. We allowed all continuous variables to have a non-linear relationship with the primary outcome using restricted cubic spline with three knots.

RESULTS

We included 251 patients. The mean EQ5D index was 0.46 ± 0.5. The design of each prediction model was based on the significant findings of the univariate analysis including; bedside EQ5D index or one of the five dimensions of the EQ5D; age, history of chronic disease, Charlson Comorbidity Index and hemoglobinemia. Multi-variate Cox proportional adjusted hazard ratio (HR) derived from the six models, identified that EQ5D index was independently associated with 90-day mortality (HR: 0.48; 95% CI: 0.25; 0.91, P = 0.02), and that anxiety and depression dimension has the greater impact on outcome (HR: 2.97; 95% CI: 1.38; 6.41, P = 0.005).

CONCLUSIONS

This study revealed that pre-admission health-related quality of life (HRQoL), and particularly pre-admission psychological HRQoL was associated with outcome of acutely ill patients 90 days after discharge.

Residents' responsibilities: Adopting a wider view

Current ACGME regulations have limited residents' weekly hours and continuous working hours, a marked change, despite its uncertain effects on physician well-being and quality of care. Although residency programs in internal medicine and family medicine have adapted schedules to conform to these regulations, increasing evidence is accumulating to suggest that these training experiences are not adequately preparing the next generation of practicing primary care and hospital-based physicians. Data from an array of sources continue to demonstrate significant deficiencies in six areas of residents' responsibilities towards their patients: diminished patient "face time" and direct patient care; focus on patients' "reason for hospitalization" or "reason for visit" at the expense of possible neglect of patients' "secondary" medical problems; limited attention to patients' emotional or contextual problems and limited empathy; deficient implementation of the essential constituents of patient-centered care; neglect of habitual "reflective practice"; and excessive distinction between inpatient and outpatient responsibilities, leading to missed opportunities for inpatient residents to be aware of and attend to patients' post-discharge course although new information and readmissions related to the index hospitalization are prevalent. Thus, redesigning residency programs to widen residents' outlook and cover these inseparable components of high-quality care, may infuse the often fatigued and burnt-out residents with purpose and fulfillment, finally incorporating the missing elements of patient-centered care as integral parts of patients' admissions and therefore, of physicians' future careers.

Simple or complex? A case study of physical and mental health co-morbidity

People with epilepsy are significantly more likely to have a mental health disorder than those without a chronic illness. The reasons for this are multiple but may include the mental health difficulties being perceived as complex due to the presence of a chronic illness. In part due to the apparent complexity of the co-occurring physical and mental illness, many are not offered evidence-based treatment (EBT) for the mental health disorder. There is little guidance to inform clinicians about the interventions to use to treat mental health disorders in people with epilepsy. The present paper reports a case of treatment for depression using a standard EBT in a young person with epilepsy. The patient also had clinically significant symptoms of anxiety and an eating disorder and would be considered ‘complex’ according to standard criteria. The intervention, however, was relatively simple and was delivered as guided self-help via 10 weekly telephone calls of approximately 30 minutes duration, and two follow-up calls at one month and three months post-intervention. Self-report and parent-report questionnaire measures were completed before and after the intervention, and at both follow-up time points. A blind-rated online diagnostic interview measure was also completed before and after the intervention. The young person and her family also completed a qualitative interview of their experiences of the intervention. This simple intervention was effective in working towards the client's goals, although pre–post measurement on standard measures was variable. This interesting case raises questions about whether patients with mental and physical comorbidities are complex, or just perceived as complex.

Role of infarct location and pre-existing depression on cardiac baroreceptor sensitivity in subacute ischemic stroke

