Psychosocial risk factors and heart failure hospitalization: a prospective cohort study

Quality of Life of Patients with Heart Failure Due to Myocardial Ischemia

Background

Heart failure caused by myocardial ischemia is a common cause encountered in clinical practice. A significant problem in heart failure is its progressive, unfavorable course and the associated increased frequency of repeated hospitalizations, as well as a significant deterioration in the functioning of patients, leading to their inability to function independently and a significant decline in the quality of life. This study aimed to assess the quality of life of patients with heart failure due to myocardial ischemia, considering the left ventricular ejection fraction, the number of "diseased" coronary arteries, co-occurring diseases, and cardiovascular risk factors.

Methods

A total of 204 patients with decompensated heart failure due to chronic myocardial ischemia were included in this study and examined twice: A: on the first day of hospitalization; A': from 4 to 8 weeks. For the individual assessment of the quality of life, the WHOQOL-BREF (The World Health Organization Quality of Life - BREF) questionnaire was used.

Results

In the group of patients with heart failure in the decompensation stage a statistically significant positive relationship was observed between the number of comorbidities and the social domain (R(A) = 0.197; p(A) = 0.005), the number of diseased coronary arteries and the mental (R(A) = 0.184; p(A) = 0.184) and environmental (R(A) = 0.149; p(A) = 0.034) domains, left ventricular ejection fraction (LVEF%) and quality of life (R(A) = 0.235; p = 0.001) and satisfaction with health (R(A) = 0.235; p = 0.001) and somatic domain (R(A) = 0.194; p = 0.005). A similar result was observed among patients in the long-term follow-up. A statistically significant negative correlation was demonstrated in the mentioned group between the LVEF% value and the social domain (R(A) = -0.235; p = 0.001), as well as in the long-term follow-up (R(A') = -0.191, p = 0.026). The level of self-assessment of quality of life and satisfaction with health was statistically significantly higher among patients with heart failure in the long-term follow-up (3.20 ± 0.62) than in patients in the decompensation stage (1.98 ± 0.69).

Conclusions

The quality of life of the examined patients with heart failure caused by chronic myocardial ischemia was poor, although it improved to average in the long-term follow-up. It was determined by left ventricular ejection fraction, the number of "diseased" coronary arteries, comorbidities, and risk factors.

Multidisciplinary care of peripartum heart failure: A scientific statement of the Heart Failure Association of the ESC

Heart failure is the most common cardiovascular complication during pregnancy and the postpartum period. It is associated with increased risk of maternal morbidity and mortality as well as potentially life-threatening foetal pathology. Management of heart failure in pregnancy requires expert knowledge of cardiovascular disease as well as obstetrics which underscores the importance of multidisciplinary cardio-obstetrics teams in order to optimize diagnosis, treatment and outcome. This includes counselling of women at risk before and during the course of pregnancy in order to strengthen the relationship between medical specialists and patients, as well as to allow patient-centred delivery of care and improve quality of life.

Association of Psychosocial Risk Factors and Outcomes in Heart Failure: Does COVID-19 Affect Outcomes?

Psychosocial risk factors (PSRFs) have emerged as crucial nontraditional risk factors affecting outcomes in patients with heart failure (HF). There is a paucity of data studying these risk factors in HF nationally. Additionally, whether the COVID-19 pandemic impacted outcomes remains unexplored, given the increased psychosocial risk during these times. Our objective is to assess the impact of PSRFs on the outcomes of HF and their comparison across non-COVID-19 and COVID-19 eras. Patients with a diagnosis of HF were selected using the 2019-2020 Nationwide Readmissions Database. Two cohorts were created based on the presence or absence of PSRFs and compared across non-COVID-19 and COVID-19 eras. We examined the association using hierarchical multivariable logistic regression models. A total of 305,955 patients were included, of which 175,348 (57%) had PSRFs. Patients with PSRFs were younger, less likely to be female, and had a higher prevalence of cardiovascular risk factors. All-cause readmissions were higher in patients with PSRFs in both the eras. All-cause mortality [odds ratio, OR 1.15 (1.04-1.27), P = 0.005] and composite of MACE [OR 1.11 (1.06-1.16), P < 0.001] were higher in patients in the non-COVID-19 era. Compared to 2019, patients with PSRFs and HF in 2020 had significantly higher all-cause mortality [OR 1.13 (1.03-1.24), P = 0.009]; however, the composite of MACE was comparable [OR 1.04 (1.00-1.09), P = 0.03]. In conclusion, the presence of PSRFs in patients with HF is associated with a significant increase in all-cause readmissions in COVID-19 and non-COVID-19 eras. The worse outcomes evident in the COVID-19 era highlights the importance of multidisciplinary care in this vulnerable population.

Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association

Background Social isolation, the relative absence of or infrequency of contact with different types of social relationships, and loneliness (perceived isolation) are associated with adverse health outcomes. Objective To review observational and intervention research that examines the impact of social isolation and loneliness on cardiovascular and brain health and discuss proposed mechanisms for observed associations. Methods We conducted a systematic scoping review of available research. We searched 4 databases, PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health, and Scopus. Findings Evidence is most consistent for a direct association between social isolation, loneliness, and coronary heart disease and stroke mortality. However, data on the association between social isolation and loneliness with heart failure, dementia, and cognitive impairment are sparse and less robust. Few studies have empirically tested mediating pathways between social isolation, loneliness, and cardiovascular and brain health outcomes using appropriate methods for explanatory analyses. Notably, the effect estimates are small, and there may be unmeasured confounders of the associations. Research in groups that may be at higher risk or more vulnerable to the effects of social isolation is limited. We did not find any intervention studies that sought to reduce the adverse impact of social isolation or loneliness on cardiovascular or brain health outcomes. Conclusions Social isolation and loneliness are common and appear to be independent risk factors for worse cardiovascular and brain health; however, consistency of the associations varies by outcome. There is a need to develop, implement, and test interventions to improve cardiovascular and brain health for individuals who are socially isolated or lonely.

Social Isolation and Incident Heart Failure Hospitalization in Older Women: Women's Health Initiative Study Findings

Background The association of social isolation or lack of social network ties in older adults is unknown. This knowledge gap is important since the risk of heart failure (HF) and social isolation increase with age. The study examines whether social isolation is associated with incident HF in older women, and examines depressive symptoms as a potential mediator and age and race and ethnicity as effect modifiers. Methods and Results This study included 44 174 postmenopausal women of diverse race and ethnicity from the WHI (Women's Health Initiative) study who underwent annual assessment for HF adjudication from baseline enrollment (1993-1998) through 2018. We conducted a mediation analysis to examine depressive symptoms as a potential mediator and further examined effect modification by age and race and ethnicity. Incident HF requiring hospitalization was the main outcome. Social isolation was a composite variable based on marital/partner status, religious ties, and community ties. Depressive symptoms were assessed using CES-D (Center for Epidemiology Studies-Depression). Over a median follow-up of 15.0 years, we analyzed data from 36 457 women, and 2364 (6.5%) incident HF cases occurred; 2510 (6.9%) participants were socially isolated. In multivariable analyses adjusted for sociodemographic, behavioral, clinical, and general health/functioning; socially isolated women had a higher risk of incident HF than nonisolated women (HR, 1.23; 95% CI, 1.08-1.41). Adding depressive symptoms in the model did not change this association (HR, 1.22; 95% CI, 1.07-1.40). Neither race and ethnicity nor age moderated the association between social isolation and incident HF. Conclusions Socially isolated older women are at increased risk for developing HF, independent of traditional HF risk factors. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT00000611.

Changes in vitality in response to acute stress: an investigation of the role of anxiety and physiological reactivity

Background: Feeling alive and invigorated, or vitality, is examined within the framework of a stress paradigm. The current study investigated whether endocrine and cardiovascular responses to acute psychological stress predict declines in vitality.Methods: A sample of 90 undergraduate students completed an in-lab stressor. We measured anxiety, state vitality, cortisol levels, heart rate, and blood pressure before the task, and measured changes in state vitality, cortisol, heart rate, and blood pressure in response to the stressor. We investigated whether pre-task anxiety predicted changes in state vitality, and whether such changes were explained by physiological responses.Results: Results indicate that cognitive and somatic anxiety preceding a stressor predict changes in vitality, which is mediated by the magnitude of diastolic (95% CI [0.017, 0.517]; [0.006, 0.454]) and systolic (95% CI [0.038, 0.705]) blood pressure responses to the task. Cortisol reactivity was associated with somatic anxiety (F(6, 83) = 3.34, p < .01, β = 0.401) but was not related to changes in vitality.Conclusions: Together, these results contribute to the understanding of how physiological reactivity to a stressor can deplete vitality.

