The 'perfect storm' and acute coronary syndrome onset: do psychosocial factors play a role?

Translational Research of the Acute Effects of Negative Emotions on Vascular Endothelial Health: Findings From a Randomized Controlled Study

BACKGROUND

Provoked anger is associated with an increased risk of cardiovascular disease events. The underlying mechanism linking provoked anger as well as other core negative emotions including anxiety and sadness to cardiovascular disease remain unknown. The study objective was to examine the acute effects of provoked anger, and secondarily, anxiety and sadness on endothelial cell health.

METHODS AND RESULTS

Apparently healthy adult participants (n=280) were randomized to an 8-minute anger recall task, a depressed mood recall task, an anxiety recall task, or an emotionally neutral condition. Pre-/post-assessments of endothelial health including endothelium-dependent vasodilation (reactive hyperemia index), circulating endothelial cell-derived microparticles (CD62E+, CD31+/CD42-, and CD31+/Annexin V+) and circulating bone marrow-derived endothelial progenitor cells (CD34+/CD133+/kinase insert domain receptor+ endothelial progenitor cells and CD34+/kinase insert domain receptor+ endothelial progenitor cells) were measured. There was a group×time interaction for the anger versus neutral condition on the change in reactive hyperemia index score from baseline to 40 minutes (P=0.007) with a mean±SD change in reactive hyperemia index score of 0.20±0.67 and 0.50±0.60 in the anger and neutral conditions, respectively. For the change in reactive hyperemia index score, the anxiety versus neutral condition group by time interaction approached but did not reach statistical significance (P=0.054), and the sadness versus neutral condition group by time interaction was not statistically significant (P=0.160). There were no consistent statistically significant group×time interactions for the anger, anxiety, and sadness versus neutral condition on endothelial cell-derived microparticles and endothelial progenitor cells from baseline to 40 minutes.

CONCLUSIONS

In this randomized controlled experimental study, a brief provocation of anger adversely affected endothelial cell health by impairing endothelium-dependent vasodilation.

Islamic Spiritual Care, Depression, and Quality of Life Among Patients With Heart Disease: A Systematic Review

Objectives: This study sought to identify the potential effect of Islamic-Spiritual care and how it is delivered in treating depression and improving the quality of life (QoL) of patients with heart disease. Methods: This systematic review is reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We searched using relevant keywords through PubMed, CINAHL, Scopus, Springer Link, and Academic Search Complete. Articles with an experimental or cohort design were included, without date restrictions. The quality of evidence was assessed using the Joanna Briggs Institute critical appraisal checklist, and data synthesis used thematic analysis. Results: The analysis included 6 of the 47 identified studies. All studies were conducted in Iran, and a small number had a low risk of bias. The intervention was given through an Islamic teaching strategy, indicating the potential to reduce depression and improve QoL. Moreover, the learning core consists of belief and surrender in God's providence, strengthened meaning and life's purposes, worship, and skills to overcome obstacles. Conclusions: The interventions had the potential to treat depression and improve the QoL. However, a further study considering the risks of bias and involving a larger patient population with other Muslim backgrounds is necessary.

Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy

BACKGROUND

Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption.

METHODS

We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients.

RESULTS

We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support.

CONCLUSIONS

We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

Impact of Acute and Chronic Stress on Thrombosis in Healthy Individuals and Cardiovascular Disease Patients

Psychological stress induces different alterations in the organism in order to maintain homeostasis, including changes in hematopoiesis and hemostasis. In particular, stress-induced hyper activation of the autonomic nervous system and hypothalamic–pituitary–adrenal axis can trigger cellular and molecular alterations in platelets, coagulation factors, endothelial function, redox balance, and sterile inflammatory response. For this reason, mental stress is reported to enhance the risk of cardiovascular disease (CVD). However, contrasting results are often found in the literature considering differences in the response to acute or chronic stress and the health condition of the population analyzed. Since thrombosis is the most common underlying pathology of CVDs, the comprehension of the mechanisms at the basis of the association between stress and this pathology is highly valuable. The aim of this work is to give a comprehensive review of the studies focused on the role of acute and chronic stress in both healthy individuals and CVD patients, focusing on the cellular and molecular mechanisms underlying the relationship between stress and thrombosis.