Reduced cardiac baroreceptor sensitivity (BRS) after acute stroke is associated with worse outcome. The underlying mechanisms of reduced BRS are unclear. We evaluated cross correlation BRS (xBRS) in 184 patients with suspected acute ischemic stroke within 72 h of symptom onset. Among these patients, 22 had a transient ischemic attack (TIA) and 27 had a stroke mimic. Sixty-four age- and sex-matched ambulant control subjects without stroke were included. Compared with controls, xBRS was significantly lower in patients with ischemic stroke, TIA, and stroke mimics (4.6, 4.7, and 4.4, respectively, vs 6.6, p < 0.01). There was no difference in xBRS between right and left hemispheric infarctions (4.3 vs 4.9, p = 0.144), right and left insular infarctions (4.5 vs 5.3, p = 0.286), and insular infarction vs non-insular infarctions (4.7 vs 4.5, p = 0.996). Stroke patients with pre-existing depression/use of antidepressant medication had lower xBRS values than stroke patients with normal mental health (2.9 vs 4.8, p < 0.05). Control patients with depression also had lower xBRS compared to controls without depression (3.4 vs 5.9, p < 0.01). Our results suggest that decreased xBRS in the subacute phase after stroke is not associated with infarct localization. We found preliminary evidence for an association between pre-existing depression and use of antidepressant medication, and decreased BRS.

Reduction in depressive symptoms in primary prevention ICD scheduled patients - One year prospective study

OBJECTIVE

Implantable Cardioverter Defibrillators (ICDs), have previously been associated with the onset of depression and anxiety. The aim of this one-year prospective study was to evaluate the rate of new onset psychopathological symptoms after elective ICD implantation.

METHODS

A total of 158 consecutive outpatients who were scheduled for an elective ICD implantation were diagnosed and screened based on the Mini International Neuropsychiatric Interview (MINI). Depression and anxiety were evaluated using the Hamilton Rating Scales for Depression (HAM-D) and Anxiety (HAM-A). Patient's attitude toward the ICD device was evaluated using a Visual Analog Scale (VAS).

RESULTS

Patients' mean age was 64±12.4years; 134 (85%) were men, with the majority of patients performing the procedure for reasons of 'primary prevention'. According to the MINI diagnosis at baseline, three (2%) patients suffered from major depressive disorder and ten (6%) from dysthymia. Significant improvement in HAM-D mean scores was found between baseline, three months and one year after implantation (6.50±6.4; 4.10±5.3 and 2.7±4.6, respectively F(2100)=16.42; p<0.001). There was a significantly more positive attitude toward the device over time based on the VAS score [F(2122)=53.31, p<0.001].

CONCLUSIONS

ICD implantation significantly contributes to the reduction of depressive symptoms, while the overall mindset toward the ICD device was positive and improved during the one-year follow-up.

Is plasminogen activator inhibitor-1 a physiological bottleneck bridging major depressive disorder and cardiovascular disease?

Major depressive disorder (MDD) is estimated to affect one in twenty people worldwide. MDD is highly comorbid with cardiovascular disease (CVD), itself one of the single largest causes of mortality worldwide. A number of pathological changes observed in MDD are believed to contribute to the development of cardiovascular disease, although no single mechanism has been identified. There are also no biological markers capable of predicting the future risk of developing heart disease in depressed individuals. Plasminogen activator inhibitor-1 (PAI-1) is a prothrombotic plasma protein secreted by endothelial tissue and has long been implicated in CVD. An expanding body of literature has recently implicated it in the pathogenesis of major depressive disorder as well. In this study, we review candidate pathways implicating MDD in CVD and consider how PAI-1 might act as a mediator by which MDD induces CVD development: chiefly through sleep disruption, adiposity, brain-derived neurotrophic factor (BDNF) metabolism, systemic inflammation and hypothalamic-pituitary-adrenal (HPA)-axis dysregulation. As both MDD and CVD are more prevalent in women than in men, and incidence of either condition is dramatically increased during reproductive milestones, we also explore hormonal and sex-specific associations between MDD, PAI-1 and CVD. Of special interest is the role PAI-1 plays in perinatal depression and in cardiovascular complications of pregnancy. Finally, we propose a theoretical model whereby PAI-1 might serve as a useful biomarker for CVD risk in those with depression, and as a potential target for future treatments.

Depression screening and treatment recall in male and female coronary artery disease inpatients: Association with symptoms one year later

BACKGROUND

This study examined whether cardiac inpatients recall depression screening and how it is related to depressive symptoms and treatment one year later.

METHODS

2635 cardiac inpatients from 11 hospitals completed a survey and were mailed a follow-up survey one year later; both surveys included the BDI-II.

RESULTS

Of the 1809 (68.7%) retained participants, 513 (30.0%) recalled depression screening. Recall was not significantly related to depressive symptoms at either time point (P > 0.05). Participants who were recommended antidepressants had higher BDI-II scores than those who were not, both as inpatients (P < 0.01) and one year later (P < 0.05). There was no significant change in depressive symptoms over time in patients who received any type of therapy.

