Relationship of blood coagulation and fibrinolysis to vital exhaustion

The Short Version of the Italian Maastricht Vital Exhaustion Questionnaire (MVEQ): Psychometric Properties and Relationships with Anxiety, Depression, and Stress in a Community Sample of Older Adults

Vital Exhaustion (VE) refers to a physical and mental state of excessive fatigue, feelings of demoralization, hopelessness, and increased irritability. The short form of the Maastricht Vital Exhaustion Questionnaire (MVEQ) is a widely used measure to assess VE. Despite its utility is broadly recognized, the validity and reliability of the scale have yet to be examined in the Italian context. The present study aimed to evaluate the psychometric properties of the shortened MVEQ in a community sample of Italian older adults. A total of 722 older adults (Mage = 72.97, SD = 7.71; 60.4% females) completed the MVEQ, as well as other self-report questionnaires assessing anxiety, depression and stress in order to evaluate the criterion-related validity of the scale. A confirmatory factor analysis (CFA) was conducted to examine the original MVEQ latent structure. Internal consistency was assessed through model-based omega coefficient. Test-retest reliability was examined by re-administering the MVEQ after three months to a subsample of 568 participants. Factorial invariance tests across gender were conducted by means of multi-group CFAs. The one-factor model showed an acceptable fit to the data. The MVEQ yielded a reliable total score (ω = 0.822) and showed moderate-to-large correlations with measures of anxiety, depression, and stress (r range 0.30 to 0.75, ps < 0.001). Test-retest reliability was supported by an Intraclass Correlation Coefficient (ICC) of 0.661. Lastly, the scale was factorially invariant across gender. Overall, the MVEQ provided evidence of reliability and criterion-related validity in a sample of Italian older adults and may be useful for both clinical and research practices.

Polygenic liabilities underlying job stress and exhaustion over a 10-year follow-up: A general population study

We investigated whether individuals, who have a high polygenic loading for schizophrenia and major depression (PGL) but have not developed the respective disorders, are still susceptible to experience milder forms of ill-being in terms of job strain or exhaustion. We used the population-based Young Finns Study data (n = 928). PGL was assessed with a cumulative score of the polygenic risk scores for schizophrenia and depression. Participants (24-49-year-olds) evaluated their exhaustion levels and perceived job characteristics over a 10-year follow-up (2001, 2007, 2011). Participants with diagnosed psychotic or affective disorders were excluded. We found that high PGL did not predict less favorable perceptions of job environment (job strain, demands, control, satisfaction, social support at work) but high PGL predicted a higher trajectory of exhaustion in early adulthood and middle age. Additionally, high (vs. low) PGL predicted a stronger increase in exhaustion at increased levels of job strain. These findings remained after controlling for sex, socioeconomic factors, health behaviors, and cognitive performance. In conclusion, individuals with high PGL may have an elevated liability to experience exhaustion especially in early adulthood and middle age (despite they perceive their job environment similarly than others), and especially and at high levels of job strain.

Depression, anxiety, and vital exhaustion are associated with pro-coagulant markers in depressed patients with coronary artery disease - A cross sectional and prospective secondary analysis of the SPIRR-CAD trial

INTRODUCTION

A hyper-coagulant state is a biological mechanism that triggers cardiac events in patients with coronary artery disease (CAD). Depressive symptoms and anxiety predict an unfavourable course of CAD. The SPIRR-CAD-RCT examined the effects of a psychological intervention and provided the opportunity to explore cross-sectional associations between indices of psychological strain and coagulation parameters, as well as prospective changes in depression scores and coagulation parameters.

METHODS

In this secondary analysis, we investigated 253 CAD patients (194 male; age m 58.9, SD 8.3 yrs.) with mild to moderate depression (≥8 on the HADS-D) at baseline and at follow-up 18 months later: TF, fibrinogen, D-dimer, VWF, FVII and PAI-1 and the course of depression (HAM-D), vital exhaustion (VE) and anxiety scores (HADS-A) were examined by ANOVA in the total and younger age groups (≤ 60).

RESULTS

HAM-D at baseline was correlated with TF (corr. R² = 0.27; F = 9.31, p = 0.001). HADS anxiety was associated with fibrinogen (corr. R².20; F = 7.27, p = 0.001). There was no detectable therapeutic effect on coagulation. Fibrinogen and VWF decreased within 18 months (time effect; p = 0.02; p = 0.04), as did HADS-D in both treatment groups (p < 0.001). Fibrinogen decreased more in patients ≤60 years with high VE compared to low VE (interaction time x group, p = 0.01).

