Sex and gender-stratified risks of psychological factors for adverse clinical outcomes in patients with ischemic heart disease: A systematic review and meta-analysis

Lifestyle factors as determinants of atherosclerotic cardiovascular health

A sedentary lifestyle, low levels of physical activity and fitness, poor dietary patterns, and psychosocial stress are strongly associated with increased morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Conversely, engaging in regular physical activity, maintaining optimal fitness levels, adhering to a heart-healthy dietary pattern, effectively managing body weight, ensuring adequate sleep, implementing stress-reduction strategies, and addressing psychosocial risk factors are associated with a reduced risk of ASCVD. This comprehensive review synthesizes current evidence from large observational studies and randomized controlled trials on lifestyle factors as determinants of ASCVD health. It also briefly reviews mechanistic insights into how factors such as low shear stress, increased reactive oxygen species production, chronic inflammation, platelets and coagulation activation, endothelial dysfunction, and sympathetic hyperactivity contribute to the initiation and exacerbation of ASCVD risk factors. These include obesity, hyperglycemia, type 2 diabetes, hypertension, and dyslipidemia, subsequently leading to the development and progression of atherosclerosis, ultimately resulting in chronic ASCVD or acute cardiovascular events. To bridge the translational gap between epidemiologic and trial-based evidence and clinical practice, practical recommendations are summarized to facilitate the translation of scientific knowledge into actionable interventions to promote ASCVD health. Acknowledged is the gap between the evidence-based knowledge and adoption within healthcare systems, which remains a crucial objective in advancing cardiovascular health at the population level.

Psychosocial distress and health status as risk factors for ten-year major adverse cardiac events and mortality in patients with non-obstructive coronary artery disease

BACKGROUND

We examined the risk of psychosocial distress, including Type D personality, depressive symptoms, anxiety, positive mood, hostility, and health status fatigue and disease specific and generic quality of life for MACE in patients with non-obstructive coronary artery disease (NOCAD).

METHODS

In the Tweesteden mild stenosis (TWIST) study, 546 patients with NOCAD were followed for 10 years to examine the occurrence of cardiac mortality, a major cardiac event, or non-cardiac mortality in the absence of a cardiac event. Cox proportional hazard models were used to examine the impact of psychosocial distress and health status on the occurrence of MACE while adjusting for age, sex, disease severity, and lifestyle covariates.

RESULTS

In total 19% of the patients (mean age baseline = 61, SD 9 years; 52% women) experienced MACE, with a lower risk for women compared to men. Positive mood (HR 0.97, 95%CI 0.95-1.00), fatigue (HR 1.03, 95%CI 1.00-1.06), and physical limitation (HR 0.99, 95%CI 0.98-1.00) were associated with MACE in adjusted models. No significant interactions between sex and psychosocial factors were present. Depressive symptoms were predictive of MACE, but no longer after adjustment.

CONCLUSIONS

In patients with NOCAD fatigue, low positive mood, and a lower physical limitation score were associated with MACE, without marked sex differences. Type D personality, psychosocial factors, and health status were not predictive of adverse outcomes. Reducing psychosocial distress is a valid intervention goal by itself, though it is less likely to affect MACE in patients with NOCAD.

Psychological interventions targeting mental health and stress among females with cardiac disease: a scoping review

Interventions that target mental health symptoms and stress among those with established cardiac disease have included predominately male samples despite female patients reporting greater severity of these symptoms. The aim of this scoping review was to synthesize the published literature on psychological interventions for females with cardiac disease. We conducted a systematic search of peer-reviewed randomized clinical trials (RCTs) published in the English language from 2003 to 2023, in three databases: Medline (Ovid), PsycInfo (Ovid), and CINAHL (EBSCO). Articles that included female samples, a control or comparison group, implemented psychological interventions, and measured depression, anxiety, or stress as an outcome were included in the review. Nine articles describing eight RCTs of psychological interventions, with a total of 1587 female patients with cardiac disease, were included. Interventions were most successful at reducing stress (75% of studies measuring stress reported efficacy), while symptoms of depression and anxiety were less responsive to intervention (∼30% of studies targeting these symptoms reported improvements) in comparison to a control condition. This scoping review highlights that further advancement in knowledge is required to better address the needs of females with cardiac disease and distress, particularly depression and anxiety.