CONCLUSION

Less than one-third of cardiac inpatients recalled being screened for depression. Recall of screening was not significantly related to depressive symptoms, and use of treatment was related to greater symptoms.

DenHeart: Differences in physical and mental health across cardiac diagnoses at hospital discharge

OBJECTIVE

To describe: (i) differences in patient reported physical and mental health outcomes at hospital discharge between a) cardiac diagnostic groups and b) cardiac patients and a national representative reference population and to describe (ii) in-hospital predicting factors for patient reported outcomes.

METHODS

A national cross-sectional survey combined with national register data. From April 2013 to April 2014 all patients (n=34,564) discharged or transferred from one of five Danish Heart Centres were invited to participate. 16,712 patients (51%) responded; 67% male and mean age 64years. All diagnostic groups were represented similar to real life proportions. Patient reported outcome measures included: SF-12, Hospital Anxiety and Depression Scale, EQ-5D, Brief Illness Perception Questionnaire, HeartQoL and Edmonton Symptom Assessment Scale.

RESULTS

Statistically significant differences were found in all patient reported outcomes across diagnostic groups. Listed from worst to best outcomes were heart failure, heart valve disease, ischemic heart disease, infectious heart disease, arrhythmia, congenital heart disease and heart transplant. Also "observation for cardiac disease" scored poorly on some aspects such as anxiety and treatment control. Compared to the reference population, cardiac patients had lower physical and mental health scores. Predicting factors for worse outcomes across diagnoses were female sex, older age, being unmarried, planned admission, longer hospital stay, and higher co-morbidity score.

CONCLUSIONS

This large nationwide study finds significant differences in patient reported outcomes across cardiac diagnostic groups, however the differences were small and did not reach minimal important difference. The total population of cardiac patients had significant and clinically relevant poorer scores on mental and physical health than the reference population. Predicting factors for poor outcomes were identified. It is the first study comparing all diagnostic groups within cardiology and it provides important benchmarks between diagnostic groups and future comparisons. This knowledge may help clinicians make better decisions about post-hospital care and prevention.

Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy

Cardiovascular dysfunction is highly comorbid with mood disorders, such as anxiety and depression. However, the mechanisms linking cardiovascular dysfunction with the core behavioral features of mood disorder remain poorly understood. In this study, we used mice bearing a knock-in sarcomeric mutation, which is exhibited in human hypertrophic cardiomyopathy (HCM), to investigate the influence of HCM over the development of anxiety and depression. We employed behavioral, MRI, and biochemical techniques in young (3-4 mo) and aged adult (7-8 mo) female mice to examine the effects of HCM on the development of anxiety- and depression-like behaviors. We focused on females because in both humans and rodents, they experience a 2-fold increase in mood disorder prevalence vs. males. Our results showed that young and aged HCM mice displayed echocardiographic characteristics of the heart disease condition, yet only aged HCM females displayed anxiety- and depression-like behaviors. Electrocardiographic parameters of sympathetic nervous system activation were increased in aged HCM females vs. controls and correlated with mood disorder-related symptoms. In addition, when compared with controls, aged HCM females exhibited adrenal gland hypertrophy, reduced volume in mood-related brain regions, and reduced hippocampal signaling proteins, such as brain-derived neurotrophic factor and its downstream targets vs. controls. In conclusion, prolonged systemic HCM stress can lead to development of mood disorders, possibly through inducing structural and functional brain changes, and thus, mood disorders in patients with heart disease should not be considered solely a psychologic or situational condition.-Dossat, A. M., Sanchez-Gonzalez, M. A., Koutnik, A. P., Leitner, S., Ruiz, E. L., Griffin, B., Rosenberg, J. T., Grant, S. C., Fincham, F. D., Pinto, J. R. Kabbaj, M. Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy.

Music therapy-induced changes in salivary cortisol level are predictive of cardiovascular mortality in patients under maintenance hemodialysis

Background

Music therapy has been applied in hemodialysis (HD) patients for relieving mental stress. Whether the stress-relieving effect by music therapy is predictive of clinical outcome in HD patients is still unclear.