Death of a child and the risk of heart failure: a population-based cohort study from Denmark and Sweden

AIMS

We aimed to investigate whether the death of a child, one of the most severe stressors, is associated with the risk of heart failure (HF).

METHODS AND RESULTS

We conducted a population-based cohort study involving parents of live-born children recorded in the Danish and Swedish Medical Birth Registers during 1973-2016 and 1973-2014, respectively (n = 6 717 349). We retrieved information on child death, HF diagnosis and sociodemographic characteristics of the parents from several nationwide registries. We performed Poisson regression models to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for HF in relation to bereavement. A total of 129 829 (1.9%) parents lost at least one child during the follow-up. Bereaved parents had a 35% higher risk of HF than the non-bereaved (IRR 1.35, 95% CI 1.29-1.41; p < 0.001). The increased HF risk was observed not only when the child died due to cardiovascular or other natural causes, but also when the loss was due to unnatural causes. The association tended to be U-shaped when we categorized the exposed parents by the number of remaining live children at loss or by the age of the deceased child.

CONCLUSION

We found that the death of a child was associated with an increased risk of HF. The finding that not only cardiovascular and other natural deaths, but also unnatural deaths were associated with HF suggests that stress-related mechanisms may contribute to the development of HF.

The Interaction Between Fatty Acid Desaturase-2 (FADS2) rs174583 Genetic Variant and Dietary Quality Indices (DASH and MDS) Constructs Different Metabolic Phenotypes Among Obese Individuals

Background and Aim: Genetic variation in fatty acid desaturases (FADS) has previously been linked to several diet-related diseases. We aimed to determine whether the FADS2 rs174583 variant interacts with the Dietary Approach to Stop Hypertension (DASH) score and Mediterranean dietary score (MDS) to influence cardio-metabolic risk factors among obese adults. Methods: This cross-sectional study was performed among 347 apparently healthy obese adults (aged 20-50 years). Dietary quality indicator scores (DASH and MDS) were generated using a validated 147-item Food Frequency Questionnaire (FFQ). The FADS2 rs174583 variant was genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The gene-diet interaction was analyzed by the ANCOVA multivariate interaction model. Results: A significant interaction was observed between rs174583 and adherence to the DASH score in relation to serum triglyceride (TG) concentration among the female group (P Interaction = 0.046); CT-genotype carriers who were assigned to the second tertile of DASH compared with those in the first tertile had a lower TG level (P < 0.05). Another significant interaction was revealed between adherence to MDS score and rs174583 polymorphism on serum glucose levels (P Interaction = 0.044); the lowest mean of glucose level was observed in homozygous minor subjects (TT) in the third tertile of MDS, in comparison with other tertiles of this dietary index (P < 0.05). There was a similar significant interaction between DASH and rs174583 in relation to diastolic blood pressure (P Interaction = 0.038) among the male group. Additionally, a significant positive association was found between TT genotype and odds of having high TG both in the crude (OR, 3.21; 95% CI, 1.02-10.14) and adjusted (OR, 3.58; 95% CI, 1.07-11.97) models, taking into account different confounders. Conclusion: Adherence to the dietary quality indicators (DASH and MDS) modified the relationship between FADS2 rs174583 polymorphism and cardio-metabolic risk factors in obese subjects. Prospective cohort studies are needed to confirm the results of our study.

Vital exhaustion in women with chest pain and no obstructive coronary artery disease: the iPOWER study

BACKGROUND

More than half of women with symptoms suggestive of myocardial ischaemia have no obstructive coronary artery disease (CAD), yet they face a higher risk of cardiovascular mortality and morbidity. Both vital exhaustion (VE) and depression have been linked to adverse cardiovascular prognosis in patients with CAD. We aimed to assess whether symptomatic women with no obstructive CAD are more vitally exhausted compared with asymptomatic women. Furthermore, we investigated the overlap between the constructs of VE and depression.