The self-management experiences of individuals who perceive health as beyond their control: An interpretive phenomenological study of individuals with ischemic heart disease

This qualitative study aimed to gain an understanding of what it means to live with ischemic heart disease for individuals who perceive health as beyond their control and how these individuals navigate their choices regarding adhering or not adhering to self-management behavior. Participants were recruited through purposive sampling, and semi-structured interviews were conducted. Content analysis was employed to identify themes and subthemes in the interview data. The theme, "attribution of ischemic heart disease," revealed that the participants attributed their condition to lifestyle, critical events, and the natural aging process. The theme, "experiences of self-management," highlighted the different behaviors among participants who perceived health to be beyond their control. The theme, "barriers and facilitators," identified factors such as a strong sense of responsibility toward family members, the work environment, and access to medical resources. Our study showed that despite perceiving their health to be beyond their control, some individuals may still adhere to self-management practices. Understanding factors such as "attribution" and "barriers and facilitators" can provide nurses with insights into the patients' decisions to adhere or not adhere to self-management behaviors.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Global Trends in the Incidence of Anxiety Disorders From 1990 to 2019: Joinpoint and Age-Period-Cohort Analysis Study

BACKGROUND

Anxiety disorders (ADs) are the most common mental illness with high prevalence, chronicity, and comorbidity. Despite rapid economic and cultural development, the global incidence of ADs continues to increase, with predominance in male individuals.

OBJECTIVE

To address the above issues, we analyzed the dynamic trends of the global incidence and disease burden of ADs from 1990 to 2019 and their different effects on age, period, and birth cohort and predicted the future trend of AD incidence.

METHODS

The data were obtained from the Global Burden of Disease study in 2019. A joinpoint regression model was used to calculate the annual percent change in AD incidence, and age-period-cohort analysis was used to estimate the independent effects of age, period, and cohort. Nordpred age-period-cohort analysis was used to predict the incidence of ADs from 2020 to 2044.

RESULTS

The age-standardized incidence rate of ADs increased by 1.06% for both sexes, and the age-standardized disability-adjusted life-year (DALY) rate (ASDR) decreased by 0.12%. Joinpoint regression indicated that increments in average annual percent changes in the age-standardized incidence rate (0.068 vs 0.012) and ASDR (0.035 vs -0.015) for ADs globally were higher among male individuals than female individuals. The age-period-cohort analyses revealed that the relative risk (RR) of the incidence and DALYs of ADs among people of different sexes increased with age in adolescence and middle age and then decreased. For the period effect, the RR of incidence decreased, whereas the RR of DALYs increased in both sexes. Moreover, the RR of the incidence gradually increased and DALYs slowly decreased with birth year for both male and female individuals. New cases of ADs in male individuals are predicted to increase in the coming 25 years.

CONCLUSIONS

This study provided the changing trend of the global incidence and disease burden of ADs in the past 3 decades, indicating that early prevention and effective control cannot be ignored. We analyzed the age-period-cohort effect of potential trends in ADs and predicted future incidence trends. The results suggest that we should take active intervention measures, focusing on high-risk groups and developing effective management and control policies to reduce the global burden of disease.

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient-Informed Investigation

BACKGROUND

Clinical practice guidelines for the management and convalescence of patients with spontaneous coronary artery dissection (SCAD) have yet to be developed. The targeted content, delivery, and outcomes of interventions that benefit this population remain unclear. Patient-informed data are required to substantiate observational research and provide evidence to inform and standardize clinical activities.

METHODS AND RESULTS

Patients diagnosed with SCAD (N=89; 86.5% women; mean age, 53.2 years) were purposively selected from 5 large tertiary care hospitals. Patients completed sociodemographic and medical questionnaires and participated in an interview using a patient-piloted semistructured interview guide. Interviews were transcribed and subjected to framework analysis using inductive and then deductive coding techniques. Approximately 1500 standard transcribed pages of interview data were collected. Emotional distress was the most commonly cited precipitating factor (56%), with an emphasis on anxiety symptoms. The awareness and detection of SCAD as a cardiac event was low among patients (35%) and perceived to be moderate among health care providers (55%). Health care providers' communication of the prognosis and self-management of SCAD were perceived to be poor (79%). Postevent psychological disorders among patients were evident (30%), and 73% feared recurrence. Short- and longer-term follow-up that was tailored to patients' needs was desired (72%). Secondary prevention programming was recommended, but there were low completion rates of conventional cardiac rehabilitation (48%), and current programming was deemed inadequate.

