Post-myocardial infarction depression: increased hospital admissions and reduced adoption of secondary prevention measures--a longitudinal study

The association of depression and patient and resuscitation characteristics with survival after out-of-hospital cardiac arrest: a cohort study

AIMS

Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide, with cardiovascular disease (CVD) being a key risk factor. This study aims to investigate disparities in patient/OHCA characteristics and survival after OHCA among patients with vs. without depression.

METHODS AND RESULTS

This is a retrospective cohort study using data from the AmsteRdam REsuscitation Studies (ARREST) registry from 2008 to 2018. History of comorbidities, including depression, was obtained from the patient's general practitioner. Out-of-hospital cardiac arrest survival was defined as survival at 30 days post-OHCA or hospital discharge. Logistic regression models were used to obtain crude and adjusted odds ratios (ORs) for the association between depression and OHCA survival and possible effect modification by age, sex, and comorbidities. The potential mediating effects of initial heart rhythm and provision of bystander cardiopulmonary resuscitation were explored. Among 5594 OHCA cases, 582 individuals had pre-existing depression. Patients with depression had less favourable patient and OHCA characteristics and lower odds of survival after adjustment for age, sex, and comorbidities [OR 0.65, 95% confidence interval (CI) 0.51-0.82], with similar findings by sex and age groups. The association remained significant among the Utstein comparator group (OR 0.63, 95% CI 0.45-0.89) and patients with return of spontaneous circulation (OR 0.60, 95% CI 0.42-0.85). Initial rhythm and bystander cardiopulmonary resuscitation partially mediated the observed association (by 27 and 7%, respectively).

CONCLUSION

Out-of-hospital cardiac arrest patients with depression presented more frequently with unfavourable patient and OHCA characteristics and had reduced chances of survival. Further investigation into potential pathways is warranted.

Pathophysiological mechanisms of post-myocardial infarction depression: a narrative review

Myocardial infarction (MI) can have significant physical and mental consequences. Depression is a prevalent psychiatric condition after MI which can reduce the quality of life and increase the mortality rates of patients. However, the connection between MI and depression has remained under-appreciated. This review examines the potential connection between depression and MI by overviewing the possible pathophysiologic mechanisms including dysregulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, coagulation system dysfunction, inflammation, environmental factors, as well as, genetic factors. Furthermore, depression can be an adverse event of medications used for MI treatment including beta-blockers, statins, or anti-platelet agents. The need for early detection and management of depression in patients with MI is, therefore, crucial for improving their overall prognosis. Adherence to treatments and regular follow-up visits can ensure the best response to treatment.

Understanding the effect of angina on general and dimensions of psychological distress: findings from understanding society

Background

The current study aimed to examine how the general and dimensions of psychological distress are affected by angina.

Methods

First, a confirmatory factor analysis (CFA) was used to produce the three-factor solution of the GHQ-12. Second, a predictive normative modeling approach to predict the expected scores for 1,081 people with angina based on a model trained on demographics from 8,821 age and sex-matched people without angina. Finally, one-sample t-tests were used to determine the differences between the actual psychological distress scores and expected psychological distress scores in participants with angina.

Results

There were three underlying structures of the GHQ-12 labeled as GHQ-12A (social dysfunction & anhedonia), GHQ-12B (depression & anxiety), and GHQ-12C (loss of confidence). Moreover, participants with angina had more psychological distress as indicated by the GHQ-12 summary score (Cohen's d = 0.31), GHQ-12A (Cohen's d = 0.34), GHQ-12B (Cohen's d = 0.21), and GHQ-12C (Cohen's d = 0.20) comparing to controls.

Conclusion

The current study implies that GHQ-12 is a valid measure of psychological distress in people with angina, and there is a need to consider the dimensions of psychological distress in angina rather than solely focusing on certain dimensions of psychological distress such as depression or anxiety issues in people with angina. Clinicians should come up with interventions to reduce psychological distress in people with angina which can then lead to better outcomes.

Underestimated prognostic value of depression in patients with obstructive coronary artery disease

OBJECTIVE

The aim of this study was to explore the different predictive values of depression among patients with different cardiac systolic function levels.

METHODS

Four hundred eighty-three consecutive patients with obstructive coronary artery disease (CAD) were included the depressive state was assessed using the Chinese version of the Patient Health Questionnaire 9 (PHQ-9). Depression was defined as have depressive symptoms with a PHQ-9 score ≥5. The level of cardiac systolic function was classified as left ventricular ejection fraction (LVEF) ≥50 and <50%.

RESULTS

Over a median of 26.2 months, 421 patients completed the follow-up and experienced 101 major adverse cardiovascular events (MACEs), 45 non-cardiac rehospitalizations, and 17 deaths. Predictors for clinical outcomes in patients with different cardiac systolic function levels were not the same. For participants with preserved LVEF, depression was associated with increased risks for cardiovascular events and composite outcomes. However, when focusing the whole population, predictive values of depression for MACEs, non-cardiac rehospitalizations, and composite endpoints all dropped. Receiver operating characteristic (ROC) analyses further confirmed that depression was the one of the main predictors for all clinical outcomes. With the combination of other simple features, area under curve (AUC) could reach 0.64-0.67.

CONCLUSIONS

Inconsistent with the general impression, depression is found to have a closer linkage with clinical outcomes in CAD patients with preserved LVEF rather than in those with decreased LVEF. These findings appeal for more attention on CAD patients with depressive symptoms and comparatively normal LVEF. Including psychological factors may be a good attempt when constructing risk prediction models.

A network meta-analysis of 12,116 individuals from randomized controlled trials in the treatment of depression after acute coronary syndrome

BACKGROUND

Post-acute coronary syndrome (ACS) depression is a common but not well understood complication experienced by ACS patients. Research on the effectiveness of various therapies remains limited. Hence, we sought to conduct a network meta-analysis to assess the efficacy of different interventions for post-ACS depression in improving patient outcomes.

METHODS AND FINDINGS

Three electronic databases were searched for randomised controlled trials describing different depression treatment modalities in post-ACS patients. Each article was screened based on inclusion criteria and relevant data were extracted. A bivariate analysis and a network meta-analysis was performed using risk ratios (RR) and standardized mean differences (SMD) for binary and continuous outcomes, respectively. A total of 30 articles were included in our analysis. Compared to standard care, psychosocial therapy was associated with the greatest reduction in depression scores (SMD:-1.21, 95% CI: -1.81 to -0.61, p<0.001), followed by cognitive behavioural therapy (CBT) (SMD: -0.75, 95% CI: -0.99 to -0.52, p<0.001), antidepressants (SMD: -0.73, 95% CI: -1.14 to -0.31, p<0.001), and lastly, combination therapy (SMD: -0.15, 95% CI: -0.28 to -0.03, p = 0.016). No treatment modalities was found to be more effective in reducing depression scores when compared to one another. Additional analysis showed that these treatment modalities did not have significant impact on the overall mortality, cardiac mortality and recurrent myocardial infarction.

CONCLUSION

This network meta-analysis found that the treatment effect of the various psychological modalities on depression severity were similar. Future trials on psychological interventions assessing clinical outcomes and improvement in adherence to ACS-specific interventions are needed.

The development and pilot testing of a behavioral activation-based treatment for depressed mood and multiple health behavior change in patients with recent acute coronary syndrome

BACKGROUND

Patients with acute coronary syndrome (ACS) with depressed mood demonstrate poor cardiovascular behavioral risk profiles and elevated risk for recurrent ACS and mortality. Behavioral Activation (BA) offers an intervention framework for an integrated treatment targeting both depression and critical health behaviors post-ACS. Behavioral Activation for Health and Depression (BA-HD) was developed and pilot tested in a multiphase iterative process.

METHODS

First, an initial treatment manual was conceptualized based on the team's prior work, as well as the extant literature. Second, qualitative interviews were conducted with target patients and target providers on the proposed BA-HD treatment rationale, content, and structure. Framework matrix analyses were used to summarize and aggregate responses. Third, an expert panel was convened to elicit additional manual refinements. Finally, patients with post-ACS depression and health behavior non-adherence were recruited to complete an open pilot trial to evaluate acceptability (Client Satisfaction Questionnaire [CSQ], exit interview) and treatment engagement (number of sessions attended; treatment completion was considered completion of 8 out of 10 possible sessions).