METHODS

Prevalence and burden of VE was assessed in symptomatic women with no obstructive CAD (n=1.266) and asymptomatic women (n=2.390). Among symptomatic women, we also assessed chest pain characteristics and symptoms of Hospital Anxiety and Depression Questionnaire.

FINDINGS

Median (IQR) VE score was 4 (1-9) and 2 (0-5) in symptomatic and asymptomatic women, respectively (age adjusted, p<0.001). The risk of severe VE was significantly higher in symptomatic women compared with asymptomatic women (OR 3.3, 95% CI 2.5 to 4.4), independent of age and risk factors, and was associated with symptom severity. VE and depression scores were correlated but principal component cluster analysis (PCCA) showed clear distinctiveness between the two constructs.

CONCLUSIONS

Women with chest pain and no obstructive CAD are more vitally exhausted compared with asymptomatic women. PCCA showed that VE is distinct from depression in symptomatic women.

CLINICAL IMPLICATIONS

Mental health screening focusing on depressive symptomatology in women with chest pain presenting with symptoms of mental and physical exhaustion may overlook VE in these patients.

Fatigue and the prediction of negative health outcomes: A systematic review with meta-analysis

INTRODUCTION

Fatigue is a common complaint among older adults. Evidence grows that fatigue is linked to several negative health outcomes. A general overview of fatigue and its relationship with negative health outcomes still lacks in the existing literature. This brings complications for healthcare professionals and researchers to identify fatigue-related health risks. Therefore, this study gives an overview of the prospective predictive value of the main negative health outcomes for fatigue in community-dwelling older adults.

METHODS

PubMed, Web of Knowledge and PsycINFO were systematically screened for prospective studies regarding the relationship between fatigue and negative health outcomes resulting in 4595 articles (last search 5th March 2020). Meta-analyses were conducted in RevMan using Odds ratios (ORs), Hazard ratios (HRs) and relative risk ratios (RR) that were extracted from the included studies. Subgroup-analyses were performed based on (1) gender (male/female), (2) length of follow-up and (3) fatigue level (low, medium and high).

RESULTS

In total, thirty articles were included for this systematic review and meta-analysis encompassing 152 711 participants (age range 40-98 years), providing information on the relationship between fatigue and health outcomes. The results showed that fatigue is related to an increased risk for the occurrence of all studied health outcomes (range OR 1.299-3.094; HR/RR 1.038-1.471); for example, mortality OR 2.14 [1.74-2.63]; HR/RR 1.44 [1.28-1.62]), the development of disabilities in basic activities of daily living (OR 3.22 [2.05-5.38]), or the occurrence of physical decline (OR 1.42 [1.29-1.57]).

CONCLUSION

Overall fatigue increases the risk for developing negative health outcomes. The analyses presented in this study show that fatigue related physical decline occurs earlier than hospitalization, diseases and mortality, suggesting the importance of early interventions.

Effects of Life Events and Social Isolation on Stroke and Coronary Heart Disease

The current coronavirus disease 2019 (COVID-19) pandemic represents a severe, life-changing event for people across the world. Life changes may involve job loss, income reduction due to furlough, death of a beloved one, or social stress due to life habit changes. Many people suffer from social isolation due to lockdown or physical distancing, especially those living alone and without family. This article reviews the association of life events and social isolation with cardiovascular disease, assembling the current state of knowledge for stroke and coronary heart disease. Possible mechanisms underlying the links between life events, social isolation, and cardiovascular disease are outlined. Furthermore, groups with increased vulnerability for cardiovascular disease following life events and social isolation are identified, and clinical implications of results are presented.

Association of psychosocial factors with all-cause hospitalizations in patients with atrial fibrillation

Background

A high burden of cardiovascular comorbidities puts patients with atrial fibrillation (AF) at high risk for hospitalizations, but the role of other factors is less clear.