Depressive symptoms do not discriminate: racial and economic influences between time-varying depressive symptoms and mortality among REGARDS participants

PURPOSE

Depressive symptoms relapse and remit over time, perhaps differentially by race and income. Few studies have examined whether time-varying depressive symptoms (TVDS) differentially predict mortality. We sought to determine whether race (white/black) and income (</≥$35,000) moderate the association between TVDS and mortality in a large cohort.

METHODS

The REGARDS study is a prospective cohort study among community-dwelling U.S. adults aged 45 years or older. Cox proportional hazard models were constructed to separately analyze the association between mortality (all cause, cardiovascular death, noncardiovascular death, and cancer death) and TVDS in race and income stratified models.

RESULTS

Point estimates were similar and statistically significant for white (aHR = 1.24 [95% CI: 1.10, 1.41]), black (aHR = 1.26 [95% CI: 1.11, 1.42]), and low-income participants (aHR = 1.28 [95% CI: 1.16, 1.43]) for the association between TVDS and mortality. High-income participants had a lower hazard (aHR = 1.19 [95% CI: 1.02, 1.38]). Baseline depressive symptoms predicted mortality in blacks only (aHR = 1.17, 95% CI: [1.00, 1.35]).

CONCLUSIONS

We found that TVDS significantly increased the immediate hazard of mortality similarly across race and income strata. TVDS may provide more robust evaluations of depression impact compared with the baseline measures, making apparent racial disparities cited in the extant literature a reflection of the imperfection of using baseline measures.

Selected psychological comorbidities in coronary heart disease: Challenges and grand opportunities

Evidence of popular interest in the interrelationships between mind, body, and heart disease dates to Ancient Grecian times and paved the way for modern-day scientific inquiry into the relationships between psychological comorbidities in coronary heart disease. Although the systematic evidence has suggested an association of poor medical prognosis and lower quality of life among patients with coronary heart disease with comorbid psychological conditions, the mechanisms are less well understood. In this selective review article, the epidemiology, mechanisms, screening, and treatment recommendations for 4 common psychological conditions (depression, anxiety, stress, and insomnia) comorbid with coronary heart disease are presented. We focus on the grand challenges and unprecedented opportunities for research in this area considering the methodological and technological innovations of the 21st century. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

New Insights Into the Comorbidity of Coronary Heart Disease and Depression

Coronary heart disease (CHD) and depression are common disorders that markedly impair quality of life and impose a great financial burden on society. They are also frequently comorbid, exacerbating patient condition, and worsening prognosis. This comorbidity strongly suggests shared pathologic mechanisms. This review focuses on the incidence of depression in patients with CHD, deleterious effects of depression on CHD symptoms, and the potential mechanisms underlying comorbidity. In addition to the existing frequent mechanisms that are well known for decades, this review summarized interesting and original potential mechanisms to underlie the comorbidity, such as endocrine substances, gut microbiome, and microRNA. Finally, there are several treatment strategies for the comorbidity, involving drugs and psychotherapy, which may provide a theoretical basis for further basic research and clinical investigations on improved therapeutic interventions.

The human coronary vasodilatory response to acute mental stress is mediated by neuronal nitric oxide synthase

Acute mental stress induces vasodilation of the coronary microvasculature. Here, we show that this response involves neuronal nitric oxide synthase in the human coronary circulation.

Mental stress-induced ischemia approximately doubles the risk of cardiac events in patients with coronary artery disease, yet the mechanisms underlying changes in coronary blood flow in response to mental stress are poorly characterized. Neuronal nitric oxide synthase (nNOS) regulates basal coronary blood flow in healthy humans and mediates mental stress-induced vasodilation in the forearm. However, its possible role in mental stress-induced increases in coronary blood flow is unknown. We studied 11 patients (6 men and 5 women, mean age: 58 ± 14 yr) undergoing elective diagnostic cardiac catheterization and assessed the vasodilator response to mental stress elicited by the Stroop color-word test. Intracoronary substance P (20 pmol/min) and isosorbide dinitrate (1 mg) were used to assess endothelium-dependent and -independent vasodilation, respectively. Coronary blood flow was estimated using intracoronary Doppler recordings and quantitative coronary angiography to measure coronary artery diameter. Mental stress increased coronary flow by 34 ± 7.0% over the preceding baseline during saline infusion (P < 0.01), and this was reduced to 26 ± 7.0% in the presence of the selective nNOS inhibitor S-methyl-l-thiocitrulline (0.625 µmol/min, P < 0.001). Mental stress increased coronary artery diameter by 6.9 ± 3.7% (P = 0.02) and 0.5 ± 2.8% (P = 0.51) in the presence of S-methyl-l-thiocitrulline. The response to substance P did not predict the response to mental stress (r² = −0.22, P = 0.83). nNOS mediates the human coronary vasodilator response to mental stress, predominantly through actions at the level of coronary resistance vessels.