CONCLUSIONS

This early-stage, pretrial research has important implications for the acute and long-term management of patients with SCAD. Additional work is required to validate the hypotheses generated from this patient-oriented research.

Depression and atrial fibrillation in a reciprocal liaison: a neuro-cardiac link

OBJECTIVE

To explore the reciprocal relationship of depression and atrial fibrillation (AF).

METHODS

A literature search was conducted in Pub Med, Scopus, and Google Scholar using relevant terms for depression and AF and respective therapies.

RESULTS

There is evidence that depression is involved in the aetiology and prognosis of AF. AF, independently of its type, incurs a risk of depression in 20-40% of patients. Also, depression significantly increases cumulative incidence of AF (from 1.92% to 4.44% at 10 years); 25% increased risk of new-onset AF is reported in patients with depression, reaching 32% in recurrent depression. Hence, emphasis is put on the importance of assessing depression in the evaluation of AF and vice versa. Persistent vs paroxysmal AF patients may suffer from more severe depression. Furthermore, depression can impact the effectiveness of AF treatments, including pharmacotherapy, anticoagulation, cardioversion and catheter ablation.

CONCLUSIONS

A reciprocal association of depression and AF, a neurocardiac link, has been suggested. Thus, strategies which can reduce depression may improve AF patients' course and treatment outcomes. Also, AF has a significant impact on risk of depression and quality of life. Hence, effective antiarrhythmic therapies may alleviate patients' depressive symptoms. KEY POINTSAF, independently of its type of paroxysmal, permanent or chronic, appears to have mental besides physical consequences, including depression and anxietyA reciprocal influence or bidirectional association of depression and AF, a neurocardiac link, has been suggestedAF has considerable impact on the risk of depression occurrence with 20-40% of patients with AF found to have high levels of depressionAlso, depression significantly increases 10-year cumulative incidence and risk of AF from 1.92% to 4.44% in people without depression, and the risk of new-onset AF by 25-32%Emphasis should be placed on the importance of assessing depression in the evaluation of AF and vice versaPersistent/chronic AF patients may suffer from more severe depressed mood than paroxysmal AF patients with similar symptom burdenDepression and anxiety can impact the effectiveness of certain AF treatments, including pharmacotherapy, anticoagulation treatment, cardioversion and catheter ablationThus, strategies which can reduce anxiety and depression may improve AF patients' course and treatment outcomesAlso, effective antiarrhythmic therapies to control AF may alleviate patients' depressive mood.

The Influence of Sex, Age, and Race on Coronary Artery Disease: A Narrative Review

Cardiovascular disease has remained one of the leading causes of mortality in the world. The basic pathophysiology of coronary artery disease (CAD) is a reduction of the blood flow in coronary vessels, leading to restricted blood flow to the heart muscle. Both modifiable and non-modifiable risk factors contribute to its multifactorial etiology. The clinical presentation ranges from asymptomatic to typical symptoms like chest pain, shortness of breath, and left arm or jaw pain. The purpose of this review is to investigate and analyze the variation of CAD depending on the biological sex, age, race, or ethnicity and how it might differ in the studied population while comparing the symptoms and prognosis of CAD. For this research, PubMed's database was used. A total of 926 articles were selected using pre-determined inclusion and exclusion criteria, with 74 articles eligible to be included in the narrative review. Studies were selected from the general population of patients with CAD, regardless of their severity, stage of diagnosis, and treatment plan. The scale for the assessment of non-systematic review articles (SANRA) was used to assess the quality of the study. As humans age, the incidence of CAD increases, and people over 75 are more likely to have multiple-vessel CAD. It has been observed that South Asians have the highest rate of CAD at 24%, while the White population has the lowest at 8%. The prevalence of CAD also depends on race, with the White population having the lowest rate at 3.2%, followed by Hispanics at 5%, Black women at 5.2%, and Black men at 5.7%. Younger Black women tend to have more chest pain. Men with CAD commonly experience chest pain, and women are more likely to present with atypical symptoms. Modifiable risk factors such as smoking and alcoholism are more commonly observed in young men than in young women. Coronary artery disease in the elderly, female, minority, and Black patients is associated with a higher mortality rate. Acknowledging the prevalence of certain risk factors, signs, results, and responses to treatment in certain socio-demographic groups, as well as the provision and accessibility of diagnosis and treatment, would lead to a better outcome for all individuals. The impact of this shift can range from an earlier diagnosis of CAD to a faster and more customized treatment plan tailored to each patient's individual requirements.