Hypothesis

To determine the relationship between psychosocial factors and the risk of unplanned hospitalizations in AF patients.

Methods

Prospective observational cohort study of 2378 patients aged 65 or older with previously diagnosed AF across 14 centers in Switzerland. Marital status and education level were defined as social factors, depression and health perception were psychological components. The pre‐defined outcome was unplanned all‐cause hospitalization.

Results

During a median follow‐up of 2.0 years, a total of 1713 hospitalizations occurred in 37% of patients. Compared to patients who were married, adjusted rate ratios (aRR) for all‐cause hospitalizations were 1.28 (95% confidence interval [CI], 0.97‐1.69) for singles, 1.31 (95%CI, 1.06‐1.62) for divorced patients, and 1.02 (95%CI, 0.82‐1.25) for widowed patients. The aRRs for all‐cause hospitalizations across increasing quartiles of health perception were 1.0 (highest health perception), 1.15 (95%CI, 0.84‐1.59), 1.25 (95%CI, 1.03‐1.53), and 1.66 (95%CI, 1.34‐2.07). No different hospitalization rates were observed in patients with a secondary or primary or less education as compared to patients with a college degree (aRR, 1.06; 95%CI, 0.91‐1.23 and 1.05; 95%CI, 0.83‐1.33, respectively). Presence of depression was not associated with higher hospitalization rates (aRR, 0.94; 95%CI, 0.68‐1.29).

Conclusions

The findings suggest that psychosocial factors, including marital status and health perception, are strongly associated with the occurrence of hospitalizations in AF patients. Targeted psychosocial support interventions may help to avoid unnecessary hospitalizations.

Trial registration

ClinicalTrials.gov Identifier NCT02105844.

Associations of perceived stress and state anger with symptom burden and functional status in patients with heart failure

Background: Psychosocial stress and anger trigger cardiovascular events, but their relationship to heart failure (HF) exacerbations is unclear. We investigated perceived stress and anger associations with HF functional status and symptoms. Methods and Results: In a prospective cohort study (BETRHEART), 144 patients with HF (77% male; 57.5 ± 11.5 years) were evaluated for perceived stress (Perceived Stress Scale; PSS) and state anger (STAXI) at baseline and every 2 weeks for 3 months. Objective functional status (6-min walk test; 6MWT) and health status (Kansas City Cardiomyopathy Questionnaire; KCCQ) were also measured biweekly. Linear mixed model analyses indicated that average PSS and greater than usual increases in PSS were associated with worsened KCCQ scores. Greater than usual increases in PSS were associated with worsened 6MWT. Average anger levels were associated with worsened KCCQ, and increases in anger were associated with worsened 6MWT. Adjusting for PSS, anger associations were no longer statistically significant. Adjusting for anger, PSS associations with KCCQ and 6MWT remained significant. Conclusion: In patients with HF, both perceived stress and anger are associated with poorer functional and health status, but perceived stress is a stronger predictor. Negative effects of anger on HF functional status and health status may partly operate through psychological stress.

Vital Exhaustion and Incidence of Dementia: Results from the Copenhagen City Heart Study

BACKGROUND

Psychological distress is potentially linked to the risk of dementia through neurologic and cardiovascular mechanisms. Vital exhaustion (VE) is a mental state of psychological distress, which could be a risk factor for dementia.

OBJECTIVE

To investigate whether VE is a risk factor for dementia in later life.

METHODS

We used data from 6,807 participants attending the third survey of the Copenhagen City Heart Study in 1991-1994. VE was assessed by 17 symptoms (score: 0-17) from the Maastricht Questionnaire. Information on dementia was obtained from national registers. Risk time for dementia was counted from five years after VE assessment for participants > 55 years at the time of VE assessment. For younger participants, risk time for dementia was counted from the year they turned 60 years and onwards. Participants were followed until 2016. We used Poisson regression to calculate incidence rate ratios (IRR) and their 95% confidence intervals (CI).

RESULTS

During an average follow-up of 10 years, 872 participants were registered with dementia. We found a dose-response relation between the number of VE symptoms and the incidence of dementia. For every additional VE symptom, the dementia incidence increased by 2% (IRR = 1.024; 95% CI: 1.004-1.043). Adjustment for socio-demographic and health-related factors did not change the results substantially. Neither did stratification by age, sex, educational level, and marital status.