NEW & NOTEWORTHY Acute mental stress induces vasodilation of the coronary microvasculature. Here, we show that this response involves neuronal nitric oxide synthase in the human coronary circulation.

Listen to this article’s corresponding podcast at http://ajpheart.podbean.com/e/nnos-and-coronary-flow-during-mental-stress/.

Postoperative Infections are Associated with Increased Risk of Cardiac Events in Vascular Patients

BACKGROUND

Despite advances in perioperative care, the rate of cardiac events in vascular patients remains high. We have previously shown that infections in trauma patients are associated with higher rates of subsequent cardiac complications, likely due to the additive effect of a second hit of an infection following the trauma. The aim of this study was to investigate whether there is an association between postoperative infections and subsequent cardiac events in vascular patients.

METHODS

A 5-year retrospective review of demographics, comorbidities, operative interventions, infectious, and cardiac events in all vascular patients who underwent an operative intervention at a single tertiary referral center was performed. In patients with clinical suspicion of myocardial injury, myocardial damage was defined as troponin >0.15 ng/mL and myocardial infarction (MI) as troponin >1 ng/mL. Pneumonia was diagnosed using bronchoalveolar lavage (BAL) and considered positive if BAL fluid culture contained >10,000 colony-forming units (cfu). Urinary tract infection (UTI) was diagnosed if the urine culture contained >100,000 cfu. All other infections were diagnosed by culture data. Regression analysis was performed to assess risk of cardiac events as a function of infections adjusting for age, gender, and comorbidities.

RESULTS

We analyzed 1,835 vascular operative interventions with the mean age of the cohort 65.5 years (65.9% male). The overall infection rate was 13.2%, with UTI being the most common (60.3%). The overall rate of myocardial damage was 8.1% and the rate of MI 3.8%. Rates of both myocardial damage (15.5 vs. 7.7%; P = 0.0015) and MI (7.1 vs. 3.4%; P = 0.018) were significantly higher in patients with infections, compared to those without infections. Adjusting for age, gender, medical comorbidities, open versus endovascular cases as well as statin and steroid use, patients with UTI were more likely to subsequently develop either myocardial damage (odds ratio [OR] = 3.57 [95% confidence interval = 1.51-8.45]) or MI (OR = 4.20 [1.23-14.3]). A similar association was noted between any infections and either myocardial damage (OR = 2.97 [1.32-6.65]) or MI (OR = 4.31 [1.44-12.94]).

CONCLUSIONS

We herein describe an association between postoperative infections, most commonly UTI, and subsequent cardiac events. Efforts should be made to minimize the risk of developing infections to ensure cardioprotection in vascular patients during perioperative period.

Effects of Concurrent Depressive Symptoms and Perceived Stress on Cardiovascular Risk in Low- and High-Income Participants: Findings From the Reasons for Geographical and Racial Differences in Stroke (REGARDS) Study

Background

Psychosocial risk for cardiovascular disease (CVD) may be especially deleterious in persons with low socioeconomic status. Most work has focused on psychosocial factors individually, but emerging research suggests that the confluence of psychosocial risk may be particularly harmful. Using data from the Reasons for Geographical and Racial Differences in Stroke (REGARDS) study, we examined associations among depressive symptoms and stress, alone and in combination, and incident CVD and all‐cause mortality as a function of socioeconomic status.

Methods and Results

At baseline, 22 658 participants without a history of CVD (58.8% female, 41.7% black, mean age 63.9±9.3 years) reported on depressive symptoms, stress, annual household income, and education. Participants were classified into 1 of 3 psychosocial risk groups at baseline: (1) neither depressive symptoms nor stress, (2) either depressive symptoms or stress, or (3) both depressive symptoms and stress. Cox proportional hazards models were used to predict physician‐adjudicated incident total CVD events (nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death) and all‐cause mortality over a median of 7.0 years (interquartile range 5.4–8.3 years) of follow‐up. In fully adjusted models, participants with both depressive symptoms and stress had the greatest elevation in risk of developing total CVD (hazard ratio 1.48, 95% CI 1.21–1.81) and all‐cause mortality (hazard ratio 1.33, 95% CI 1.13–1.56) but only for those with low income (<$35 000) and not high (≥$35 000) income. This pattern of results was not observed in models stratified by education.