CONCLUSIONS

This is the first study to show an association between TF and depression. Coagulation parameters as potential mediators of CAD progression correlated cross-sectionally with depression and anxiety and prospectively with VE. Further studies should replicate these correlations in depressed and non-depressed CAD patients.

ISRCTN

76240576; clinicaltrials.gov.

Anticoagulants and the Hemostatic System: A Primer for Occupational Stress Researchers

Anticoagulation, the body’s mechanism to prevent blood clotting, is an internal biomarker of an individual’s response to stress. Research has indicated that understanding the causes, processes, and consequences of anticoagulation can provide important insight into the experience of individuals facing emotional and occupational strain. Unfortunately, despite their importance, the mechanisms and implications of anticoagulation are unfamiliar to many researchers and practitioners working with trauma-exposed professionals. This paper provides an accessible primer on the topic of anticoagulation, including an overview of the biological process, the research connecting these processes with emotional and occupational functioning, as well as some potential methods for assessment.

Meta-Analysis of Relation of Vital Exhaustion to Cardiovascular Disease Events

To assess the net impact of vital exhaustion on cardiovascular events and all-cause mortality, we conducted a systematic search of PubMed, EMBASE, and PsychINFO (through April 2016) to identify all studies which investigated the relation between vital exhaustion (VE) and health outcomes. Inclusion criteria were as follows: (1) a cohort study (prospective cohort or historical cohort) consisting of adults (>18 years); (2) at least 1 self-reported or interview-based assessment of VE or exhaustion; (3) evaluated the association between vital exhaustion or exhaustion and relevant outcomes; and (4) reported adjusted risk estimates of vital exhaustion/exhaustion for outcomes. Maximally adjusted effect estimates with 95% CIs along with variables used for adjustment in multivariate analysis were also abstracted. Primary study outcome was cardiovascular events. Secondary outcomes were stroke and all-cause mortality. Seventeen studies (19 comparisons) with a total of 107,175 participants were included in the analysis. Mean follow-up was 6 years. VE was significantly associated with an increased risk for cardiovascular events (relative risk 1.53, 95% CI 1.28 to 1.83, p <0.001) and all-cause mortality (relative risk 1.48, 95% CI 1.28 to 1.72, p <0.001). VE also showed a trend for increased incident stroke (relative risk 1.46, 95% CI 0.97 to 2.21, p = 0.07). Subgroup analyses yielded similar results. VE is a significant risk factor for cardiovascular events, comparable in potency to common psychosocial risk factors. Our results imply a need to more closely study VE, and potentially related states of exhaustion, such as occupational burnout.

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.

Fatigue is associated with excess mortality in the general population: results from the EPIC-Norfolk study

BACKGROUND

Significant fatigue is a frequent reason for seeking medical advice in the general population. Patients, however, commonly feel their complaint is ignored. This situation may be because clinicians perceive fatigue to be benign, unrelated to traditional biomedical outcomes such as premature mortality. The present study aimed to investigate whether an association between significant fatigue and mortality actually exists, and, if so, to identify potential mechanisms of this association.

METHODS

A population-based cohort of 18,101 men and women aged 40-79 years who completed a measure of fatigue (Short Form 36 vitality domain, SF36-VT) in addition to providing information on possible confounding factors (age, sex, body mass index, marital status, smoking, education level, alcohol consumption, social class, depression, bodily pain, diabetes, use of β blockers, physical activity and diet) and mechanisms (haemoglobin, C-reactive protein and thyroid function) were followed up prospectively for up to 20 years. Mortality from all causes, cancer and cardiovascular disease was ascertained using death certification linkage with the UK Office of National Statistics.

RESULTS

During 300,322 person years of follow-up (mean 16.6 years), 4397 deaths occurred. After adjusting for confounders, the hazard ratio (HR) for all-cause mortality was 1.40 (95 % confidence interval [CI] 1.25-1.56) for those reporting the highest fatigue (bottom SF36-VT quartile) compared with those reporting the lowest fatigue (top SF36-VT quartile). This significant association was specifically observed for those deaths related to cardiovascular disease (HR 1.45, 95 % CI 1.18-1.78) but not cancer (HR 1.09, 95 % CI 0.90-1.32). Of the considered mechanisms, thyroid function was most notable for attenuating this association. The risk of all-cause mortality, however, remained significant even after considering all putative confounders and mechanisms (HR 1.26, 95 % CI 1.10-1.45).