Methods

We recruited a convenience sample of 99 patients on maintenance HD and randomly assigned them to the experimental (n=49) or control (n=50) group. The experimental group received relaxing music therapy for 1 week, whereas the control group received no music therapy. In the experimental group, we compared cardiovascular mortality in the patients with and without cortisol changes.

Results

The salivary cortisol level was lowered after 1 week of music therapy in the experimental group (−2.41±3.08 vs 1.66±2.11 pg/mL, P<0.05), as well as the frequency of the adverse reaction score (−3.35±5.76 vs −0.81±4.59, P<0.05), the severity of adverse reactions score (−1.93±2.73 vs 0.33±2.71, P<0.05), and hemodialysis stressor scale (HSS) score (−6.00±4.68 vs −0.877±7.08, P<0.05). The difference in salivary cortisol correlated positively with HD stress score scales (r=0.231, P<0.05), systolic blood pressure (r=0.264, P<0.05), and respiratory rates (r=0.369, P<0.05) and negatively with finger temperature (r=−0.235, P<0.05) in the total study population. The 5-year cardiovascular survival in the experimental group was higher in patients whose salivary cortisol lowered by <0.6 pg/mL than that in patients whose salivary cortisol lowered by >0.6 pg/mL (83.8% vs 63.6%, P<0.05).

Conclusion

Providing music during HD is an effective complementary therapy to relieve the frequency and severity of adverse reactions, as well as to lower salivary cortisol levels. Differences in salivary cortisol after music therapy may predict cardiovascular mortality in patients under maintenance HD.

Depressive symptoms, functional measures and long-term outcomes of high-risk ST-elevated myocardial infarction patients treated by primary angioplasty

The presence of major depressive symptoms is usually considered a negative long-term prognostic factor after an acute myocardial infarction (AMI); however, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention. The aims of this study are to evaluate if depression still retains long-term prognostic significance in our era of immediate coronary reperfusion, and to study possible correlations with clinical parameters of physical performance. In 184 patients with recent ST-elevated AMI (STEMI), treated by immediate reperfusion, moderate or severe depressive symptoms (evaluated by Beck Depression Inventory version I) were present in 10 % of cases. Physical performance was evaluated by two 6-min walk tests and by a symptom-limited cardiopulmonary exercise test: somatic/affective (but not cognitive/affective) symptoms of depression and perceived quality of life (evaluated by the EuroQoL questionnaire) are worse in patients with lower levels of physical performance. Follow-up was performed after a median of 29 months by means of telephone interviews; 32 major adverse cardiovascular events (MACE) occurred. The presence of three vessels disease and low left ventricle ejection fraction are correlated with a greater incidence of MACE; only somatic/affective (but not cognitive/affective) symptoms of depression correlate with long-term outcomes. In patients with recent STEMI treated by immediate reperfusion, somatic/affective but not cognitive/affective symptoms of depression show prognostic value on long-term MACE. Depression symptoms are not predictors "per se" of adverse prognosis, but seem to express an underlying worse cardiac efficiency, clinically reflected by poorer physical performance.

Inflammation-Associated Co-morbidity Between Depression and Cardiovascular Disease

Morbidity and mortality of cardiovascular disease (CVD) is exceedingly high worldwide. Depressive illness is a serious psychiatric illness that afflicts a significant portion of the world population. Epidemiological studies have confirmed the high co-morbidity between these two disease entities. The co-morbidity is bidirectional and the mechanisms responsible for it are complex and multifaceted. In addition to genetic, biological systems, psychosocial, and behavioral factors that are involved include the central and autonomic nervous systems, the neuroendocrine, immune, and the vascular and hematologic systems. Specific pathophysiologic factors across these systems include homeostatic imbalance between the sympathetic and the parasympathetic systems with loss of heart rate variability (HRV) in depression, sympathoadrenal activation, hypothalamic-pituitary-adrenal (HPA) axis activation, immune system dysregulation resulting in a pro-inflammatory status, platelet activation, and endothelial dysfunction. These abnormalities have been demonstrated in most individuals diagnosed with major depressive disorder (MDD), bipolar disorder (BPD), and probably in other psychiatric disorders. A likely common instigator underlying the co-morbidity between cardiovascular pathology and depression is mental stress. Chronic stress shifts the homeostatic balance in the autonomic nervous system with sustained sympathetic overdrive and diminished vagal tone. Diminished vagal tone contributes to a pro-inflammatory status with associated sequelae. Stress hormones and certain pro-inflammatory substances released by macrophages and microglia upregulate the rate-limiting enzymes in the metabolic pathway of tryptophan (TRP). This enzymatic upregulation stimulates the kynurenine (KYN) pathway resulting in the formation of neurotoxic metabolites. Inflammation occurs in cardiac, cardiovascular, and cerebrovascular pathology independent of the presence or absence of depression. Inflammation is closely associated with endothelial dysfunction, a preamble to atherosclerosis and atherothrombosis. Endothelial dysfunction has been detected in depression and may prove to be a trait marker for this illness. Thus understanding vascular biology in conjunction with psychiatric co-morbidity will be of critical importance. Antidepressant drug therapy is of definite benefit to patients with medical and psychiatric co-morbidity and may reverse the pro-inflammatory status associated with depression. There is, however, an urgent need to develop novel pharmacotherapeutic approaches to benefit a much larger proportion of patients suffering from these disease entities.