Conclusions

Findings suggest that screening for a combination of elevated depressive symptoms and stress in low‐income persons may help identify those at increased risk of incident CVD and mortality.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Depression and doctor-patient communication in the emergency department

OBJECTIVE

Depression may adversely affect health outcomes by influencing doctor-patient communication. We aimed to determine the association between depressive symptoms and doctor-patient communication among patients presenting to the emergency department (ED) with a suspected acute coronary syndrome (ACS).

METHOD

We enrolled a consecutive sample of 500 patients evaluated for ACS symptoms from the ED of an urban medical center. Depressive symptoms (8-item Patient Health Questionnaire, PHQ-8) and doctor-patient communication in the ED (Interpersonal Processes of Care) were assessed during hospitalization. Logistic regression was used to determine the association between depressive symptoms and doctor-patient communication, adjusting for age, sex, race, ethnicity, education, language, health insurance status and comorbidities.

RESULTS

Compared to nondepressed patients, depressed patients (PHQ-8≥10) were more likely (P<.05) to report suboptimal communication on five of seven communication domains: clarity, elicitation of concerns, explanations, patient-centered decision making and discrimination. A greater proportion of depressed versus nondepressed patients reported suboptimal overall communication (39.8% versus 22.9%, P<.001). In adjusted analyses, depressed patients remained more likely to report suboptimal doctor-patient communication (adjusted odds ratio 2.42, 95% confidence interval 1.52-3.87; P<.001).

CONCLUSIONS

Depressed patients with ACS symptoms reported less optimal doctor-patient communication in the ED than nondepressed patients. Research is needed to determine whether subjectively rated differences in communication are accompanied by observable differences.

Elucidating the Association Between Depressive Symptoms, Coronary Heart Disease, and Stroke in Black and White Adults: The REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

Background

Depression is a relapsing and remitting disease. Prior studies on the association between depressive symptoms and incident cardiovascular disease (CVD) have been limited by single measurements, and few if any have examined both incident coronary heart disease and stroke in a large biracial national cohort. We aimed to assess whether time‐dependent depressive symptoms conferred increased risk of incident CVD.

Methods and Results

Between 2003 to 2007, 22 666 black and white participants (aged ≥45 years) without baseline CVD in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were recruited. Cox proportional hazards regression analyses assessed the association between up to 3 measurements of elevated depressive symptoms (4‐item Center for Epidemiologic Studies Depression Scale score ≥4) and incident coronary heart disease, stroke, and CVD death adjusting for age, sex, region, income, health insurance, education, blood pressure, cholesterol, medication, obesity, diabetes mellitus, kidney disease, C‐reactive protein, corrected QT interval, atrial fibrillation, left ventricular hypertrophy, smoking, alcohol, physical inactivity, medication adherence, and antidepressant use. The participants’ average age was 63.4 years, 58.8% were female, and 41.7% black. Time‐varying depressive symptoms were significantly associated with CVD death (adjusted hazard ratio 1.30, 95% CI 1.04–1.63), with a trend toward significance for fatal and nonfatal stroke (adjusted hazard ratio 1.26, 95% CI 0.99–1.60) but not fatal and nonfatal coronary heart disease (adjusted hazard ratio 1.11, 95% CI 0.89–1.38). Race did not moderate the association between depressive symptoms and CVD.

Conclusions

Proximal depressive symptoms were associated with incident fatal and nonfatal stroke and CVD death even after controlling for multiple explanatory factors, further supporting the urgent need for timely management of depressive symptoms.

Psychosocial predictors of long-term mortality among women with suspected myocardial ischemia: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation

This paper evaluated long-term associations between psychosocial factors and premature mortality among women with suspected coronary artery disease (CAD). We tracked total mortality events over a median 9.3 years in a cohort of 517 women [baseline mean age = 58.3 (11.4) years]. Baseline evaluations included coronary angiography, psychosocial testing, and CAD risk factors. Measures included the Spielberger Trait Anxiety Scale, Beck Depression Inventory, self-rated health, and Social Network Index. Cox regression analysis was used to assess relationships. Covariates included age, CAD risk factors, and CAD severity. BDI scores (HR 1.09, 95 % CI 1.02-1.15), STAI scores (HR .86, 95 % CI .78-.93), and very good self-rated health (relative to the poor self-rated health group; HR .33, 95 % CI .12-.96) each independently predicted time to mortality outcomes in the combined model. SNI scores (HR .91, 95 % CI .81-1.06) and other self-rated health categories (i.e., fair, good, and excellent categories) were not significant mortality predictors after adjusting for other psychosocial factors. These results reinforce and extend prior psychosocial research in CAD populations.