RESULTS

The initial BA-HD treatment manual expanded an existing treatment manual for post-ACS BA-based mood management and smoking cessation to target four health behaviors relevant to post-ACS patients (e.g., smoking cessation, medication adherence, physical activity, and diet). After the initial conceptualization, ten post-ACS patients and eight cardiac rehabilitation professionals completed qualitative interviews. Patients endorsed bi-directional interactions between mood and health behaviors post-ACS. Both patients and providers expressed general support of the proposed treatment rationale and values-guided, collaborative goal-setting approach. Patients, providers, and experts provided feedback that shaped the iterative manual development. After the BA-HD manual was finalized, eight participants were enrolled in a single-arm pilot trial. The mean CSQ score was 30.57 ± 2.23, indicating high satisfaction. Seven out of eight (88%) completed treatment. Pre- to post treatment improvements in depressed mood and health behaviors were promising.

CONCLUSIONS

BA-HD treatment is an acceptable approach to target both mood and health behaviors in post-ACS patients with depression. A future larger, controlled trial is needed to evaluate the efficacy of the BA-HD treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04158219.

Prevalence Estimates, Severity, and Risk Factors of Depressive Symptoms among Coronary Artery Disease Patients after Ten Days of Percutaneous Coronary Intervention

BACKGROUND

Depression and cardiovascular disorders are significant determinants of health that affect the quality of life and life expectations. Despite the high importance of depression screening among Coronary Artery Disease (CAD) patients, the time being to assess and treat it remains controversial.

OBJECTIVES

This study aims to assess the prevalence estimates and severity of depressive symptoms and determine the risk factors associated with developing such symptoms among CAD patients after ten days of Percutaneous Coronary Intervention (PCI).

METHODS

All patients who underwent elective PCI between October 5, 2019, and Mid-March 2020 and diagnosed with CAD were included in this cross-sectional study. CAD was defined as intra-luminal stenosis of ≥ 50% in one or more of the coronary arteries. Depressive symptoms were screened after ten days of the PCI utilizing the patient health questionnaire-9 (PHQ-9) tool. A linear regression model was used to assess the adjusted effects of independent variables on PHQ-9 scores. Electronic medical records, clinical charts, and PCI and echocardiogram reports were reviewed.

RESULTS

Out of 385 CAD patients, a total of 335 were included in this study, with a response rate of 87%. The participants' mean (±SD) age was 57.5±10.7 years, 75.2% were males, 43% were current smokers, and 73.7% had below bachelor's education. The prevalence estimates of patients with moderate to severe depressive symptoms (PHQ-9 ≥10) was 34%, mild depression 45.1%, and normal 20.9%. Female gender, low educational level and diabetes mellitus were found to be the significant independent predictors of depression among our cohort with (t(333) = 3.68, p<0.001); (t(333) = 5.13, p<0.001); and (t(333) = 2.79, p=0.042), respectively.

CONCLUSION

This study suggests a high prevalence of depressive symptoms among CAD patients after ten days of PCI. Approximately one out of three patients with CAD have significant symptoms of depression, which is an alarming finding for clinicians. Moreover, this study demonstrates a lack of sufficient depression recognition and management in similar study settings. Integration of mental health assessment and treatment among patients with CAD as soon as after PCI is recommended for optimal and effective treatment and to obtain the best outcomes.

Depression and anxiety following acute myocardial infarction in women

Cardiovascular disease is the leading global cause of mortality, with ischemic heart disease causing the majority of cardiovascular deaths. Despite this, diagnostic delay commonly occurs in women experiencing acute myocardial infarction (AMI) who have a higher associated in-hospital mortality. Several studies have demonstrated that women are significantly more likely than men to experience depression and anxiety following AMI which is linked with increased morbidity, rehospitalization, and mortality, as well as decreased quality of life. Thus, it is imperative that future work aims to understand the factors that put women at higher risk for depression and anxiety following AMI, informing prevention and intervention. This narrative review will summarize the current literature on the association between AMI and mental health in women, including the impact on morbidity, mortality, and quality of life.

Coronary Heart Disease and Depression or Anxiety: A Bibliometric Analysis

This study aimed to conduct a bibliometric analysis of published studies on the association between coronary heart disease (CHD) and depression or anxiety. The study also aimed to identify leading authors, institutions, and countries to determine research hotspots and obtain some hints from the speculated future frontiers. Publications about CHD and depression or anxiety between 2004 and 2020 were collected from the Web of Science Core Collection (WOSCC) database. Bibliographic information, such as authorship, country, citation frequency, and interactive visualization, was generated using VOSviewer1.6.16 and CiteSpace5.6.R5. In total, 8,073 articles were identified in the WOSCC database. The United States (2,953 publications), Duke University and Harvard University (214 publications), Psychosomatic Medicine (297 publications), and Denollet Johan. (99 publications) were the most productive country, institutions, journal, and author, respectively. The three hotspots of the research were “The relationship between depression and CHD,” “depression and myocardial infarction,” and “The characteristic of women suffering depression after MI.” The four future research frontiers are predicted to be “treating depression in CHD patients with multimorbidity,” “psychometric properties of instruments for assessing depression and anxiety in CHD patients,” “depression or anxiety in post-PCI patients,” and “other mental diseases in CHD patients.” Bibliometric analysis of the association between CHD and depressive disorders might identify new directions for future research.

A cross-sectional study of factors predicting readmission in Thais with coronary artery disease

BACKGROUND

Coronary artery disease is a major cause of morbidity and mortality with high readmission rates. Hospital readmissions for coronary artery disease contribute to rising healthcare costs and are a marker of quality of care. Despite this, prior studies have found that readmission rates vary widely.

AIMS

This study aims to determine the impact of social support, depression, comorbidities, symptom severity, quality of life and readmission among coronary artery disease patients in Thailand.

METHODS

A total of 321 coronary artery disease patients from tertiary care hospitals across all regions of Thailand were recruited for this study. Data were analysed using multiple regression analysis.

RESULTS

The coefficient for social support (beta = -0.22) was found to be significant (p < 0.05), whereas comorbidity, symptom severity, depression and quality of life were not significant. Thus, social support was found to be the most significant predictive factor for readmission.

CONCLUSIONS

Accordingly, when designing effective nursing interventions, nurses should promote social support interventions for coronary artery disease patients to improve the quality of care, decrease readmission rates and improve patients' quality of life.

Screening for depression and anxiety among patients with acute coronary syndrome in acute care settings: a scoping review

OBJECTIVE

The aim of this review was to scope the literature for publications on the practice of screening for depression and anxiety in acute coronary syndrome patients in acute care by identifying instruments for the screening of anxiety and/or depression; determining if screening for anxiety and/or depression has been integrated into cardiac models of care and clinical pathways; and identifying any evidence practice gap in the screening and management of anxiety and/or depression in this population.

INTRODUCTION

Depression in acute coronary syndrome is bidirectional. Depression is an independent risk factor for cardiovascular disease, and comorbid depression is associated with a twofold greater risk of mortality in patients with cardiovascular disease. The presence of acute coronary syndrome increases the risk of depressive disorders or anxiety during the first one to two years following an acute event, and both depression and anxiety are associated with a higher risk of further acute coronary health concerns. Clinical practice guidelines have previously recommended routine screening for depression following a cardiac event, although many current guidelines do not include recommendations for screening in an acute setting. To date there have been no previous scoping reviews investigating depression and anxiety screening in patients with acute coronary syndrome in the acute care setting.

INCLUSION CRITERIA

Adults (18 years and over) with acute coronary syndrome who are screened for anxiety and/or depression (not anxiety alone) in an acute care setting.

METHODS

A systematic search of the literature was conducted by a research librarian. Research studies of any design published in English from January 1, 2012, to May 31, 2018, were included. Data were extracted from the included studies to address the three objectives. Purposefully designed tables were used to collate information and present findings. Data are also presented as figures and by narrative synthesis.

RESULTS

Fifty-one articles met the inclusion criteria. Primary research studies were from 21 countries and included 21,790 participants; clinical practice guidelines were from two countries. The most common instruments used for the screening of depression and anxiety were: i) the Hospital Anxiety and Depression Scale (n = 18); ii) the Beck Depression Inventory (n = 16); and iii) the nine-item Patient Health Questionnaire (n = 7). Eleven studies included screening for anxiety in 2181 participants (30% female) using the full version of the Hospital Anxiety and Depression Scale. The State-Trait Anxiety Inventory was used to screen 444 participants in three of the studies. Four studies applied an intervention for those found to have depression, including two randomized controlled trials with interventions targeting depression. Of the seven acute coronary syndrome international guidelines published since 2012, three (43%) did not contain any recommendations for screening for depression and anxiety, although four (57%) had recommendations for treatment of comorbidities.