Healthy Living Medicine in the Workplace: More Work to Do

Non-communicable diseases (NCDs) are five of the top ten causes of death for Americans: cardiovascular disease (CVD), cancer, lower respiratory disease, stroke and diabetes mellitus. Risk factors for these NCDs and for CVD are tobacco use, poor diet quality, physical inactivity, increase body mass index, increased blood pressure, increased blood cholesterol, and glucose intolerance. Depression, depressive symptoms and anxiety also contribute to CVD risk. There is also evidence work stress itself contributes to CVD risk. By 2024 there is expected to be approximately 164 million workers in the US labor force and the share of older workers will likewise increase. Currently, about 25 million of those are over the age of 55, the age at which many diseases of lifestyle become clinically apparent. Furthermore, Americans spend as much as half of their waking hours at work. This makes the worksite an important target for the delivery of healthy living medicine.

Depressive symptoms and early mortality following lung transplantation: A pilot study

BACKGROUND

Impaired psychological function is common among lung transplant candidates and may affect clinical outcomes following transplantation. Although numerous studies have examined the relationship between pretransplant depression, quality of life (QoL), and post-transplant outcomes, few have examined the relationship between depression and QoL shortly following transplantation and subsequent clinical outcomes. We therefore examined the association between depression, QoL, and short-term mortality in a consecutive series of lung transplant recipients.

METHODS

Depression (Patient Health Questionnaire-9; Hospital Anxiety and Depression Scale; Centers for Epidemiologic Studies Depression Scale) and QoL (UCSD Shortness of Breath Questionnaire; Pulmonary Quality of Life Scale) were assessed prior to transplantation (median 0.9 months [IQR=1.6]) and again approximately 2 weeks following transplantation (median=0.5 months [IQR=0.5]), in a series of 66 patients transplanted between March 2013 and April 2014. The association between psychiatric diagnoses from participants' comprehensive pretransplant assessment and mortality also was examined. Cox proportional hazards models were used to examine the association between depression, QoL, and mortality.

RESULTS

During a median follow-up of 2.8 years (range 0.4-3.3), 21 patients died (32%). Greater depressive symptoms assessed shortly after transplant were associated with subsequent mortality (HR=2.17 [1.01, 4.67], P=.048), and this relationship persisted after controlling for primary graft dysfunction, duration of transplant hospitalization, and gender. In contrast, neither pretransplant depression, history of depression, nor QoL was associated with mortality.

CONCLUSIONS

Greater post-transplant depressive symptoms are independently associated with mortality among lung transplant recipients.

Cardiovascular Disease and Health Care System Impact on Functionality and Productivity in Argentina: A Secondary Analysis

OBJECTIVES

To examine the impact of cardiovascular disease (CVD) events on patient functionality and productivity on the basis of patient use of public or social/private institution health care.

METHODS

A secondary analysis was conducted of data drawn from records of Argentinian patients, 3 to 15 months posthospitalization after a CVD event, who had originally participated in a multicountry, cross-sectional study assessing the microeconomic impact of a CVD event. Respondents were stratified according to their use of health care institution (public or social/private). Among these groups, pre- and post-CVD event changes in functionality and productivity were compared.