The clinics of acute coronary syndrome

Risk stratification and management of patients with chest pain continues to be challenging despite considerable efforts made in the last decades by many clinicians and researchers. The throutful evaluation necessitates that the physicians have a high index of suspicion for acute coronary syndrome (ACS) and always keep in mind the myriad of often subtle and atypical presentations of ischemic heart disease, especially in certain patient populations such as the elderly ones. In this article we aim to review and discuss the available evidence on the value of clinical presentation in patients with a suspected ACS, with special emphasis on history, characteristics of chest pain, associated symptoms, atypical presentations, precipitating and relieving factors, drugs, clinical rules and significance of clinical Gestalt.

Acute coronary syndrome and depression: A review of shared pathophysiological pathways

OBJECTIVE

To examine the evidence for shared pathophysiological pathways in acute coronary syndrome and major depression and to conceptualise the dynamic interplay of biological systems and signalling pathways that link acute coronary syndrome and depression within a framework of neuro-visceral integration.

METHODS

Relevant articles were sourced via a search of published literature from MEDLINE, EMBASE and PubMed using a variety of search terms relating to biological connections between acute coronary syndrome and depression. Additional articles from bibliographies of retrieved papers were assessed and included where relevant.

RESULTS

Despite considerable research efforts, a clear understanding of the biological processes connecting acute coronary syndrome and depression has not been achieved. Shared abnormalities are evident across the immune, platelet/endothelial and autonomic/stress-response systems. From the available evidence, it seems unlikely that a single explanatory model could account for the complex interactions of biological pathways driving the pathophysiology of these disorders and their comorbidity.

CONCLUSION

A broader conceptual framework of mind-body or neuro-visceral integration that can incorporate the existence of several causative scenarios may be more useful in directing future research and treatment approaches for acute coronary syndrome-associated depression.

Perfect storm: concurrent stress and depressive symptoms increase risk of myocardial infarction or death

BACKGROUND

Depression and stress have each been found to be associated with poor prognosis in patients with coronary heart disease. A recently offered psychosocial perfect storm conceptual model hypothesizes amplified risk will occur in those with concurrent stress and depressive symptoms. We tested this hypothesis in a large sample of US adults with coronary heart disease.

METHODS AND RESULTS

Participants included 4487 adults with coronary heart disease from the REasons for Geographic and Racial Differences in Stroke study, a prospective cohort study of 30,239 black and white adults. We conducted Cox proportional hazards regression with the composite outcome of myocardial infarction or death and adjustment for demographic, clinical, and behavioral factors. Overall, 6.1% reported concurrent high stress and high depressive symptoms at baseline. During a median 5.95 years of follow-up, 1337 events occurred. In the first 2.5 years of follow-up, participants with concurrent high stress and high depressive symptoms had increased risk for myocardial infarction or death (adjusted hazard ratio, 1.48 [95% confidence interval, 1.08-2.02]) relative to those with low stress and low depressive symptoms. Those with low stress and high depressive symptoms (hazard ratio, 0.92 [95% confidence interval, 0.66-1.28]) or high stress and low depressive symptoms (hazard ratio, 0.86 [95% confidence interval, 0.57-1.29]) were not at increased risk. The association on myocardial infarction or death was not significant after the initial 2.5 years of follow-up (hazard ratio, 0.89 [95% confidence interval, 0.65-1.22]).

CONCLUSIONS

Our results provide initial support for a psychosocial perfect storm conceptual model; the confluence of depressive symptoms and stress on medical prognosis in adults with coronary heart disease may be particularly destructive in the shorter term.

Age at onset of major depression and adulthood cardiovascular risk

Childhood-onset compared to adulthood-onset of major depression is associated with increased rates of serious cardiovascular events, independently of cardiovascular risk factors. This could be explained by a longer duration of exposure to depression. Cardiovascular disease risk should be systematically assessed in individuals with long duration of major depression.

Psychosocial stress as a risk factor for sepsis: a population-based cohort study

OBJECTIVE

To characterize the relationship between stress and future risk of sepsis. We also evaluated the role of depression in this relationship.