CONCLUSIONS

This review has identified a lack of consistency in how depression and anxiety screening tools are integrated into cardiac models of care and clinical pathways. Guidelines for acute coronary syndrome are not consistent in their recommendations for screening for depression and/or anxiety, or in identifying the best screening tools.

Depression Is Associated With Reduced Outpatient Cardiac Rehabilitation Completion Rates: A SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

PURPOSE

Depression is associated with recurrent cardiac events and death in patients with coronary heart disease and congestive heart failure. Furthermore, depression may be associated with reduced completion of outpatient cardiac rehabilitation (CR), an empirically supported treatment for patients with coronary heart disease and congestive heart failure that reduces recurrent coronary events and cardiac mortality. The goal of the current systematic review and meta-analysis was to explore the association between depression and outpatient CR completion.

METHOD

A systematic literature review cross-referenced 3 electronic databases (PsycINFO, MEDLINE, and Dissertation Abstracts International) from inception through February 15, 2015. Studies quantifying an association between depression and outpatient CR completion were identified for review. A random-effects model was used to pool quantitative data, moderators were tested, and publication bias was analyzed.

RESULTS

Seventeen studies with 19 independent samples consisting of 30 586 cardiac patients were included in the meta-analysis. A moderate inverse relationship between depression and outpatient CR completion was observed (g = -0.44; 95% CI, -0.59 to -0.29), indicating that depressed CR patients were significantly less likely to complete their prescribed CR programs. No significant moderator variables were identified. A minor amount of publication bias was detected.

CONCLUSION

Depression is associated with reduced outpatient CR completion rates. Future research should focus on attendance interventions for depressed CR patients, as completion of outpatient CR reduces cardiac and all-cause mortality.

Role of psychosocial factors in long-term adherence to secondary prevention measures after myocardial infarction: a longitudinal analysis

PURPOSE

Psychosocial factors have been linked to myocardial infarction (MI) outcomes. Whether psychosocial factors affect post-MI long-term adherence to secondary prevention recommendations remains uncertain.

METHODS

Patients ≤65 years (n = 616) were assessed for optimism, perceived social support (PSS), sense of coherence (SOC), anxiety, and depression at initial hospitalization for acute MI (1992-1993). Adherence to secondary prevention measures was recorded in interviews 3-6 months, 1-2, 5, and 10-13 years after MI. Prevention score (proportion of recommendations met) was developed based on: (1) medication adherence; (2) exercise; (3) nonsmoking; (4) healthy diet; (5) maintaining recommended body weight. Associations between psychosocial factors and prevention scores were estimated using Generalized Estimating Equation models. The role of the prevention score in long-term survival was assessed using time-dependent Cox regression analysis.

RESULTS

Average follow-up prevention scores ranged from 0.70 to 0.80 (SD, ≈0.20). After multivariable adjustment, PSS (β = 0.087, P = .002, per 1 SD increase) and SOC (β = 0.082, P = .006, per 1 SD increase) were positively associated with secondary prevention adherence. The prevention score predicted survival over 23-year follow-up (adjusted hazard ratio = 0.79; 95% CI: 0.68-0.91, per 1 SD increase).

CONCLUSIONS

Psychosocial factors following MI, particularly PSS and SOC, were associated with long-term adherence to secondary prevention measures.

Association Between Depression and Outcomes in Chinese Patients With Myocardial Infarction and Nonobstructive Coronary Arteries

Background Myocardial infarction with nonobstructive coronary arteries ( MINOCA ) occurs in ≈10% of all patients with myocardial infarction. Studies on effects of depression on MINOCA outcomes are lacking. Therefore, the aim of this study was to examine the association of depression with clinical outcomes in Chinese patients with MINOCA . Methods and Results We conducted a prospective cohort study of 633 participants with MINOCA and followed up for 3 years. End points were defined as all-cause mortality and cardiovascular events. Diagnosis of depression was ascertained using the psychiatric interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). During the follow-up period, all-cause death occurred in 93 individuals and cardiovascular events developed in 170 individuals. Kaplan-Meier curves showed a significant association of depression with all-cause mortality (log-rank P<0.001) and cardiovascular events (log-rank P<0.001). Multiple Cox regression identified the new diagnosis of depression as an independent prognostic factor for all-cause mortality as well as cardiovascular events (adjusted hazard ratio, 7.250; 95% CI, 4.735-11.100; P<0.001; and hazard ratio, 3.411; 95% CI , 2.490-4.674; P<0.001, respectively). Conclusions The new diagnosis of depression at the time of myocardial infarction is associated with increased risk of adverse clinical outcomes in patients with MINOCA.

Connecting Social, Clinical, and Home Care Services for Persons with Serious Illness in the Community

The medical, psychological, cognitive, and social needs of older adults with serious illness are best met by coordinated and team-based services and support. These services are best provided in a seamless care model anchored by integrated biopsychosocial assessments focused on what matters to older adults and their social determinants of health; individualized care plans with shared goals; care provision and management; and quality measurement with continuous improvement. This model requires (1) racially and ethnically diverse healthcare professionals, including mental health and direct service workers, with training in aging and team collaboration; (2) an integrated network of community-based organizations (CBOs) providing in-home services; (3) an electronic communication platform that spans the system of providers and organizations with skilled technology staff; and (4) payment models that incentivize team-based care across the continuum of services, including CBOs, with adequate salaries and academic loan forgiveness to recruit and retain high-quality team members. Assuring that this model is effective requires ongoing quality assurance measures that include not only quality of care and utilization data to demonstrate cost offsets of service integration, but also quality of life for both the older adults and the family members caring for them. Although this may seem a lofty ideal in comparison with our current fragmented system, we review models that provide the key elements effectively and cost efficiently. We then propose an Essential Care Model that defines best practice in meeting the needs of older adults with serious illness and their families. J Am Geriatr Soc 67:S412-S418, 2019.

Risk Factors for Post-Acute Coronary Syndrome Depression: A Meta-analysis of Observational Studies

BACKGROUND

The incidence of depression is very common among patients with post-acute coronary syndrome (ACS) and leads to adverse outcomes.

AIMS

The aim of this meta-analysis was to detect risk factors for depression among patients with ACS and to provide clinical evidence for its prevention.

METHODS

The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline to search the PubMed, Web of Science, EMBASE, and EBSCO databases from January 1996 to March 2018. Data that met the inclusion criteria were extracted to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk factors of post-ACS depression.

RESULTS

A total of 30 articles met the inclusion criteria, and 25 risk factors were found to be associated with depression. The top 5 risk factors are as follows: antidepression treatment (OR, 4.25; 95% CI, 3.41-5.31), housewife status (OR, 4.17; 95% CI, 1.83-9.53), history of depressive disorders (OR, 3.52; 95% CI, 2.69-4.61), widow status (OR, 2.34; 95% CI, 1.05-5.21), and history of congestive heart failure (OR, 2.03; 95% CI, 1.04-3.97). The authors also found that a married status, high education level, and employment are protective factors.

CONCLUSION

Clinical personnel should be alerted with regard to the high risk factors of depression, including female gender, low education level, unmarried status, living alone, unemployed status, unhealthy lifestyle, and complications such as cardiovascular, respiratory, and metabolic diseases. In particular, staff should pay attention to a history of previous depression, be concerned with the psychological condition of the patient, and monitor and perform early interventions to reduce the incidence of depression.

Economic burden associated with inadequate antidepressant medication management among patients with depression and known cardiovascular diseases: insights from a United States-based retrospective claims database analysis

Aims: The current study examined the association between insufficient major depressive disorder (MDD) care and healthcare resource use (HCRU) and costs among patients with prior myocardial infarction (MI) or stroke.Methods: This was a retrospective study conducted using the MarketScan Claims Database (2010-2015). The date of the first MI/stroke diagnosis was defined as the cardiovascular disease (CVD) index date and the first date of a subsequent MDD diagnosis was the index MDD date. Adequacy of MDD care was assessed during the 90 days following the index MDD date (profiling period) using 2 measures: dosage adequacy (average fluoxetine equivalent dose of ≥20 mg/day for nonelderly and ≥10 mg/day for elderly patients) and duration adequacy (measured as the proportion of days covered of 80% or higher for all MDD drugs). Study outcomes included all-cause and CVD-related HCRU and costs which were determined from the end of the profiling period until the end of study follow-up. Propensity-score adjusted generalized linear models (GLMs) were used to compare patients receiving adequate versus inadequate MDD care in terms of study outcomes.Results: Of 1,568 CVD patients who were treated for MDD, 937 (59.8%) were categorized as receiving inadequate MDD care. Results from the GLMs suggested that patients receiving inadequate MDD care had 14% more all-cause hospitalizations, 4% more all-cause outpatient visits, 17% more CVD-related outpatient visits, 13% more CVD-related emergency room (ER) visits, higher per patient per year CVD-related hospitalization costs ($21,485 vs. $17,756), higher all-cause outpatient costs ($2,820 vs. $2,055), and higher CVD-related outpatient costs ($520 vs. $434) compared to patients receiving adequate MDD care.Limitations: Clinical information such as depression severity and frailty, which are potential predictors of adverse CVD outcomes, could not be ascertained using administrative claims data.Conclusions: Among post-MI and post-stroke patients, inadequate MDD care was associated with a significantly higher economic burden.