CONCLUSIONS

High levels of fatigue are associated with excess mortality in the general population. This commonly dismissed symptom demands greater evaluation and should not automatically be considered benign.

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.

Women's exhaustion and coronary artery atherosclerosis progression: The Stockholm Female Coronary Angiography Study

OBJECTIVE

Vital exhaustion (VE) has been associated with incident and recurrent cardiac events. The present study investigated the impact of VE on coronary atherosclerosis progression for 3 years. We further aimed to detect the relative importance of the VE subcomponents, fatigue, and depressed mood.

METHODS

103 women (age range, 30-65 years) who had experienced an acute coronary event underwent quantitative coronary angiography at baseline and again after 3 years. VE and subcomponents were assessed using the Maastricht Questionnaire.

RESULTS

VE correlated significantly with coronary artery diameter change for 3 years (r = -0.239, p = .015). When analyzed in quartiles, women of the highest VE level showed the most pronounced coronary artery luminal diameter narrowing (mean = 0.21 mm, 95% confidence interval [CI] = 0.15-0.27), women in the third quartile were intermediate (mean = 0.11 mm, 95% CI = 0.05-0.17), and women within the two lower quartiles showed no significant change. High levels of the depressed mood and fatigue subscales were also associated with coronary artery diameter narrowing (mean = 0.19 mm, 95% CI = 0.12-0.26, p = .003; and mean = 0.17 mm, 95% CI = 0.08-0.26, p = .03, respectively). However, the associations were attenuated when both variables were entered into the model simultaneously: 0.17 mm (95% CI = 0.09-0.25, p = .05) and 0.14 mm (95% CI = 0.03-0.25, p = .67), respectively.

CONCLUSIONS

VE was associated with accelerated coronary atherosclerosis progression in relatively young women who had experienced an acute coronary event. This association was mainly driven by depressed mood.

The effect of work shift and sleep duration on various aspects of police officers' health

Police officers are prone to cardiovascular disease, overweight, and obesity. Because night-shift work affects sleep, a modifiable risk factor linked to chronic disease, the researchers explored the relationship among shift work, sleep, and wellness for police officers. Sleep, C-reactive protein (CRP) levels, stress, fatigue, and body mass index were used to compare officers who worked primarily day shifts to those who worked primarily evening or night shifts, and officers who slept less than 6 hours per day to those who slept at least 6 hours per day. A cross-sectional study of 85 male officers, 20 to 63 years old, was completed at three Midwestern police departments. The Pittsburgh Sleep Quality Index was used to assess sleep. A questionnaire was used to collect officer demographics and work hours. Other measurements included serum CRP, height, weight, perceived stress, and vital exhaustion. The relative risk of sleeping less than 6 hours per day for officers who primarily worked non-day shifts, compared to those who worked day shifts, was 14.27 (95% confidence interval [CI], 1.98-102.95, p < .001), and the relative risk of overall poor sleep quality for officers who slept less than 6 hours per day, compared to those who slept more hours, was 2.44 (95% CI, 1.15-5.20, p = .027). CRP was not associated with shift or sleep duration, even when adjusted for officers' ages.

Vital exhaustion, depressive symptoms and serum triglyceride levels in high-risk middle-aged men

The role of elevated serum triglyceride level as a risk factor of coronary artery disease is well established. Previous results have also indicated that depression or depressive symptoms and vital exhaustion correlate with triglyceride levels. The aim of this study was to investigate the associations of depressive symptoms, vital exhaustion, and health behavior with serum triglyceride levels. The study sample comprised 444 high-risk middle-aged men. Participants completed self-report questionnaires before laboratory tests. Triglyceride concentrations were measured by the enzymatic method. Vital exhaustion and depression were associated with unhealthy lifestyles and triglycerides. Vital exhaustion and depression were closely correlated constructs with comparable relations with known coronary artery disease risk factors. When comparing vital exhaustion (VE) to Beck Depression Inventory (BDI), however, the first one had a stronger correlation with triglycerides (TG), and also, path analyses showed a direct link from vital exhaustion to body mass index but not from depression. Both vital exhaustion and depression are related to triglyceride levels. The relations are partly mediated by unfavorable lifestyles. Although vital exhaustion is not so commonly assessed as depression, results of this study support the importance of vital exhaustion as a health-related psychological risk factor.