RESULTS

Participants' (N = 431) mean age was 56.5 years, and 73.5% were men. Public sector patients reported significantly higher rates of decline in ability to perform moderate activities (P < 0.05), a greater decrease in time spent at work (P < 0.01), a greater limit in the type of work-related activities (P < 0.01), and a higher rate of emotional problems (P < 0.01). Having health insurance (private or social) (odds ratio [OR] = 0.55; 95% confidence interval [CI] 0.35-0.85; P < 0.01) and a higher income (OR = 0.99; 95% CI 0.99-0.99; P < 0.01) were inversely and significantly associated with loss of productivity. Cerebrovascular disease (OR = 2.55; 95% CI 1.42-4.60; P < 0.01) was also significantly associated with productivity loss.

CONCLUSIONS

In Argentina, patients receiving care in the public sector experienced a greater impact on functionality and productivity after their hospitalization for a CVD event. Lack of insurance, low income, and cerebrovascular disease event were the major determinants of productivity loss. Further investigation is needed to better understand contributors to these differences.

Selective Serotonin Reuptake Inhibitors and Operative Bleeding Risk: A Review of the Literature

OBJECTIVE

This study aimed to review the data on the effect of selective serotonin reuptake inhibitors (SSRIs) on bleeding during or after operative procedures and to offer guidelines for clinical management.

DATA SOURCES

Search of PubMed and MEDLINE for all articles in English from 1990-2016 with key words depression, antidepressants, bleeding, platelets, and operation.

STUDY SELECTION

Studies were included if they reported information on bleeding complications during operative or childbirth procedures in patients taking antidepressants.

DATA EXTRACTION

Because of the limited number and heterogeneity of studies with respect to the range of operative procedures and definition of bleeding complications, a qualitative approach was taken to summarize results rather than abstracting and aggregating data.

RESULTS

The weight of the evidence is that SSRI use increases the risk of bleeding complications during and immediately after surgery. However, given the limited data, we cannot estimate the risk for a given patient having a given procedure.

CONCLUSIONS

Clinicians must consider the risk-to-benefit ratio of discontinuing an SSRI before an elective operative procedure. Discontinuing SSRI medications may result in discontinuation syndrome, symptom recrudescence, or relapse of depression, whereas continuing an SSRI during surgery exposes patients to significant bleeding risks. Antidepressant prescribers must be cognizant of and take responsibility for discussing this potential problem and considering different options. This issue must also be the responsibility of the doctor performing the procedure, but, frequently, it will be the prescribing physician who alerts the surgeon to the potential bleeding risk associated with SSRIs.

Urdu translation of the Hamilton Rating Scale for Depression: Results of a validation study

OBJECTIVE

To develop a standardized validated version of the Hamilton Rating Scale for Depression (HAM-D) in Urdu.

METHODS

After translation of the HAM-D into the Urdu language following standard guidelines, the final Urdu version (HAM-D-U) was administered to 160 depressed outpatients. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation between HAM-D-U scores at baseline and after a 2-week interval was evaluated for test-retest reliability. Moreover, scores of two clinicians on HAM-D-U were compared for inter-rater reliability. For establishing concurrent validity, scores of HAM-D-U and BDI-U were compared by using Spearman correlation coefficient. The study was conducted at Mayo Hospital, Lahore, from May to December 2014.

RESULTS

The Cronbach alpha for HAM-D-U was 0.71. Composite scores for HAM-D-U at baseline and after a 2-week interval were also highly correlated with each other (Spearman correlation coefficient 0.83, p-value < 0.01) indicating good test-retest reliability. Composite scores for HAM-D-U and BDI-U were positively correlated with each other (Spearman correlation coefficient 0.85, p < 0.01) indicating good concurrent validity. Scores of two clinicians for HAM-D-U were also positively correlated (Spearman correlation coefficient 0.82, p-value < 0.01) indicated good inter-rater reliability.

CONCLUSION

The HAM-D-U is a valid and reliable instrument for the assessment of Depression. It shows good inter-rater and test-retest reliability. The HAM-D-U can be a tool either for clinical management or research.