The prevalence and impact of depression and anxiety in cardiac rehabilitation: A longitudinal cohort study

BACKGROUND

Co-morbid depression and anxiety symptoms are frequently under-recognised and under-treated in heart disease and this negatively impacts self-management.

AIMS

The purpose of this study was to determine the prevalence, correlates and predictors of depression and anxiety in cardiac rehabilitation programmes, the impact of cardiac rehabilitation on moderate depression, anxiety and stress symptoms, and the relationship between moderate depression, anxiety and stress symptoms and cardiac rehabilitation adherence.

METHODS

This was a retrospective cohort study of 5908 patients entering cardiac rehabilitation programmes from 2006-2017, across two Sydney metropolitan teaching hospitals. Variables included demographics, diagnoses, cardiovascular risk factors, medication use, participation rates, health status (Medical Outcomes Study Short Form-36) and psychological health (Depression Anxiety Stress Scales) subscale scores.

RESULTS

Moderate depression, anxiety or stress symptoms were prevalent in 18%, 28% and 13% of adults entering cardiac rehabilitation programmes, respectively. Adults with moderate depression (24% vs 13%), anxiety (32% vs 23%) or stress (18% vs 10%) symptoms were significantly less likely to adhere to cardiac rehabilitation compared with those with normal-mild symptoms (p < 0.001). Anxiety (odds ratio 4.395, 95% confidence interval 3.363-5.744, p < 0.001) and stress (odds ratio 4.527, 95% confidence interval 3.315-6.181, p < 0.001) were the strongest predictors of depression. Depression (odds ratio 3.167, 95% confidence interval 2.411-4.161) and stress (odds ratio 5.577, 95% confidence interval 4.006-7.765, p < 0.001) increased the risk of anxiety on entry by more than three times, above socio-demographic factors, cardiovascular risk factors, diagnoses and quality of life.

CONCLUSION

Monitoring depression and anxiety symptoms on entry and during cardiac rehabilitation can assist to improve adherence and may identify the need for additional psychological health support. Exploring the relevance and use of adjunct psychological support strategies within cardiac rehabilitation programmes is warranted.

Variation in coronary angiography and revascularisation procedures in relation to psychological distress among patients admitted to hospital with myocardial infarction or angina

OBJECTIVE

Cardiac patients with psychological distress have a poorer prognosis than patients without distress; which may in part reflect differences in treatment. We quantified variation in coronary angiography and revascularisation procedures according to psychological distress among patients admitted with incident acute myocardial infarction (AMI) or angina.

METHODS

Questionnaire data (collected 2006-09) from 45 and Up Study participants were linked to hospitalisation and mortality data, to 30 June 2016. Among patients free from ischaemic heart disease at baseline and subsequently hospitalised with AMI or angina, Cox regression was used to model the association between distress (Kessler-10 scores: low [10-<12], mild [12-<16], moderate [16-<22] and high [22-50]) - assessed on the questionnaire - and coronary angiography and revascularisation procedures (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) within 30 days of admission, adjusting for personal characteristics, including physical functioning.

RESULTS

Proportions receiving angiography and PCI/CABG were 71.4% and 51.7% following AMI (n = 3749), and 61.3% and 31.3% for angina patients (n = 3772), respectively. Following AMI, age-sex-adjusted rates of PCI/CABG were lower with higher levels of distress (test for trend: p = .037), as were rates of angiography and PCI/CABG (p < .01) following admission with angina. After additional adjustment for personal characteristics, associations between distress and procedure rates attenuated substantively and were no longer significant, except that PCI/CABG rates remained lower among angina patients with high versus low distress (HR = 0.76, 95%CI: 0.59-0.99).

CONCLUSION

Distress-related variation in coronary procedures largely reflects differences in personal characteristics. Whether lower revascularisation rates among angina patients with high compared to low distress are clinically appropriate or represent under-treatment remains unclear.

Psychological distress and medication use for secondary prevention of cardiovascular events: Evidence from a large-scale population-based cohort study

OBJECTIVE

Cardiac patients with psychological distress have a poorer prognosis than patients without distress, potentially reflecting differences in preventive care. We aimed to examine distress-related variation in guideline-recommended medication use for secondary prevention of cardiovascular disease (CVD).

METHODS

Baseline questionnaire data from the 45 and Up Study (collected 2006-2009) were linked to hospitalisation, pharmaceutical dispensing and death records (to exclude those who died). Among participants hospitalised with myocardial infarction, angina, stroke/transient ischaemic attack in the six years before the questionnaire, Modified Poisson regression was used to estimate relative risks (RR) for distress (Kessler 10 scores: low[10- < 12], mild[12- < 16], moderate[16- < 22] and high[22-50]) and use of both blood pressure- and lipid-lowering medications, and use of neither medication in the three months following the questionnaire, adjusting for sociodemographic and health characteristics.

RESULTS

Among 7598 participants, 34.0% had low, 35.4% mild, 18.3% moderate and 12.3% high psychological distress. Around two-thirds (63.4%) were using both medications and the proportion declined with increasing levels of distress: RRs were 1.01(95%CI:0.97-1.05), 0.95(0.90-1.00) and 0.91(0.86-0.97) for mild, moderate and high compared to low distress, respectively (p(trend) = 0.001). The proportion using neither medication was 9.1% and increased with increasing distress: RRs for mild, moderate and high compared to low distress were 0.99(0.82-1.19), 1.30(1.06-1.59) and 1.60(1.28-1.98), respectively (p(trend) < 0.001).

CONCLUSION

Patients with psychological distress may need more support to optimise their use of secondary CVD prevention medications. Increasing the use of these medications for distressed patients may improve prognosis for patients with distress and improve population-level secondary prevention of CVD more broadly.

Persistent emotional distress after a first-time myocardial infarction and its association to late cardiovascular and non-cardiovascular mortality

BACKGROUND

Patients with symptoms of depression and/or anxiety - emotional distress - after a myocardial infarction (MI) have been shown to have worse prognosis and increased healthcare costs. However, whether specific subgroups of patients with emotional distress are more vulnerable is less well established. The purpose of this study was to identify the association between different patterns of emotional distress over time with late cardiovascular and non-cardiovascular mortality among first-MI patients aged <75 years in Sweden.

METHODS

We utilized data on 57,602 consecutive patients with a first-time MI from the national SWEDEHEART registers. Emotional distress was assessed using the anxiety/depression dimension of the European Quality of Life Five Dimensions questionnaire two and 12 months after the MI, combined into persistent (emotional distress at both time-points), remittent (emotional distress at the first follow-up only), new (emotional distress at the second-follow up only) or no distress. Data on cardiovascular and non-cardiovascular mortality were obtained until the study end-time. We used multiple imputation to create complete datasets and adjusted Cox proportional hazards models to estimate hazard ratios.

RESULTS

Patients with persistent emotional distress were more likely to die from cardiovascular (hazard ratio: 1.46, 95% confidence interval: 1.16, 1.84) and non-cardiovascular causes (hazard ratio: 1.54, 95% confidence interval: 1.30, 1.82) than those with no distress. Those with remittent emotional distress were not statistically significantly more likely to die from any cause than those without emotional distress.

DISCUSSION

Among patients who survive 12 months, persistent, but not remittent, emotional distress was associated with increased cardiovascular and non-cardiovascular mortality. This indicates a need to identify subgroups of individuals with emotional distress who may benefit from further assessment and specific treatment.

Social Support, Self-Efficacy, and Helplessness Following Myocardial Infarctions

Numerous factors impact patient recovery following an acute myocardial infarction (AMI). Negative emotional outcomes, such as learned helplessness, are predictors of mortality following AMI, though little is known about these relationships. The purpose of this study was to examine the relationships between social support and self-efficacy with learned helplessness in individuals post-AMI. Using a descriptive cross-sectional design, subjects with a diagnosed AMI within 12 months were recruited. Standardized instruments were used to evaluate social support and self-efficacy and their impact on learned helplessness. A statistically significant, direct relationship was found between social support and self-efficacy, and learned helplessness, suggesting that individuals with better social support and self-efficacy experience less learned helplessness within the first year following an AMI. In developing post-AMI treatment plans, health care staff need to consider encouraging a patient's supportive social network and self-efficacy as meaningful interventions against negative emotional outcomes.