Childhood maltreatment and leukocyte telomere length in men and women with chronic illness: an evaluation of moderating and mediating influences

BACKGROUND

Childhood maltreatment can result in lifelong psychological and physical sequelae, including coronary artery disease (CAD). Mechanisms leading to increased risk of illness may involve emotional dysregulation and shortened leukocyte telomere length (LTL).

METHODS

To evaluate whether (1) childhood maltreatment is associated with shorter LTL among older adults with CAD or other chronic illnesses; (2) sex and/or CAD status influence these results; and (3) symptoms of anxiety, depression, and stress moderate or mediate the association between childhood maltreatment and LTL, men and women (N = 1247; aged 65 ± 7.2 years) with and without CAD completed validated questionnaires on childhood maltreatment, symptoms of depression, anxiety, and perceived stress. LTL was measured using quantitative polymerase chain reaction. Analyses included bivariate correlations, hierarchical regressions, and moderation/mediation analyses, controlling for sociodemographic and lifestyle variables.

RESULTS

Childhood maltreatment was associated with significantly shorter LTL (r = -0.059, p = 0.038, b = -0.016, p = 0.005). This relation was not moderated by depression, anxiety, nor perceived stress, though there was mitigated evidence for absence of a maltreatment-LTL relation in men with CAD. Stress perception (but not anxiety or depression) partially mediated the relation between childhood maltreatment and LTL [Indirect effect, b = -0.0041, s.e. = 0.002, 95% CI (-0.0085 to -0.0002)].

CONCLUSIONS

Childhood maltreatment was associated with accelerated biological aging independently of patient characteristics. Emotional dysregulation resulting in chronic stress may contribute to this process. Whether stress management or other interventions may help prevent or slow premature aging in those who have suffered maltreatment requires study.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Pharmacological approaches to the management of panic disorder in older patients: a systematic review

INTRODUCTION

Recommendations for treating panic disorder (PD) in older patients are scarce. The authors have systematically reviewed whether several recommended medications are superior to others and their optimal doses in this age group.

METHODS

A database search of studies involving patients with PD with/without agoraphobia aged ≥ 60 years was carried out using PubMed, PsycINFO, Embase, and Clinical Trials.gov, from their inception dates to 1 March 2023. Only four (published from 2002 to 2010) of the 1292 records screened were included. A risk of bias assessment was provided. This systematic review was performed using The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

RESULTS

Two studies were randomized clinical trials, whereas two were open-label, including paroxetine, citalopram, escitalopram, and sertraline; three studies reported short-term evaluations, whereas one study included a 26-week follow-up. Medications provided benefits, with good tolerability. Preliminary results suggested greater benefits of paroxetine in reducing panic attacks vs. cognitive - behavioral therapy, and an earlier decrease in PAs with escitalopram vs. citalopram. Risk of bias was considerable.

CONCLUSIONS

The pharmacological management of PD in older patients has received no attention. Findings are scant, dated, and affected by methodological flaws; thus, they do not provide significant advances.

Peripheral inflammation over the course of a cognitive behavioral intervention in PTSD

Inflammation has an important predictive role for long-term health. This is also true when looking at the specific population of trauma survivors with PTSD. There are emerging findings showing that PTSD is related to reduced somatic health as well as evidence linking inflammation with disease outcomes in this group, such as heart diseases and early mortality, regardless of age, gender or conventional risk factors. The effectiveness of cognitive behavioral therapy for PTSD symptom severity has been demonstrated by several previous studies. In contrast, literature is scarce, yet, whether inflammation improves over the course of treatment for PTSD. Therefore, the aim of this study was to investigate whether not only PTSD symptoms, but also inflammation changes over the course of psychological treatment. Twenty-nine PTSD patients were followed while attending an outpatient clinic receiving cognitive behavioral therapy. Inflammation, determined by the C-reactive protein (CRP) assessed via the dried blood spot (DBS) technique, and symptom severity, surveyed by the PTSD Checklist for DSM-5 (PCL) were measured at 5 points before trauma-focused therapy, as well as after four, eight and twelve weeks of intervention; furthermore, a 10-month follow-up assessment was conducted. Results revealed significant improvements of PTSD symptom severity during investigation, but no significant changes in the inflammatory biomarker (CRP). Results in terms of improvement in PTSD symptom severity are in line with prior findings. The results obtained for inflammation may suggest that risk factors for somatic health consequences in PTSD patients remain despite successful psychological treatment. Further longitudinal studies are needed to fully understand the relationship between inflammation and therapeutic outcome and to develop interventions normalizing inflammation in PTSD patients.