CONCLUSION

We found evidence that VE is a risk factor for dementia. Our sensitivity analyses supported that this association was not only due to VE being a potential prodromal sign of dementia.

Vital exhaustion and risk of alcohol use disorders: A prospective cohort study

OBJECTIVE

Vital exhaustion is an emotional state characterized by fatigue and depressive symptoms. We examined the prospective association between vital exhaustion and risk of alcohol use disorders (AUD). Furthermore, we investigated whether cohabitation status modifies the effect of this potential association.

METHODS

Vital exhaustion was assessed by a condensed, 17 item, version of the Maastricht Questionnaire as part of the Copenhagen City Heart Study in 1991-93. The study population consisted of 8956 individuals aged 21-93 years, who were followed for a first-time diagnosis of AUD in national registers until 2016. The mean length of follow-up was 16.6 years.

RESULTS

During follow-up, AUD was diagnosed in 146 men and 103 women. For both sexes, the risk of AUD increased dose-dependently with increasing vital exhaustion. Individuals who reported high vital exhaustion had a 2- to 3-fold higher risk of AUD in both men (HR = 2.46, 95% CI: 1.40-4.29) and women (HR = 3.34, 95% CI: 1.62-6.85). A potential modifying effect of cohabitation status on the relation between vital exhaustion and AUD was found for men.

CONCLUSION

The results showed that vital exhaustion is significantly associated with a higher risk of AUD in both men and women and that living with a cohabitee may have a protective effect among men.

Use of hypnotics and the risk of or mortality from heart disease: a meta-analysis of observational studies

BACKGROUND/AIMS

Some observational epidemiologic studies have reported conflicting results on the relationship between hypnotics use and the risk of developing and/or dying from heart disease. We investigated these associations using a meta-analysis of available literatures.

METHODS

We searched the databases PubMed and EMBASE, along with the bibliographies of relevant articles to find additional publications in February 2016.

RESULTS

Of 495 articles satisfying our initial criteria, two case-control studies and six cohort studies met our inclusion criteria and were included in the final analyses. Compared with never having used any kind of hypnotics, the odds ratio for overall use was 0.84 for risk of or mortality from heart disease (95% confidence interval, 0.79 to 0.89) in a random-effects meta-analysis of all eight studies. With respect to the geographical region, use of hypnotics was associated with a decreased risk or mortality of heart disease in Asia but not in Western countries. Among various types of sleep medications, zolpidem showed a decreased risk (-29%) of developing or dying from heart disease, but benzodiazepines were related with an increased risk (80%) of or mortality from heart disease.

CONCLUSIONS

The current meta-analysis of observational epidemiological studies suggested an evidence of association between hypnotics use and a decreased risk of heart disease.

Major life events and risk of alcohol use disorders: a prospective cohort study

AIMS

To estimate associations of individual major life events as well as accumulated major life events in childhood, adult private life and adult work life with risk of alcohol use disorders (AUD).

DESIGN

Prospective cohort study with baseline examination in 1991-93 and linkage to national registers to identify AUD at follow-up.

SETTING

Copenhagen, Denmark.

PARTICIPANTS

Individuals (aged 21-93 years) who participated in the Copenhagen City Heart Study in 1991-93 (n = 8758).

MEASUREMENTS

The primary outcome was first registration with AUD during follow-up (n = 249). AUD was identified in the Danish National Patient Register, in the Danish Psychiatric Central Register and in an outpatient treatment register. Major life events were assessed by a questionnaire in the Copenhagen City Heart study. Data were analysed by Cox proportional hazards models adjusted for age, sex, educational level, household income, cohabitation status and psychiatric comorbidity.

FINDINGS

Serious family conflicts in childhood [hazard ratio (HR) = 1.35; 95% confidence interval (CI) = 1.00, 1.83] and serious economic problems in adult life (HR = 2.22; 95% CI = 1.64, 3.01) were associated significantly with increased risk of AUD. Prospective analyses did not show consistent effects of accumulation of major life events in childhood or adult life, but an additional analysis based on all AUD registrations suggested an association between accumulated childhood events and risk of AUD.