Prevalence of depression in myocardial infarction: A PRISMA-compliant meta-analysis

BACKGROUND

Depression is common in the aftermath of myocardial infarction (MI) and may not only lead to impaired long-term quality of life, but also cause increased mortality among patients with MI. The reported prevalence of depression among patients with MI varied considerably across studies, for which a pooled prevalence was obtained in the only 1 meta-analysis conducted in March 2004. Subsequently, numerous relevant studies have been published, indicating the need for an update on the pooled prevalence. Therefore, this study was aimed at updating the pooled prevalence of depression among patients with MI.

METHODS

A comprehensive literature search in 3 electronic databases, PubMed, Embase, and PsycINFO, was performed in April 2018. The heterogeneity across studies was examined by the Cochran's Q test and quantified by the I statistic. If significant heterogeneity was observed, meta-regression analyses and subgroup analyses were performed to identify the source of heterogeneity. Publication bias was assessed by a funnel plot and verified by the Egger's and Begg's tests.

RESULTS

Nineteen eligible studies conducted in 10 countries were included, which consisted of 12,315 patients with MI, among whom 3818 were identified with depression. High heterogeneity was observed across the eligible studies (I = 98.4%), with the reported prevalence of depression ranging from 9.17% to 65.88%. The pooled prevalence of depression among patients with MI was 28.70% (95% CI: 22.39-35.46%) by a random effects model. Subgroup analyses showed that the pooled prevalence differed significantly by region, tool used to identify depression, study quality, sex, race, anterior MI, and diabetes status (P < .05). Meta-regression analyses did not identify any moderators of heterogeneity, and the heterogeneity was high within most subgroups. Nonetheless, for unmarried subjects, the heterogeneity was low (I = 19.5). The Egger's test and the Begg's test indicated no evidence of publication bias (P > .05).

CONCLUSIONS

Given the high pooled prevalence of depression found in this study and the association between depression and adverse health outcomes among patients with MI, more psychological resources including early assessment and effective treatment of depression should be allocated to patients with MI.

Burden of Depressive Symptoms Over 2 Decades and Risk of Nursing Home Placement in Older Women

OBJECTIVES

To determine the association between cumulative burden of depressive symptoms and risk of nursing home (NH) placement over 2 decades.

DESIGN

Prospective cohort study with data linked to Medicare claims files.

SETTING

Clinic sites in Baltimore, Maryland; Minneapolis, Minnesota; and the Monongahela Valley near Pittsburgh, Pennsylvania.

PARTICIPANTS

Initially community-dwelling women aged 65 and older (N=3,646).

MEASUREMENTS

Depressive symptom burden was determined using the Geriatric Depression Scale measured over 18 years to calculate accumulation of burden. NH placement was determined using Medicare claims data.

RESULTS

In Fine-Gray proportional hazards analyses including demographic characteristics, medical comorbidities, functional impairment, and recent depression exposure and accounting for competing risk of death, women with low depressive symptom burden were twice as likely to experience NH placement as those with minimal burden (hazard ratio (HR) = 1.92, 95% confidence interval (CI) = 1.16-3.20), women with moderate burden were more than twice as likely (HR = 2.62, 95% CI = 1.59-4.31), and women with high burden (HR = 3.08, 95% CI = 1.87-5.08) were three times as likely. The addition of antidepressant use to this model attenuated the risk only slightly.

CONCLUSION

In older women, cumulative burden of depressive symptoms over nearly 2 decades is associated with greater risk of transitioning from community-living to a NH irrespective of recent depression exposure, medical comorbidities, functional impairment, and the competing risk of death. This work supports the need for improving recognition, monitoring, and treatment of depressive symptoms early, which may reduce or delay NH placement.

Recommendations and practices for the screening of depression and anxiety in acute coronary syndrome: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify and map current recommendations and practices for the screening of depression and anxiety in acute coronary syndrome patients in the acute care setting.Specifically, the review questions are.

Impact of Depressive Disorder on Access and Quality of Care in Veterans With Prevalent Cardiovascular Disease

Although depressive disorders have been associated with increased risk of worse outcomes with cardiovascular diseases (CVDs), its relation with access to and quality of cardiovascular care is not well studied. Accordingly, we sought to assess the association between depressive disorders and access and quality of care among United States veterans with CVD. The 2013 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 13,126 veterans with CVD. Demographic and clinical history were recorded in adults with and without a depressive disorder (defined as self-reported diagnosis of depression, major depression, minor depression, or dysthymia). Among 13,126 veterans studied, a total of 2,889 (22.0%) adults had a depressive disorder whereas 10,237 (78.0%) did not. The veterans with a depressive disorder were younger, more often female and non-white, and had higher rates of multiple medical co-morbidities. They were more likely to report a delay in receiving medical care and financial barriers to seeking care and taking prescription drugs. They also reported significantly lower rates of aspirin and antihypertensive drug use. In multivariate analysis, depressive disorder was independently associated with higher risk of delay in receiving medical care (OR [odds ratio] 2.07, 95% CI [confidence interval] 1.65 to 2.60), financial barriers to medical care (OR 1.96, 95% CI 1.45 to 2.65), and prescription drugs (OR 1.45, 95% CI 1.02 to 2.08). In conclusion, depressive disorders were associated with impaired access to care among United States veterans with CVD.

Association Between Severity of Depression and Cardiac Risk Factors Among Women Referred to a Cardiac Rehabilitation and Prevention Clinic

PURPOSE

Depression comorbid with cardiovascular disease is associated with higher rates of morbidity and mortality, with studies suggesting that this is especially true among women. This study examined depressive symptoms and their relationship to cardiac risk factors among women referred to a women's cardiac rehabilitation and primary prevention program.

METHODS

A secondary analysis of data collected between 2004 and 2014 for 1075 women who completed a baseline assessment at the Women's Cardiovascular Health Initiative, a women-only cardiac rehabilitation and prevention program in Toronto, Canada. Descriptive statistics for sociodemographic variables, quality of life (SF-36), and cardiac risk factors were stratified by depression symptom severity using cutoff scores from the Beck Depression Inventory-2nd version (BDI-II) and compared with analysis of variance and χ statistics. Prevalence of antidepressant use among those with moderate to high depressive symptoms was assessed as an indicator of under- or untreated depression.

RESULTS

Overall, 38.6% of women scored above the BDI-II cutoff for depression; 23.6% in the moderate or severe range. Socioeconomic status and quality of life decreased with increasing depression severity. Body mass index increased with depressive severity (P < .001), as did the percentage of individuals with below target age predicted fitness (P < .001). Only 39.0% of women in the moderate and severe BDI-II groups were taking antidepressants.

CONCLUSION

In this sample, we found a significant prevalence of untreated and undertreated depressive symptoms among women with, or at high risk of developing, cardiovascular disease. Additional strategies are needed to identify these patients early and link them to appropriate treatment.

Morning and afternoon serum cortisol level in patients with post-myocardial infarction depression

BACKGROUND

Post-myocardial depression is a highly prevalent condition which worsens the course and prognosis of coronary artery disease. One possible pathogenetic factor is dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in cortisol profile disturbances.

METHODS

Thirty seven patients hospitalized due to a first myocardial infarction (MI) were enrolled in this study. The Beck Depression Inventory (BDI) was used to rate the severity of their depressive symptoms. Morning and afternoon serum cortisol samples were taken on the fifth day of the MI.

RESULTS

Depression, defined as BDI ≥ 10, was present in 34.4% of the patients. A statistically significant difference was observed between the mean morning and the evening plasma concentrations in patients with depression compared to the no-depression group: F (1.29) = 5.0405, p = 0.0328.

CONCLUSIONS

Patients with depressive symptoms directly after MI have a flattened diurnal serum cortisol profile. This is particularly expressed in patients with longer lasting symptoms.

Economic Impact of Subsequent Depression in Patients With a New Diagnosis of Stable Angina: A Population-Based Study

BACKGROUND

Depression is strongly linked to increased morbidity and mortality in patients with chronic stable angina; however, its associated healthcare costs have been less well studied. Our objective was to identify the characteristics of chronic stable patients found to have depression and to determine the impact of an occurrence of depression on healthcare costs within 1 year of a diagnosis of stable angina.