Short-term effects of extreme meteorological factors on daily outpatient visits for anxiety in Suzhou, Anhui Province, China: a time series study

Anxiety disorders are a major public health concern in China. Previous studies have provided evidence for associations between ambient temperature and anxiety outpatient visits, but no studies have examined short-term effects of other meteorological factors such as sunshine duration, wind speed, and precipitation on increased anxiety outpatient visits. We aimed to assess the association between climatic factors and outpatient visits for anxiety in Suzhou, a city with a temperate climate in Anhui Province, China. Daily anxiety outpatient visits, meteorological factors, and air pollutants from 2017 to 2019 were collected. A quasi-Poisson generalized linear regression model combined with distributed lag non-linear model (DLNM) was used to quantify the effects of extreme meteorological factors (sunshine duration, wind speed, and precipitation) on anxiety outpatient visits. All effects were presented as relative risk (RR), with the 90th and 10th percentiles of meteorological factors compared to the median. Subgroup analyses by age and gender were performed to identify susceptible subgroups. A total of 11,323 anxiety outpatient visits were reported. Extremely low sunshine duration and low and high wind speed increased the risk of anxiety outpatient visits. The strongest cumulative effects occurred at lag 0-14 days, and the corresponding RRs of extremely low sunshine duration and low and high wind speed were 1.417 (95% CI: 1.056-1.901), 1.529 (95% CI: 1.028-2.275), and 1.396 (95% CI: 1.007-1.935), respectively. Subgroup analyses showed that males and people aged ≥45 years appeared to be more susceptible to the cumulative effects of extremely low sunshine duration. In addition, the adverse effects of extreme wind speed were more pronounced in the cold season. This study provides evidence that extreme climatic factors have a lagged effect on anxiety outpatient visits. In the context of climate change, these findings may help develop weather-based early warning systems to minimize the effects of extreme meteorological factors on anxiety.

Relationships between depression, anxiety, type D personality, and worry and rumination in patients with coronary heart disease

Psychological distress, including depression and anxiety, and Type-D personality are prevalent in patients with coronary heart disease (CHD) and associated with poor cardiovascular outcomes. Worry and rumination may be among the core features responsible for driving psychological distress in these patients. However, the nature of associations between these constructs remains to be delineated, yet they may have implications for the assessment and treatment of CHD patients. This study aimed to (1) explore the factorial structure and potential overlap between measures of depression, anxiety and the Type-D personality factors known as negative affectivity and social inhibition, and (2) examine how these constructs relate to worry and rumination in a sample of 1,042 CHD outpatients who participated in the in the cross-sectional NORwegian CORonary Prevention study. We conducted confirmatory factor analyses (n = 1,042) and regression analyses (n = 904) within a structural equation modeling framework. Results showed all constructs to have acceptable factor structure and indicated an overlap between the constructs of depression and negative affectivity. Worry was most strongly associated with anxiety, whereas rumination was most strongly associated with depression and negative affectivity. The results suggest conceptual similarities across the measures of depression and negative affectivity. They further suggest that intervention efforts could benefit from targeting worry and/or rumination in the treatment of CHD outpatients presenting with symptoms of psychological distress.

Age-Period-Cohort Analysis of Ischemic Heart Disease Morbidity and Mortality in China, 1990-2019

BACKGROUND

The disease burden of ischemic heart disease (IHD) continues to increase. This study aimed to assess the age, period, and cohort effects on the long-term trends of IHD incidence and mortality in China from 1990 to 2019.