Relationship of Cardiovascular Disease to Stress and Vital Exhaustion in an Urban, Midwestern Police Department

This study explored risk factors for cardiovascular disease (CVD) among 336 officers of a Midwestern police force. Instruments used included the Perceived Stress Scale, the Maastricht Questionnaire (measuring vital exhaustion), and a general Health Risk Appraisal. Rates of CVD, hypertension, and hypercholesterolemia were 3%, 28%, and 43%, respectively. The relative risk of hypercholesterolemia for male officers, compared to female officers, was 1.98 (95% confidence interval [CI], 1.10 to 3.56). The officers' average body mass index was 28.6 ( SD = 4.9), with 80% being overweight or obese. The average vital exhaustion score was higher for female officers than male officers ( p < .05). Bivariate relationships of CVD with perceived stress, vital exhaustion, and age were statistically significant (p < .05). When controlling for age, odds ratios were 1.20 (95% CI, 1.03 to 1.39; p< .05) for perceived stress and 1.31 (95% CI, 1.12 to 1.53; p < .01) for vital exhaustion.

Relationship of cardiovascular disease to stress and vital exhaustion in an urban, midwestern police department

This study explored risk factors for cardiovascular disease (CVD) among 336 officers of a Midwestern police force. Instruments used included the Perceived Stress Scale, the Maastricht Questionnaire (measuring vital exhaustion), and a general Health Risk Appraisal. Rates of CVD, hypertension, and hypercholesterolemia were 3%, 28%, and 43%, respectively. The relative risk of hypercholesterolemia for male officers, compared to female officers, was 1.98 (95% confidence interval [CI], 1.10 to 3.56). The officers' average body mass index was 28.6 (SD = 4.9), with 80% being overweight or obese. The average vital exhaustion score was higher for female officers than male officers (p < .05). Bivariate relationships of CVD with perceived stress, vital exhaustion, and age were statistically significant (p < .05). When controlling for age, odds ratios were 1.20 (95% CI, 1.03 to 1.39; p < .05) for perceived stress and 1.31 (95% CI, 1.12 to 1.53; p < .01) for vital exhaustion.

Vital exhaustion and cardiovascular prognosis in myocardial infarction and heart failure: predictive power of different trajectories

BACKGROUND

We examined the different trajectories of vital exhaustion (VE) over a 12-month period and their impact on prognosis in a sample of myocardial infarction (MI) and chronic heart failure (CHF) patients.

METHOD

Consecutive MI (n=407) and CHF patients (n=297) were assessed at baseline, and at 3- and 12-month follow-up for symptoms of VE. Latent growth mixture modelling was used to examine the course of VE over time. The combined clinical endpoint was defined as cardiac hospital readmission or death.

RESULTS

Four distinct trajectories for VE were found: low VE, decreasing VE, increasing VE, and severe VE. Sex, marital status, left ventricular ejection fraction, psychotropic medication, sample group (CHF v. MI) and depressive symptoms were associated with VE, varying according to classes. The mean follow-up period was 25.3 months in which 34.7% of the patients experienced an event. Multivariate Cox regression showed that, compared with patients in the low VE class, patients in the increasing VE class [hazard ratio (HR)=1.16, 95% confidence interval (CI) 1.58-3.61, p=0.01], and the severe VE class (HR=1.69, 95% CI 1.31-2.64, p=0.02) had an increased risk for adverse cardiovascular events (i.e. cardiovascular hospital readmission or cardiovascular death). Decreasing VE was not related to adverse cardiovascular events (HR=0.97, 95% CI 0.66-1.69, p=0.81).

CONCLUSIONS

VE trajectories varied across cardiac patients, and had a differential effect on cardiovascular outcome. Increasing VE and severe VE classes were predictors of poor cardiovascular prognosis. These results suggest that identification of cardiac patients with an increased risk of adverse health outcomes should be based on multiple assessments of VE.