METHODS AND RESULTS

In this population-based study conducted in Ontario, Canada, we identified patients diagnosed with stable angina based on angiogram between October 1, 2008, and September 30, 2013. Depression was ascertained by physician billing codes and hospital admission diagnostic codes contained within administrative databases. The primary outcome was cumulative mean 1-year healthcare costs following index angiogram. Generalized linear models were developed with a logarithmic link and γ distribution to determine predictors of cost. Our cohort included 22 917 patients with chronic stable angina. Patients with depression had significantly higher mean 1-year healthcare costs ($32 072±$41 963) than patients without depression ($23 021±$25 741). After adjustment for baseline comorbidities, depression was found to be a significant independent predictor of cost, with a cost ratio of 1.33 (95% confidence interval, 1.29-1.37). Higher costs in depressed patients were seen in all healthcare sectors, including acute and ambulatory care.

CONCLUSIONS

Depression is an important driver of healthcare costs in patients following a diagnosis of chronic stable angina. Further research is needed to understand whether improvements in the approach to diagnosis and treatment of depression will translate to reduced expenditures in this population.

Psychological sequelae of myocardial infarction

Patient with myocardial infarction (MI) are often affected by psychological disorders such as depression, anxiety, and post-traumatic stress disorder. Psychological disorders are disabling and have a negative influence on recovery, reduce the quality of life and causes high mortality rate in MI patients. Despite tremendous advancement in technologies, screening scales, and treatment strategies, psychological sequelae of MI are currently understudied, underestimated, underdiagnosed, and undertreated. Depression is highly prevalent in MI patients followed by anxiety and post-traumatic stress disorder. Pathophysiological factors involved in psychopathologies observed in patients with MI are sympathetic over-activity, hypothalamic-pituitary-adrenal axis dysfunction, and inflammation. Numerous preclinical and clinical studies evidenced a positive association between MI and psychopathologies with a common molecular pathophysiology. This review provides an update on diagnostic feature, prevalence, pathophysiology, clinical outcomes, and management strategies of psychopathologies associated with MI. Moreover, preclinical research findings on molecular mechanisms involved in post-MI psychopathologies and future therapeutic strategies have been outlined in the review.

Burden, screening, and treatment of depressive and anxious symptoms among women referred to cardiac rehabilitation: a prospective study

Background

Cardiovascular disease (CVD) is one of the leading causes of morbidity and mortality among women. Women with CVD experience a greater burden of psychosocial distress than men, and practice guidelines promote screening in cardiac patients, especially women. The objectives herein were to describe the burden of psychosocial distress, extent of screening, forms of treatment, and whether receipt of treatment was related to psychosocial distress symptom severity at follow-up, among women.

Methods

Within a multi-center trial of women randomized to cardiac rehabilitation models, consenting participants were asked to complete surveys upon consent and 6 months later. Clinical data were extracted from charts. This study presents a secondary analysis of the surveys, including investigator-generated items assessing screening and treatment, the Beck Depression Inventory-II, the Hospital Anxiety and Depression Scale, and Patient Health Questionnaire-2.

Results

Of the 128 (67.0%) participants with valid baseline and follow-up survey results, 48 (40.3%) self-reported that they recalled being screened, and of these, 10 (21.3%) recalled discussing the results with a health care professional. Fifty-six (43.8%) retained participants had elevated symptoms of psychosocial distress at baseline, of which 25 (44.6%) were receiving treatment. Regression analyses showed that treatment of psychosocial distress was not significantly associated with follow-up depressive symptoms, but was significantly associated with greater follow-up anxiety.

Conclusions

Findings reiterate the great burden of psychosocial distress among women with CVD. Less than half of patients with elevated symptoms were treated, and the treatment approaches appeared to insufficiently achieve symptom relief.

Learned Helplessness and Depressive Symptoms Following Myocardial Infarction

Psychosocial factors are known to impact depressive symptoms across clinical populations. Learned helplessness has the potential of affecting depressive symptoms following acute myocardial infarction (AMI), though little is known about this relationship. The purpose of this study was to examine the relationship between learned helplessness and depressive symptoms in patients following an AMI. Using a descriptive cross-sectional design, participants with a diagnosed AMI within the past 12 months were recruited. Standardized instruments and measures were used to evaluate learned helplessness and depressive symptoms. A statistically significant direct relationship was found between learned helplessness and depressive symptoms, suggesting that individuals with higher self-reported levels of learned helplessness also reported more depressive symptoms. These results indicate learned helplessness is associated with depressive symptoms in individuals following an AMI. In developing post-AMI treatment plans, health care staff should focus on psychologic points of intervention to the same extent as physiologic interventions.

Prevalence of Fibromyalgia Syndrome and Its Correlations with Arrhythmia in Patients with Palpitations

OBJECTIVE

It is aimed to determine the prevalence of fibromyalgia syndrome (FMS) and its correlations with arrhythmia in patients with palpitations.

MATERIAL AND METHODS

Sixty-two patients who underwent electrophysiological study (EPS) due to palpitation complaints in Cardiology department and 40 healthy controls were included in the study. The precise diagnosis of arrhythmia was established using EPS. All participants were screened for FMS using American College of Rheumatology 2010 Fibromyalgia diagnostic criteria. Clinical assessments included measurement of severity of pain, fatigue and morning fatigue with visual analog scale (VAS), functional status with Fibromyalgia Impact Questionnaire (FIQ), and anxiety/depression with Hospital Anxiety and Depression Scale (HAD).

RESULTS

FMS was diagnosed in 22 of the 62 patients (36%), and 4 of the 40 healthy controls (10%) (p 0.05). EPS+ patients with FMS had higher fatigue levels, HAD and FIQ scores than EPS- patients, although statistically insignificant. HV durations were statistically longer in the EPS- subgroup (p < 0.05) but other EPS data were similar.

CONCLUSION

FMS frequency and HAD anxiety scores were found to be higher in patients with palpitation complaints. However, we found no association between arrhythmia, EPS parameters and FMS. In our clinical practice we should keep in mind to carry out assessments in terms of FMS in patients with palpitation.

Impact of a Type D Personality on Clinical and Psychometric Properties in a Sample of Turkish Patients With a First Myocardial Infarction

BACKGROUND

Recent studies have shown that a Type D personality is associated with an increased risk of cardiac mortality.

OBJECTIVE

This study aimed to examine the impact of a Type D personality on clinical and psychometric properties in a sample of Turkish patients with a first myocardial infarction (MI).

METHOD

The study included 131 patients who were admitted to the coronary care unit of a hospital. All of the patients underwent a psychiatric assessment within 2 to 6 months after their MI. Psychiatric interviews were conducted using the Structured Clinical Interview for DSM-IV (SCID-I). Patients also completed the Beck Depression Inventory, the Spielberger State-Trait Anxiety Inventory, the Health Anxiety Inventory, and the Type D personality scale.

RESULTS

The patients were divided into 2 groups on the basis of the presence or absence of Type D personality. There was a 38.2% prevalence of Type D personality in the patients with a first MI. Those with this type of personality had a significantly higher frequency of hypertension and stressful life events. The Type D patients also had more psychiatric disorders, including depressive and anxiety disorders, than the non-Type D patients.

CONCLUSIONS

Our findings suggest that Type D personality traits may increase the risk of hypertension and the risk of psychiatric morbidity in patients with a first MI. We suggest that this type of personality is a contributor to depression and anxiety disorders. These findings emphasize the importance of screening for Type D personality as both a cardiovascular and psychiatric risk marker in patients who have had an MI.

Depression in Cardiovascular Patients in Middle Eastern Populations: A Literature Review

Cardiovascular disease (CVD) is increasing in Middle Eastern countries. Depression is associated with increased morbidity and mortality rates among cardiovascular (CV) patients. Early detection of and intervention for depression among CV patients can reduce morbidity and mortality and save health care costs. Public information on mental health care needs of Arab CV patients living in Middle East regions is scattered and limited. This literature review surveyed and summarized research studies to learn what is known about the relationship between depression and CVD in Middle Eastern populations. The information will raise awareness among health care professionals and policy makers regarding the clinical significance of depression in Arab CV patients. It might contribute to development of culturally appropriate and effective mental health care services. Multiple databases were searched and 60 articles were assessed, including studies that investigated depression in Arab CV patient populations, physiological mechanisms of depression-CVD comorbidity, and intervention strategies that affect CV risk in depressed Arab patients. We discuss the extent to which this issue has been explored in Arab populations living in Middle East regions and Arab populations living abroad. We recommend that more comprehensive and in-depth research studies be conducted with Arab cardiac patients to enable implementation of culturally appropriate and effective mental health care interventions.