METHODS AND RESULTS

The data were obtained from the Global Burden of Disease Study (GBD) 2019, and the age-standardized incidence/mortality rate (ASIR/ASMR) was calculated. The age-period-cohort (APC) model, which is a generalized linear model revealing the correlation of disease rate and attained age, period, and cohort, was applied to estimate the net drift (estimated annual percentage change [EAPC]s), the local drifts (age-specific EAPCs), the age, period, and cohort effects. The analyses elucidated that the ASIR and ASMR of IHD declined after 2013. The net drift of incidence was 0.212% in females, and the net drift of mortality was 0.371% in males. The local drifts of mortality were above 0 in males aged 20-84 years and in females aged 65-84 years. The age effects showed elevated trends during the study period. The period effects declined after 2013. The cohort effects of mortality in males were higher than that in females.

CONCLUSIONS

The decrease of ASIR and ASMR indicated that measures to prevent IHD have been effective in China. However, the cardiovascular health of the elderly and males should be considered in future policy decisions.

Severity of psychological distress over five years differs as a function of sex and presence of coronary artery disease

BACKGROUND

Psychological distress is more prevalent and severe among patients with coronary artery disease (CAD) compared to healthy individuals. Little is known regarding its time course, and whether these differences extend to individuals with non-cardiovascular (CV) illnesses. This study examined the presence, severity, and time course of psychological distress in men and women with CAD and those of similarly aged individuals suffering from non-CV conditions.

METHODS

1229 individuals (61% men; mean_age = 60.4 ± 7.0 years) with stable CAD or non-CV illnesses reported on social support, hostility, stress, anxiety and depression at baseline as well as 4.8 ± 0.8 years later. Analyses involved mixed (Sex*CAD status*Time) repeated measures analyses (controlling for relevant covariates), as well as Chi-square and McNemar analyses.

RESULTS

Women with CAD reported more symptoms of depression compared to other participants at both evaluations (p's < 0.01), and reported more symptoms of anxiety and stress compared to others at T1 (p's < 0.05). At T2, perceived stress remained significantly greater among women with CAD compared to men (p's < 0.01), though differences in anxiety were no longer significant. Men reported more hostility than women (p = 0.001). CAD women fell within the clinical range for depression (p < 0.001), anxiety (p = 0.001), and stress (p = 0.030) more frequently compared to others at T1, and for depression (p = 0.009) and stress (p = 0.002) at T2.

CONCLUSIONS

The evolution of patient distress differed as a function of the measure examined, their sex, and/or CV status. While psychological distress was prevalent among these patients with diverse health conditions, women with CAD were particularly and chronically vulnerable.

Adiposity and Smoking Mediate the Relationship Between Depression History and Inflammation Among Young Adults

BACKGROUND

Depression is associated with inflammation, but the mechanisms underlying this association are unclear. We examined adiposity and smoking as potential pathways through which childhood depression may lead to an elevated inflammatory status among young adults.

METHODS

The sample included 294 subjects with histories of depression (probands), 270 never-depressed siblings of probands (high-risk siblings), and 169 controls. C-reactive protein (CRP), interleukin-6 (IL-6), and soluble intercellular adhesion molecule-1 (sICAM-1) were assessed in serum samples. An adiposity score was computed from body mass index and waist circumference. Smoking behavior was evaluated during an interview. Mixed-effects models were used to test whether adiposity and smoking mediate the relationship between depression and inflammation.

RESULTS

Probands (p = .004), but not siblings (p = .071), had higher levels of sICAM-1 compared to controls. However, depression history and risk status had no direct effects on CRP (ps > .13) or IL-6 (ps > .16). Importantly, adiposity indirectly mediated the effect of group (probands vs. controls; siblings vs. controls) on all three inflammatory markers. Smoking indirectly mediated the effect of group (probands vs. controls; siblings vs. controls) on sICAM-1 only.

CONCLUSIONS

Among young adults, the adverse inflammatory consequences of depression history are significant for sICAM-1. Adiposity and smoking are pathways through which depression can indirectly impact several inflammatory markers, suggesting possible preventive interventions to improve the immunologic and cardiovascular health of depression-prone individuals.

Association of major depressive disorder with chronic diseases and multimorbidity in Brazilian adults, stratified by gender: 2019 National Health Survey

OBJECTIVE

To analyze the association of major depressive disorder with chronic non-communicable diseases and multimorbidity in Brazilian adults, stratified by gender, as well as examine the interaction between gender and chronic non-communicable diseases in association with major depressive disorder.

METHODS

Based on a sample of 65,803 adults from the 2019 National Health Survey, we estimated the prevalence of major depressive disorder (≥10 points in the Patient Health Questionnaire) according to the presence of chronic non-communicable diseases and multimorbidity (≥2 chronic diseases). Prevalence ratios and their respective confidence intervals were calculated by Poisson regression, and multiplicative interaction terms were used to assess the role of gender in the associations.