Sex differences in the combined effect of chronic stress with impaired vascular endothelium functioning and the development of early atherosclerosis: the Cardiovascular Risk in Young Finns study

Background

The syndrome of vital exhaustion (VE), characterized by fatigue and irritability, may contribute to an increased risk of atherosclerosis. The aim of the study was to explore sex differences in the interactions of VE with endothelial dysfunction and VE with reduced carotid elasticity, the important contributors to the development of early atherosclerosis, on preclinical atherosclerosis.

Methods

The participants were 1002 women and 719 men aged 24-39 examined in the Cardiovascular Risk in Young Finns study. Vital exhaustion was measured using the Maastricht Questionnaire. Preclinical atherosclerosis was assessed by carotid intima-media thickness (IMT), endothelial function was measured by brachial flow-mediated dilatation (FMD), and arterial elasticity by carotid artery compliance (CAC) using ultrasound techniques.

Results

We found a significant CAC x VE interaction for IMT only for the men. Our results imply that high VE level significantly related to high IMT levels among the men with low CAC, but not among the women with low CAC or among the women or men with high CAC. No significant FMD x VE interactions for IMT for the women or men were found.

Conclusions

High VE may exert an effect on IMT for men with impaired arterial elasticity. The results suggest that high vitally exhausted men with reduced arterial elasticity are at increased risk of atherosclerosis in early life and imply men's decreased stress coping in relation to stressful psychological coronary risk factors.

Vital exhaustion as a risk factor for adverse cardiac events (from the Atherosclerosis Risk In Communities [ARIC] study)

Vital exhaustion, defined as excessive fatigue, feelings of demoralization, and increased irritability, has been identified as a risk factor for incident and recurrent cardiac events, but there are no population-based prospective studies of this association in US samples. We examined the predictive value of vital exhaustion for incident myocardial infarction or fatal coronary heart disease in middle-aged men and women in 4 US communities. Participants were 12,895 black or white men and women enrolled in the Atherosclerosis Risk In Communities (ARIC) study cohort and followed for the occurrence of cardiac morbidity and mortality from 1990 through 2002 (maximum follow-up 13.0 years). Vital exhaustion was assessed using the 21-item Maastricht Questionnaire and scores were partitioned into approximate quartiles for statistical analyses. High vital exhaustion (fourth quartile) predicted adverse cardiac events in age-, gender-, and race-center-adjusted analyses (1.69, 95% confidence interval 1.40 to 2.05) and in analyses further adjusted for educational level, body mass index, plasma low-density lipoprotein and high-density lipoprotein cholesterol levels, systolic and diastolic blood pressure levels, diabetes mellitus, cigarette smoking status, and pack-years of cigarette smoking (1.46, 95% confidence interval 1.20 to 1.79). Risk for adverse cardiac events increased monotonically from the first through the fourth quartile of vital exhaustion. Probabilities of adverse cardiac events over time were significantly higher in people with high vital exhaustion compared to those with low exhaustion (p = 0.002). In conclusion, vital exhaustion predicts long-term risk for adverse cardiac events in men and women, independent of established biomedical risk factors.

Increased Serum PAI-1 Levels in Subjects with Metabolic Syndrome and Long-Term Adverse Mental Symptoms: A Population-Based Study

Depression is an independent risk factor for cardiovascular diseases and is associated with metabolic syndrome (MetS). Levels of plasminogen activator inhibitor-1 (PAI-1), an inhibitor of tissue-type and urokinase-type plasminogen activators, are associated with MetS. To clarify the role of PAI-1 in subjects with long-term adverse mental symptomatology (LMS; including depression) and MetS, we measured circulating PAI-1 levels in controls (n = 111), in subjects with MetS and free of mental symptoms (n = 42), and in subjects with both MetS and long-term mental symptoms (n = 70). PAI-1 increased linearly across the three groups in men. In logistic regression analysis, men with PAI-1 levels above the median had a 3.4-fold increased likelihood of suffering from the comorbidity of long-term adverse mental symptoms and MetS, while no such associations were detected in women. In conclusion, our results suggest that in men high PAI-1 levels are independently associated with long-term mental symptomatology.