Changing depressive symptoms following percutaneous coronary intervention, clustering and effect on adherence - The THORESCI study

BACKGROUND

Depressive symptom dimensions may have a differential effect on cardiac prognosis. It is yet unknown whether and how depressive symptoms change together over time and how this may affect disease progression. We examined the clustering of changing depressive symptoms over the first 6 months after percutaneous coronary intervention (PCI), and examined the influence of the change profile on the predictive value of depression for treatment adherence at 6 months post-PCI.

METHODS

PCI patients (N=219, age: 62±15, 20% women) reported on depressive symptoms (PHQ-9, BDI; 30 symptoms) and adherence (MOS-GAS) at 1 and 6 months post-PCI. Principal component analysis (PCA) was performed on the individual symptom change scores. Multivariable linear regression examined the role of change profiles in predicting general treatment adherence, while adjusting for demographic and clinical characteristics.

RESULTS

Four change-factors emerged from PCA. One somatic-affective change-factor (10 symptoms), two cognitive-affective change-factors (6 general cognitive-affective and 7 severe cognitive symptoms) and one mixed factor were identified. We extracted 5 symptom change profiles. Linear regression showed the moderating role of the change profiles. In patients reporting a net increase in depressive symptoms, higher cognitive affective symptoms (β=-.46, p=.001) and higher somatic-affective symptoms (β=-.29; p=.044) were associated with worse general adherence.

DISCUSSION

Four distinct depressive symptom change-factors were identified that moderated the association of somatic-affective and cognitive-affective depressive symptom levels with general treatment adherence. This is of clinical importance as not only current symptoms, but also symptom change over the preceding months may be important to consider in screening and risk prediction.

Depression following acute coronary syndrome: a Danish nationwide study of potential risk factors

PURPOSE

Depression is common following acute coronary syndrome, and thus, it is important to provide knowledge to improve prevention and detection of depression in this patient group. The objectives of this study were to examine: (1) whether indicators of stressors and coping resources were risk factors for developing depression early and later after an acute coronary syndrome and (2) whether prior depression modified these associations.

METHODS

The study was a register-based cohort study, which includes 87,118 patients with a first time diagnosis of acute coronary syndrome during the period 2001-2009 in Denmark. Cox regression models were used to analyse hazard ratios (HRs) for depression.

RESULTS

1.5 and 9.5 % develop early (≤30 days) and later (31 days-2 years) depression after the acute coronary syndrome. Among all patients with depression, 69.2 % had first onset depression, while 30.8 % developed a recurrent depression. Most patient characteristics (demographic factors, socioeconomic status, psychosocial factors, health-related behavioural factors, somatic comorbidities, and severity of acute coronary syndrome) were significantly associated with increased HRs for both early and later depressions. Prior depression modified most of these associations in such a way that the association was attenuated in patients with a prior depression.

CONCLUSION

Our results indicate that first time and recurrent depression following acute coronary syndrome have different risk profiles. This is important knowledge that may be used to focus future interventions for prevention and detection.

Depression risk in patients with coronary heart disease in Germany

AIM

To determine the prevalence of depression and its risk factors among patients with coronary heart disease (CHD) treated in German primary care practices.

METHODS

Longitudinal data from nationwide general practices in Germany (n = 1072) were analyzed. Individuals initially diagnosed with CHD (2009-2013) were identified, and 59992 patients were included and matched (1:1) to 59992 controls. The primary outcome measure was an initial diagnosis of depression within five years after the index date among patients with and without CHD. Cox proportional hazards models were used to adjust for confounders.

RESULTS

Mean age was equal to 68.0 years (SD = 11.3). A total of 55.9% of patients were men. After a five-year follow-up, 21.8% of the CHD group and 14.2% of the control group were diagnosed with depression (P < 0.001). In the multivariate regression model, CHD was a strong risk factor for developing depression (HR = 1.54, 95%CI: 1.49-1.59, P < 0.001). Prior depressive episodes, dementia, and eight other chronic conditions were associated with a higher risk of developing depression. Interestingly, older patients and women were also more likely to be diagnosed with depression compared with younger patients and men, respectively.

CONCLUSION

The risk of depression is significantly increased among patients with CHD compared with patients without CHD treated in primary care practices in Germany. CHD patients should be routinely screened for depression to ensure improved treatment and management.

Time trend in depression diagnoses among acute coronary syndrome patients and a reference population from 2001 to 2009 in Denmark

Introduction In the last decade a range of recommendations to increase awareness of depression in acute coronary syndrome patients have been published. To test the impact of those recommendations we examine and compare recent time trends in depression among acute coronary syndrome patients and a reference population. Methods 87 218 patients registered with acute coronary syndrome from 2001-2009 in Denmark and a match reference population were followed through hospital registries and medication prescriptions for early (≤30 days), intermediate (31 days to 6 months) and later (6 months to 2 years) depression in the acute coronary syndrome population and overall depression in the reference population. Cox regression models were used to compare hazard ratios (HRs) for depression over calendar years. Results During the study period, 11.0% and 6.2% were diagnosed with depression in the acute coronary syndrome population and in the reference population, respectively. For the acute coronary syndrome population, the adjusted HRs increased for early (HR (95% CI) 1.04 (1.01-1.06)) and intermediate depression (HR (95% CI) 1.01 (1.00-1.03)), whereas the adjusted HRs did not change for later depression (HR (95% CI) 0.99 (0.98-1.00)). For the reference population the adjusted HRs for depression increased through the study period (HR (95% CI) 1.01 (1.01-1.03)). Conclusion Increase in diagnoses of depressions within 6 months of acute coronary syndrome may be explained by increased focus on depression in this patient group in combination with increased awareness of depression in the general population.

Biopsychosocial health disparities among young women enrolled in cardiac rehabilitation

PURPOSE

Our aim was to compare the biopsychosocial characteristics of young women with those of older women who were enrolled in cardiac rehabilitation (CR). The baseline characteristics of women who prematurely terminated CR participation were also explored.

METHODS

Baseline physiological and psychosocial indices of women ≤ 55 years compared with older women eligible for CR were evaluated 1 week before enrolling in either a traditional CR or a gender-specific, motivationally enhanced CR.

RESULTS

A greater proportion of young women (n = 65) compared with their older counterparts (n = 187) were diagnosed with acute myocardial infarction during their index hospitalization. They demonstrated lower high-density lipoprotein cholesterol, higher total cholesterol/high-density lipoprotein cholesterol ratios, and greater body weight compared with older women and were more likely to be active smokers. Young women compared with older women reported significantly worse health perceptions, quality of life, optimism, hope, social support, and stress and significantly more symptoms of depression and anxiety. Women who prematurely terminated CR participation were younger, more obese, with worse quality of life, and greater symptoms of depression and anxiety compared with women completing CR.

CONCLUSIONS

Notable differences in physiological and psychosocial profiles of young women compared with older women enrolled in CR were evident, placing them at high risk for nonadherence to secondary prevention interventions as well as increased risk for disease progression and subsequent cardiac adverse events. Continued existence of these health differentials represents an important public health problem and warrants further research to address these age-related and sex-specific health disparities among women with coronary heart disease.

Depressive symptom trajectories over a 6-year period following myocardial infarction: predictive function of cognitive appraisal and coping

The association between distinct patterns of depression and coping variables in myocardial infarction (MI) survivors over the long-term is unclear. The study aims to evaluate depressive trajectories and their covariates, including coping and cognitive appraisal, following MI over a period of 6 years. Depressive symptoms were assessed in 200 patients a few days after the first MI, and 1 month, 6 months and 6 years later. Cognitive appraisal and coping were assessed during the first three time points. Three latent depressive trajectories were identified: chronic (high; increasing then decreasing; n = 49), rising (moderate; decreasing then increasing; n = 121) and low (low; decreasing then stabilizing; n = 30). The chronic trajectory was associated with higher negative appraisal and emotion-focused coping. The findings clarify the long-term longitudinal trajectories of post-MI depressive symptoms and their association with coping variables, revealing the unfavorable impact of negative cognition and palliative coping.

Design and baseline data from the Gratitude Research in Acute Coronary Events (GRACE) study

BACKGROUND

Positive psychological constructs, especially optimism, have been linked with superior cardiovascular health. However, there has been minimal study of positive constructs in patients with acute coronary syndrome (ACS), despite the prevalence and importance of this condition. Furthermore, few studies have examined multiple positive psychological constructs and multiple cardiac-related outcomes within the same cohort to determine specifically which positive construct may affect a particular cardiac outcome.