RESULTS

The prevalence of major depressive disorder among Brazilian adults (18-59 years) was 10.9%, with a statistically significant difference between men (6.0%) and women (15.4%) (p<0.001). Individuals with any chronic non-communicable disease and multimorbidity showed a higher prevalence of major depressive disorder, both in the general population and in each gender. However, the association of major depressive disorder with chronic non-communicable diseases tended to be stronger among men. Data also showed an interaction between the male gender and multimorbidity or specific diseases, such as arthritis or rheumatism, heart disease, and chronic kidney disease, in association with major depressive disorder.

CONCLUSION

The results reveal a significant association between major depressive disorder and chronic non-communicable diseases in both genders and raise the hypothesis that the effects of multimorbidity and certain diseases may be greater on the mental health of men.

Cardiac medication use in patients with suspected ischaemia without obstructive coronary arteries: sex differences and psychological distress

BACKGROUND

Ischaemia without obstructive coronary arteries (INOCA) is more prevalent in women and associated with psychological distress. Pharmacological treatment goals are angina relief and cardiovascular risk management. The present study aims to examine sex differences in cardiac and non-cardiac medication use, as well as medication and sex differences related to consistent psychological distress in patients with suspected INOCA.

DESIGN

A TweeSteden mild stenosis observational cohort study in patients with suspected INOCA as detected by ischaemic reason for referral and non-obstructive arteries based on coronary angiography or computed tomography.

METHODS

Medication documented in the hospital records of 488 patients (53% women) was coded as angina relief medication, blood-pressure-lowering medication, antithrombotics, statins, and non-cardiac medication, using the Anatomical Therapeutic Chemical code. Depressive symptoms and anxiety were recoded as 'consistent distress' (above the cut-off score for depression and anxiety on validated questionnaires), 'inconsistent distress' (above the cut-off for depression or anxiety) or 'no distress' (below the cut-off).

RESULTS

No sex differences were observed in cardiac medication use. Women used anxiolytic benzodiazepines more often (12% vs 4%, p = 0.002) compared to men. Consistent distress was more prevalent in women (22% vs 15%, p = 0.004) and was related to the use of more angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and diuretics in women and to calcium antagonist use as well as lower adherence levels in men. Women who reported chest pain more often received angina relief medication and blood-pressure-lowering medication than men.

CONCLUSION

No sex differences were observed in cardiac medication use in patients with suspected INOCA. Psychological distress may reflect hypertension and subsequent medication use in women, and experiencing chest pain and subsequent medication use in men.

Gender-specificity of resilience in major depressive disorder

INTRODUCTION

The major stressors associated with the COVID-19 pandemic provide an opportunity to understand the extent to which protective factors against depression may exhibit gender-specificity.

METHOD

This study examined responses from multiple waves of a 50 states non-probability internet survey conducted between May 2020 and January 2021. Participants completed the PHQ-9 as a measure of depression, as well as items characterizing social supports. We used logistic regression models with population reweighting to examine association between absence of even mild depressive symptoms and sociodemographic features and social supports, with interaction terms and stratification used to investigate sex-specificity.

RESULTS

Among 73,917 survey respondents, 31,199 (42.2%) reported absence of mild or greater depression-11,011/23,682 males (46.5%) and 20,188/50,235 (40.2%) females. In a regression model, features associated with greater likelihood of depression-resistance included at least weekly attendance of religious services (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 1.04-1.16) and greater trust in others (OR: 1.04 for a 2-unit increase, 95% CI: 1.02-1.06), along with level of social support measured as number of social ties available who could provide care (OR: 1.05, 95% CI: 1.02-1.07), talk to them (OR: 1.10, 95% CI: 1.07-1.12), and help with employment (OR: 1.06, 95% CI: 1.04-1.08). The first two features showed significant interaction with gender (p < .0001), with markedly greater protective effects among women.

CONCLUSION

Aspects of social support are associated with diminished risk of major depressive symptoms, with greater effects of religious service attendance and trust in others observed among women than men.