CONCLUSIONS

Serious economic problems in adult life are associated strongly with risk of alcohol use disorders, and there may be an influence of accumulated childhood events on risk of alcohol use disorders.

Vital Exhaustion and Coronary Heart Disease Risk: A Systematic Review and Meta-Analysis

OBJECTIVE

The construct of vital exhaustion has been identified as a potential independent psychological risk factor for incident and recurrent coronary heart disease (CHD). Despite several decades of research, no systematic review or meta-analysis has previously attempted to collate the empirical evidence in this field. The purpose of this study was to review and quantify the impact of vital exhaustion on the development and progression of CHD.

METHODS

Prospective and case-control studies reporting vital exhaustion at baseline and CHD outcomes at follow-up were derived from PubMed, PsycINFO (1980 to July 2015; articles in English and published articles only), and bibliographies. Information on aim, study design, sample size, inclusion and exclusion criteria, assessment methods of psychological risk factors, and results of crude and adjusted regression analyses were abstracted independently by two authors.

RESULTS

Thirteen prospective (n = 52,636) and three case-control (cases, n = 244; controls, n = 457) studies assessed vital exhaustion and could be summarized in meta-analyses. The pooled adjusted risk of CHD in healthy populations was 1.50 (95% confidence interval [CI] = 1.22-1.85) for prospective studies, and 2.61 (95% CI = 1.66-4.10) for case-control studies using hospital controls. Risk of recurrent events in patients with CHD was 2.03 (95% CI = 1.54-2.68). The pooled adjusted risk of chronic heart failure in healthy populations was 1.37 (95% CI = 1.21-1.56), but this was based on results from only two studies.

CONCLUSIONS

Vital exhaustion is associated with increased risk of incident and recurrent CHD.

From Vitality to Vital Exhaustion and Other States of "Tense Tiredness": A New Biopsychosocial Risk Domain

Fatigue is a common prodromal symptom for various medical conditions, including acute myocardial infarction. Fatigue is also the core component of vital exhaustion, which consists of a specific triad: excessive fatigue, increased irritability, and feelings of demoralization. In this issue of Psychosomatic Medicine, Frestad and Prescott present a meta-analysis of 16 studies, involving 53,337 participants, which found vital exhaustion to be associated with an increased risk of incident coronary heart disease (CHD) and recurrent cardiac events among individuals with established CHD. After discussing methodological limitations of the studies included in this meta-analysis, we describe these findings in terms of a larger genre of risk that is biopsychosocial in origin and tied to two types of tiredness: "calm tiredness" and "tense tiredness." The former is regenerative, while the latter enhances disease risk. We propose that besides vital exhaustion, other symptoms of negative affect may combine with tiredness to produce increased clinical risk, such as the presence of depressed mood, an inability to relax or recover after work, and symptoms of burnout. We further propose that vital exhaustion can be considered as part of a larger paradigm, ranging from a positive state of vitality to a negative state of exhaustion of vitality. We conclude this editorial by emphasizing the importance of improving vitality and the need to clarify biobehavioral mechanisms that play a role in the association between vital exhaustion and adverse CHD outcomes. New interventions are needed that target reducing exhaustion and improving vitality for individuals at high risk of CHD.

Ranking of psychosocial and traditional risk factors by importance for coronary heart disease: the Copenhagen City Heart Study

AIMS

To rank psychosocial and traditional risk factors by importance for coronary heart disease.