Depression in heart failure: Intricate relationship, pathophysiology and most updated evidence of interventions from recent clinical studies

Heart failure (HF) is a burgeoning chronic health condition affecting more than 20million people worldwide. Patients with HF have a significant (17.1%) 30-day readmission rate, which invites substantial penalty in payment to hospitals from Centers for Medicare and Medicaid Services, as per the newly introduced Hospital Readmissions Reduction Program. Depression is one of the important risk factors for readmission in HF patients. It has a significant prevalence in patients with HF and contributes to the overall poor quality of life in them. Several behavioral (smoking, obesity, lack of exercise and medication noncompliance) and pathophysiological factors (hypercortisolism, elevated inflammatory biomarkers, fibrinogen, and atherosclerosis) have been found responsible for the adverse outcome in patients with HF and concomitant depression. Hippocampal volume loss noted in patients with acute HF exacerbations may contribute to the development of depressive symptoms in them. Screening for depression in HF patients continues to be challenging due to a considerable overlap in symptoms. Published trials on the use of antidepressants and cognitive behavioral therapy (CBT) have shown variable outcomes. Newer modalities like internet-based CBT have been tried in small studies, with promising results. A recent meta-analysis observed the beneficial role of aerobic exercise training in patients with HFrEF. Future long-term prospective studies may contribute to the formulation of a detailed screening and management guideline for patients with HF and depression. Our review is aimed to summarize the intricate relationship between depression and heart failure, with respect to their epidemiology, pathophysiological aspects, and optimal management approach.

Clinical predictors of depression treatment outcomes in patients with coronary heart disease

OBJECTIVES

Patients with coronary heart disease (CHD) who respond to treatment for depression are at lower risk of mortality than are nonresponders. This study sought to determine whether variables that have been shown to predict both depression treatment outcomes in psychiatric patients and cardiac events in patients with CHD, also predict poor response to depression treatment in patients with CHD.

METHODS

One hundred fifty-seven patients with stable CHD who met the DSM-IV criteria for a major depressive episode were treated with cognitive behavior therapy (CBT) for 16weeks, either alone or in combination with an antidepressant.

RESULTS

The mean Beck Depression Inventory (BDI-II) score was 30.2±8.5 at baseline and 8.5±7.8 at 16weeks. Over 50% of the participants were in remission (HAM-D-17 score ≤7) at the end of treatment. Of the hypothesized predictors, severe depression at baseline (p=0.02), stressful life events during the first (p=0.03) and last (p<0.0001) 8weeks of treatment, and the completion of CBT homework assignments (p=0.001) predicted depression outcomes. History of prior episodes, anxiety symptoms, antidepressant therapy at study enrollment, and medical hospitalizations or emergency department visits during treatment did not predict treatment outcome.

CONCLUSIONS

Patients who are under considerable stress do not respond as well to evidence-based treatments for depression as do patients with less stress. If future studies support these findings, more work will be needed to better address stressful life events in patients who may otherwise remain at high risk for mortality and medical morbidity following depression treatment.

The association between type D personality, and depression and anxiety ten years after PCI

OBJECTIVE

There are indications that type D personality and depression are associated in patients treated with percutaneous coronary intervention (PCI). However, at present it is unclear whether this relationship holds in the long term. This study's aim was to investigate the association between type D personality at 6 months post-PCI (baseline), and depression at 10-year follow-up. A secondary aim was to test the association between type D personality at baseline and anxiety at 10-year follow-up.

METHODS

A cohort of surviving consecutive patients (N = 534) who underwent PCI between October 2001 and October 2002. Patients completed the type D personality scale (DS14) measuring type D personality at baseline, and the Hospital Anxiety and Depression Scale (HADS) measuring anxiety and depression at baseline and at 10 years post-PCI.

RESULTS

At baseline, the prevalence of type D personality was 25 % (135/534). Type D personality patients were more often depressed (42 %) than non-type D personality patients (9 %). Response rate of anxiety and depression questionnaires at 10 years was 75 %. At 10-year follow-up, 31 % of type D personality patients were depressed versus 13 % of non-type D personality patients. After adjustments, baseline type D personality remained independently associated with depression at 10 years (OR = 3.69; 95 % CI [1.89-7.19]). Type D showed a similar association with anxiety at 10 years, albeit somewhat lower (OR = 2.72; 95 % CI [1.31-5.63]).

CONCLUSIONS

PCI patients with type D personality had a 3.69-fold increased risk for depression and a 2.72-fold increased risk for anxiety at 10 years of follow-up.