Anxiety Disorders Are Associated With Coronary Endothelial Dysfunction in Women With Chest Pain and Nonobstructive Coronary Artery Disease

Background

Anxiety disorders are the most prevalent mental disorders and are an emerging risk factor for coronary artery disease and its complications. We determine the relationship between having a clinical diagnosis of an anxiety disorder and coronary endothelial dysfunction (CED) using invasive coronary reactivity testing across both sexes.

Methods and Results

Patients presenting with chest pain and nonobstructive coronary artery disease (stenosis <40%) at coronary angiography underwent an invasive assessment of CED. Patients were categorized as having a clinical diagnosis of an anxiety disorder at the time of coronary angiography by chart review. The frequency of CED was compared between patients with versus without an anxiety disorder and after stratifying patients by sex. Between 1992 and 2020, 1974 patients (mean age, 51.3 years; 66.2% women) underwent invasive coronary reactivity testing, of which 550 (27.9%) had a documented anxiety disorder at the time of angiography. There was a significantly higher proportion of patients with any type of CED in those with an anxiety disorder in all patients (343 [62.7%] versus 790 [56.4%]; P=0.011) that persisted in women but not in men. After adjusting for covariables, anxiety was significantly associated with any CED among all patients (odds ratio [95% CI], 1.36 [1.10–1.68]; P=0.004), and after stratifying by sex in women but not in men.

Conclusions

Anxiety disorders are significantly associated with CED in women presenting with chest pain and nonobstructive coronary artery disease. Thus, CED may represent a mechanism underpinning the association between anxiety disorders and coronary artery disease and its complications, highlighting the role of anxiety as a potential therapeutic target to prevent cardiovascular events.

Anxiety disorders

Anxiety disorders form the most common group of mental disorders and generally start before or in early adulthood. Core features include excessive fear and anxiety or avoidance of perceived threats that are persistent and impairing. Anxiety disorders involve dysfunction in brain circuits that respond to danger. Risk for anxiety disorders is influenced by genetic factors, environmental factors, and their epigenetic relations. Anxiety disorders are often comorbid with one another and with other mental disorders, especially depression, as well as with somatic disorders. Such comorbidity generally signifies more severe symptoms, greater clinical burden, and greater treatment difficulty. Reducing the large burden of disease from anxiety disorders in individuals and worldwide can be best achieved by timely, accurate disease detection and adequate treatment administration, scaling up of treatments when needed. Evidence-based psychotherapy (particularly cognitive behavioural therapy) and psychoactive medications (particularly serotonergic compounds) are both effective, facilitating patients' choices in therapeutic decisions. Although promising, no enduring preventive measures are available, and, along with frequent therapy resistance, clinical needs remain unaddressed. Ongoing research efforts tackle these problems, and future efforts should seek individualised, more effective approaches for treatment with precision medicine.

Impact of history of depression on 1-year outcomes in patients with chronic coronary syndromes: An analysis of a contemporary, prospective, nationwide registry

BACKGROUND

Depression is common in patients with acute cardiovascular conditions and it is associated with adverse clinical events.

METHODS

Using the data from a nationwide, prospective registry on patients with chronic coronary syndromes (CCS), we assessed the impact of depression on major adverse cardiovascular events (MACE), a composite of all-cause death and hospitalization for myocardial infarction, revascularization, heart failure or stroke, and quality of life (QoL) at 1-year follow-up.

RESULTS

From the 5070 consecutive CCS patients enrolled in the registry, 531 (10.5%) presented a history of depression and the remaining 4539 (89.5%) did not. At 1 year (median 369; IQR 362-378 days) from enrolment, the incidence of the primary composite outcome was 9.8% for patients with a history of depression and 7.2% for non-depressed patients (p = 0.03). Patients with history of depression had a significantly higher rate of all-cause mortality (3.0% vs 1.4%; p = 0.004) and hospital admission for heart failure (3.4% vs 1.3%; p = 0.0002) compared to the group without depression. However, history of depression did not result as an independent predictor of MACE at multivariable analysis [hazard ratio 1.17, 95% confidence interval (0.87-1.58), p = 0.31]. Depressed patients had worse QoL according to all domains of the EQ. 5D-5L questionnaire as compared to non-depressed patients (all p < 0.001), at both enrolment and follow-up.

CONCLUSIONS

In this contemporary, large cohort of consecutive patients with CCS, patients with a history of depression experienced a two-fold rate of mortality, a higher incidence of MACE and a worse QoL at 1-year follow-up, compared to non-depressed patients.