MATERIALS AND METHODS

The Gratitude Research in Acute Coronary Events (GRACE) study examines the association between optimism/gratitude 2weeks post-ACS and subsequent clinical outcomes. The primary outcome measure is physical activity at 6months, measured via accelerometer, and key secondary outcome measures include levels of prognostic biomarkers and rates of nonelective cardiac rehospitalization at 6months. These relationships will be analyzed using multivariable linear regression, controlling for sociodemographic, medical, and negative psychological factors; associations between baseline positive constructs and subsequent rehospitalizations will be assessed via Cox regression.

RESULTS

Overall, 164 participants enrolled and completed the baseline 2-week assessment; the cohort had a mean age of 61.5+/?10.5years and was 84% men; this was the first ACS for 58% of participants.

CONCLUSION

The GRACE study will determine whether optimism and gratitude are prospectively and independently associated with physical activity and other critical outcomes in the 6months following an ACS. If these constructs are associated with superior outcomes, this may highlight the importance of these constructs as independent prognostic factors post-ACS.

Inpatient and outpatient costs in patients with coronary artery disease and mental disorders: a systematic review

Background

To systematically review in- and outpatient costs in patients with coronary artery disease (CAD) and comorbid mental disorders.

Methods

A comprehensive database search was conducted for studies investigating persons with CAD and comorbid mental disorders (Medline, EMBASE, PsycINFO, Psyndex, EconLit, IBSS). All studies were included which allowed a comparison of in- and outpatient health care costs (assessed either monetarily or in terms of health care utilization) of CAD patients with comorbid mental disorders (mood, anxiety, alcohol, eating, somatoform and personality disorders) and those without. Random effects meta-analyses were conducted and results reported using forest plots.

Results

The literature search resulted in 7,275 potentially relevant studies, of which 52 met inclusion criteria. Hospital readmission rates were increased in CAD patients with any mental disorder (pooled standardized mean difference (SMD) = 0.34 [0.17;0.51]). Results for depression, anxiety and posttraumatic stress disorder pointed in the same direction with heterogeneous SMDs on a primary study level ranging from −0.44 to 1.26. Length of hospital stay was not increased in anxiety and any mental disorder, while studies on depression reported heterogeneous SMDs ranging from −0.08 to 0.82. Most studies reported increased overall and outpatient costs for patients with comorbid mental disorders. Results for invasive procedures were non-significant respectively inconclusive.

Conclusions

Comorbid mental disorders in CAD patients are associated with an increased healthcare utilization in terms of higher hospital readmission rates and increased overall and outpatient health care costs. From a health care point of view, it is requisite to improve the diagnosis and treatment of comorbid mental disorders in patients with CAD to minimize incremental costs.

Effect and mechanism of fluoxetine on electrophysiology in vivo in a rat model of postmyocardial infarction depression

BACKGROUND

Major depression is diagnosed in 18% of patients following myocardial infarction (MI), and the antidepressant fluoxetine is shown to effectively decrease depressive symptoms and improve coronary heart disease prognosis. We observed the effect of fluoxetine on cardiac electrophysiology in vivo in a rat model of post-MI depression and the potential mechanism.

METHODS AND RESULTS

Eighty adult male Sprague Dawley rats (200-250 g) were randomly assigned to five groups: normal control (control group), MI (MI group), depression (depression group), post-MI depression (model group), and post-MI depression treated with intragastric administration of 10 mg/kg fluoxetine (fluoxetine group). MI was induced by left anterior descending coronary artery ligation. Depression was developed by 4-week chronic mild stress (CMS). Behavior measurement was done before and during the experiment. Electrophysiology study in vivo and Western blot analysis were carried on after 4 weeks of CMS. After 4 weeks of CMS, depression-like behaviors were observed in the MI, depression, and model groups, and chronic fluoxetine administration could significantly improve those behaviors (P<0.05 vs model group). Fluoxetine significantly increased the ventricular fibrillation threshold compared with the model group (20.20±9.32 V vs 14.67±1.85 V, P<0.05). Expression of Kv4.2 was significantly reduced by 29%±12%, 24%±6%, and 41%±15%, respectively, in the MI group, CMS group, and model group, which could be improved by fluoxetine (30%±9%). But fluoxetine showed no improvement on the MI-induced loss of Cx43.

CONCLUSION

The susceptibility to ventricular arrhythmias was increased in depression and post-MI depression rats, and fluoxetine may reduce the incidence of ventricular arrhythmia in post-MI depression rats and thus improve the prognosis. This may be related in part to the upregulation of Kv4.2 by fluoxetine.

Is there any difference between the early age myocardial infarction and late age myocardial infarction in terms of psychiatric morbidity in patients who have survived acute myocardial infarction?

OBJECTIVE

We aimed to compare the rates of psychiatric morbidity in patients who had early age and late age MI in patients who have survived acute myocardial infarction?

METHODS

One hundred sixteen patients who were hospitalized in the coronary care unit were included in the study. Psychiatric assessment of the patients was carried out within 1-6months post-MI. Psychiatric interviews were conducted with the Structured Clinical Interview for DSM-IV (SCID-I). Also used were the Beck Depression Inventory (BDI), Spielberger State-Trait Anxiety Inventory (STAI), and Health Anxiety Inventory (HAI).

RESULTS

A total of 116 patients were divided into two groups according to age as an early age myocardial infarction group (EA-MI) and a late age myocardial infarction group (LA-MI). The EA-MI group included 24 patients 45years of age and under. The LA-MI group included 92 patients over 45years of age. Current psychiatric disorders, lifetime psychiatric disorders and lifetime depressive disorders were significantly more frequent in the EA-MI group than in the LA-MI group.

CONCLUSION

EA-MI patients have experienced a depressive episode prior to the onset of the MI, whereas in the LA-MI group, the patients typically experienced depressive episodes after MI. Our findings suggest that depression may increase the risk of MI at an early age.

Impact of identification and treatment of depression in heart transplant patients

Background. The effects of clinical depression after orthotopic heart transplantation (OHT) are relatively unknown. The purpose of this study was to evaluate the impact of depression on outcomes after OHT. Methods. We performed a single center retrospective review of 102 consecutive patients who underwent OHT at Northwestern Memorial Hospital from June 2005 to October 2009. The diagnosis of depression was obtained from attending physician documentation. The primary endpoints were all-cause mortality (ACM), hospitalizations, and rejection. Results. Of 102 OHT patients, 26 (26%) had depression. Depressed patients were similar in age to nondepressed patients (57.6 years versus 56.9, P = 0.79). There was no statistical difference in survival between groups at 5 years after OHT (P = 0.94). All-cause hospitalizations were higher in depressed versus nondepressed patients (4.3 versus 2.6 hospitalizations P = 0.05). There were no significant differences in hospitalizations between the two groups for the following complications: cardiac (heart failure, edema, arrhythmias, and acute rejection) and infections. There was no significant difference in episodes of 2R and 3R rejection. Conclusion. Early identification and treatment of depression in OHT patients result in outcomes similar to nondepressed patients.

[Depression in Acute Coronary Syndromes: Application of the Beck Depression Inventory]

BACKGROUND

Depression has been related to the occurrence of cardiovascular diseases, and also appears to increase the risk of death from coronary artery disease. The presence of depression after the occurrence of an acute coronary syndrome (ACS) and its relationship with socioeconomic factors has not been studied in Colombia.

OBJECTIVE

To describe the frequency of depression and associated factors in patients hospitalized with an ACS.

METHODS

A cross-sectional study was carried out between April and May 2008 in three coronary care units in Santa Marta, Colombia. The presence of depression was evaluated with the Beck Depression Inventory (BDI). Depression was considered to be present if BDI was equal or greater than 10. The relationship between the presence of depression and demographic, clinic and laboratory characteristics was analyzed.

RESULTS

A BDI score ≥10 (any degree of depression) was seen in 21 (63.64%) of the patients. In 9 out of 10 (91.66%) patients without stable income had depression in contrast to 12 out of 23 (57.14%) with stable income (P=.037). Depression was found in in 8 of the 8 (100%) patients with electrocardiographic pathological T wave inversion, in contrast to 13 out of the 25 (52%) without changes in T wave (P=.014). Depression was detected in 17 of 22 (77.27%) patients who smoked cigarettes versus 4 of 11 (36.36%) of patients who have never smoked (P=.021).

CONCLUSIONS

Depressive symptoms are significantly present in patients suffering an acute coronary syndrome. Unemployment, pathological T wave inversion, and smoking seem to be associated with the presence of depressive symptoms after an acute coronary event.