METHODS

We used population-based data on 30,183 participants in the Reasons for Geographic and Racial Differences in Stroke cohort, characterizing stress using the Perceived Stress Scale (PSS) and depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). We identified incident sepsis events as hospitalizations for a serious infection with the presence of at least two systemic inflammatory response syndrome criteria. We assessed associations between PSS and incidence of sepsis for 1 and 10 years of follow-up, adjusting for demographics and chronic medical conditions and assessing the role of health behaviors and CES-D in these relationships.

RESULTS

In 2003 to 2012, 1500 participants experienced an episode of sepsis. Mean PSS and CES-D scores were 3.2 (2.9) and 1.2 (2.1). PSS was associated with increased 1-year adjusted incidence of sepsis (hazard ratio [HR] = 1.21 per PSS standard deviation, 95% confidence interval = 1.06-1.38); multivariable adjustment for health behaviors and CES-D did not change this association (1.20, 1.03-1.39). PSS was also associated with increased 10-year adjusted incidence of sepsis (HR = 1.07 per PSS standard deviation; 95% confidence interval = 1.02-1.13). Multivariable adjustment showed that health behaviors did not affect this long-term association, whereas the addition of CES-D reduced the association between PSS and sepsis during 10-year follow-up (HR = 1.04, 0.98-1.11).

CONCLUSIONS

Increased stress was associated with higher 1-year adjusted incidence of sepsis, even after accounting for depressive symptoms. The association between stress and 10-year adjusted incidence of sepsis was also significant, but this association was reduced when adjusting for depressive symptoms. Reduction of stress may limit short-term sepsis risk.

Confluence of depression and acute psychological stress among patients with stable coronary heart disease: effects on myocardial perfusion

Background

Depression is prevalent in coronary heart disease (CHD) patients and increases risk for acute coronary syndrome (ACS) recurrence and mortality despite optimal medical care. The pathways underlying this risk remain elusive. Psychological stress (PS) can provoke impairment in myocardial perfusion and trigger ACS. A confluence of acute PS with depression might reveal coronary vascular mechanisms of risk. We tested whether depression increased risk for impaired myocardial perfusion during acute PS among patients with stable CHD.

Methods and Results

Patients (N=146) completed the Beck Depression Inventory‐I (BDI‐I), a measure of depression linked to recurrent ACS and post‐ACS mortality, and underwent single‐photon emission computed tomography myocardial perfusion imaging at rest and during acute PS. The likelihood of new/worsening impairment in myocardial perfusion from baseline to PS as a function of depression severity was tested. On the BDI‐I, 41 patients scored in the normal range, 48 in the high normal range, and 57 in the depressed range previously linked to CHD prognosis. A BDI‐I score in the depressed range was associated with a significantly greater likelihood of new/worsening impairment in myocardial perfusion from baseline to PS (odds ratio =2.89, 95% CI: 1.26 to 6.63, P=0.012). This remained significant in models controlling ACS recurrence/mortality risk factors and medications. There was no effect for selective serotonin reuptake inhibitor medications.

Conclusions

Depressed patients with CHD are particularly susceptible to impairment in myocardial perfusion during PS. The confluence of PS with depression may contribute to a better understanding of the depression‐associated risk for ACS recurrence and mortality.

Disruption of social bonds induces behavioral and physiological dysregulation in male and female prairie voles

The social disruption of losing a partner may have particularly strong adverse effects on psychological and physiological functioning. More specifically, social stressors may play a mediating role in the association between mood disorders and cardiovascular dysfunction. This study investigated the hypothesis that the disruption of established social bonds between male and female prairie voles would produce depressive behaviors and cardiac dysregulation, coupled with endocrine and autonomic nervous system dysfunction. In Experiment 1, behaviors related to depression, cardiac function, and autonomic nervous system regulation were monitored in male prairie voles during social bonding with a female partner, social isolation from the bonded partner, and a behavioral stressor. Social isolation produced depressive behaviors, increased heart rate, heart rhythm dysregulation, and autonomic imbalance characterized by increased sympathetic and decreased parasympathetic drive to the heart. In Experiment 2, behaviors related to depression and endocrine function were measured following social bonding and social isolation in both male and female prairie voles. Social isolation produced similar levels of depressive behaviors in both sexes, as well as significant elevations of adrenocorticotropic hormone and corticosterone. These alterations in behavioral and physiological functioning provide insight into the mechanisms by which social stressors negatively influence emotional and cardiovascular health in humans.