METHODS AND RESULTS

The Copenhagen City Heart Study is a prospective cardiovascular population study randomly selected in 1976. The third examination was carried out from 1991 to 1994, and 8882 men and women free of cardiovascular diseases were included in this study. Events were assessed until April 2013. Forward selection, population attributable fraction, and gradient boosting machine were used for determining ranks. The importance of vital exhaustion for risk prediction was investigated by C-statistics and net reclassification improvement. During the follow-up, 1731 non-fatal and fatal coronary events were registered. In men, the highest ranking risk factors for coronary heart disease were vital exhaustion [high vs. low; hazard ratio (HR) 2.36; 95% confidence interval (CI), 1.70-3.26; P < 0.001] and systolic blood pressure (≥160 mmHg or blood pressure medication vs. <120 mmHg; HR 2.07; 95% CI, 1.48-2.88; P < 0.001). In women, smoking was of highest importance (≥15 g tobacco/day vs. never smoker; HR 1.74; 95% CI, 1.43-2.11; P < 0.001), followed by vital exhaustion (high vs. low; HR 2.07; 95% CI, 1.61-2.68; P < 0.001). Vital exhaustion ranked first in women and fourth in men by population attributable fraction of 27.7% (95% CI, 18.6-36.7%; P < 0.001) and 21.1% (95% CI, 13.0-29.2%; P < 0.001), respectively. Finally, vital exhaustion significantly improved risk prediction.

CONCLUSION

Vital exhaustion was one of the most important risk factors for coronary heart disease, our findings emphasize the importance of including psychosocial factors in risk prediction scores.

Interleukin-6 gene polymorphism, chronic stress and atherosclerosis: interleukin-6-174G>C polymorphism, chronic stress and risk of early atherosclerosis in the Cardiovascular Risk in Young Finns Study

OBJECTIVE

Interleukin-6 protein has been suggested as a mediator connecting chronic stress and cardiovascular diseases. We investigated whether the functional G174C polymorphism (rs1800795) of interleukin-6 gene is associated with vital exhaustion, a measure of chronic stress, or with preclinical atherosclerosis.

METHODS

Associations between the interleukin-6-174G>C polymorphism, preclinical atherosclerosis, and vital exhaustion were examined in 1673 women and men aged 24-39years participating in the Cardiovascular Risk in Young Finns study. Vital exhaustion was measured using Maastricht Questionnaire. Preclinical atherosclerosis was assessed by carotid intima-media thickness using ultrasound techniques. DNA was genotyped for the interleukin-6-174G>C polymorphism (rs1800795).

RESULTS

The GG genotype of the interleukin-6-174G>C polymorphism was associated with higher vital exhaustion. Moreover, higher vital exhaustion was associated with greater intima-media thickness in men carrying G alleles, adjusted for cardiovascular risk factors.

CONCLUSION

Our findings support a role for the interleukin-6-174G>C polymorphism in increased risk of atherosclerosis in individuals with chronic stress. In addition, individuals carrying the G allele of the interleukin-6-174G>C polymorphism may be more prone to adverse effects of psychosocial stress.

Understanding the role of depression and anxiety on cardiovascular disease risk, using structural equation modeling; the mediating effect of the Mediterranean diet and physical activity: the ATTICA study

PURPOSE

To evaluate the mediating role of behavioral patterns, such as adherence to the Mediterranean diet and physical activity status, in the relationship between depression, anxiety, and the cardiovascular disease (CVD) risk score HellenicSCORE.

METHODS

In the context of the ATTICA study, a cross-sectional survey, 453 men (45 ± 13 years) and 400 women (44 ± 18 years), with complete psychological evaluation were studied. Participants were without any evidence of cardiovascular or other chronic disease. Depression was assessed with the Zung Self-Rating Depression Scale and anxious state by the Spielberger State Anxiety Inventory Scale. Physical activity was assessed using the International Physical Activity Questionnaire and adherence to the Mediterranean diet was assessed by the MedDietScore. Structural equation modeling methodology was implemented in the statistical analysis.

RESULTS

Five latent depression and anxiety factors were revealed and associated with CVD risk score through mediation of physical activity status and adherence to the Mediterranean diet with very good fit to the data (χ(2)/df ratio = 2.34; root mean square error of approximation = 0.021; 90% confidence interval, 0.020-0.022; comparative fit index = 0.951). Significant total effect on CVD risk was found for the "anxiety-worry" latent factor, and this effect was through the inverse relationship of "anxiety-worry" with MedDietScore (P = .002). Moreover, "positive feelings" latent construct was associated with lower CVD risk, and this seems to be through the higher adherence to the Mediterranean diet (P = .01).

CONCLUSIONS

Adherence to the Mediterranean diet seems to mediate the unfavorable effect of depression and anxiety on CVD risk.