The relationship between temperament, job stress and overcommitment: a cross-sectional study using the TEMPS-A and a scale of ERI

This cross-sectional study examined the relationship between temperament, job stress, and overcommitment using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire version (TEMPS-A) and a scale of the effort-reward imbalance (ERI) model. In July 2004, self-administered questionnaires were distributed to all employees in a Japanese IT service company through the company postal system. Total response rate was 63% (N=874), with 730 completed questionnaires. Information collected included individual attributes, employment and organizational characteristics. The TEMPS-A and the Japanese version of the ERI questionnaire were self-administered. The completed data of 637 personal computer technical support staff (87%) were used in a hierarchical regression analysis. Our results showed that depressive and anxious temperaments attenuate the influence of working hours and influence effort and rewards independently. While actual working hours had more impact on perceived high effort, our findings regarding rewards suggest that understanding anxious and depressive temperaments has a significant role in stress self-management. Temperaments explained 36% of the variance of overcommitment, and the variance was more than that of mean working hours. Our research has provided meaningful insights into occupational health, which could assist employees in self-management of job stress and contribute to better adaptation at the workplace.

Independent relation of vital exhaustion and inflammation to fibrinolysis in apparently healthy subjects

OBJECTIVE

Vital exhaustion (VE) and a hypercoagulable state both have been associated with coronary artery disease (CAD). Candidate mechanisms by which VE predicts CAD events are impaired fibrinolysis and inflammatory changes, the latter also affecting hemostasis. We investigated whether VE and inflammation would independently relate to hemostasis.

DESIGN

Study participants were 217 (mean age+/-SD, 40+/-9 years) apparently healthy men and women working at an airplane manufacturing plant in Germany who completed the Shortened 9-item VE Maastricht Questionnaire. All subjects had a set of classic cardiovascular risk factors assessed, and plasma levels of fibrin D-dimer, type I plasminogen activator inhibitor (PAI-1) antigen, C-reactive protein (CRP), and tumor necrosis factor (TNF)-alpha were measured.

RESULTS

PAI-1 correlated with VE (r=0.18, p=0.009), CRP (r=0.20, p=0.004), and TNF-alpha (r=0.18, p=0.009); D-dimer correlated with CRP (r=0.16, p=0.018). In linear regression analyses, VE and TNF-alpha independently explained 2 and 1%, respectively, of the variance in PAI-1.

CONCLUSION

Our study corroborates previous findings on impaired fibrinolysis in VE. The findings suggest that VE and inflammation may impair fibrinolysis by different pathways, and independently of traditional cardiovascular risk factors.

Association of vital exhaustion and depressive symptoms with changes in fibrin D-dimer to acute psychosocial stress

OBJECTIVE

Vital exhaustion and depression are psychosocial risk factors of coronary artery disease. A hypercoagulable state in response to acute psychosocial stress contributes to atherothrombotic events. We aimed to investigate the hypothesis that vital exhaustion and depression correlate with stress-induced changes in the hypercoagulability marker D-dimer.

METHODS

Thirty-eight healthy and nonsmoking school teachers (mean age 50+/-8 years, 55% women) completed the nine-item Maastricht Vital Exhaustion Questionnaire and the seven-item depression subscale of the Hospital Anxiety and Depression Scale. Within 1 week, subjects twice underwent the Trier Social Stress Test (i.e., preparation phase, mock job interview, and mental arithmetic that totaled 13 min). Plasma D-dimer levels were determined at five time points during the protocol.

RESULTS

Vital exhaustion (P=.022; eta(2)=.080) and depressive symptoms (P=.011; eta(2)=.090) were associated with stress-induced changes in D-dimer levels over time controlling for sex and age. Elevated levels of vital exhaustion (r=-.46, P=.005) and of depression (r=-.51, P=.002) correlated with reduced D-dimer increase from pre-stress to immediately post-stress. Also, elevated vital exhaustion (r=.34, P=.044) and depression (r=.41, P=.013) were associated with increase (i.e., attenuated recovery) of D-dimer levels between 20 and 45 min post-stress. Controlling for stress hormone and blood pressure reactivity did not substantially alter these results.

CONCLUSION

The findings suggest an attenuated immediate D-dimer stress response and delayed recovery of D-dimer levels post-stress with elevated vital exhaustion and depressive symptoms. In particular, the prolonged hypercoagulability after stress cessation might contribute to the atherothrombotic risk previously observed with vital exhaustion and depression, even at subclinical levels.

Vital exhaustion in chronic heart failure: symptom profiles and clinical outcome

OBJECTIVE

The aim of this study was to examine the components of vital exhaustion (VE) in chronic heart failure (CHF) patients and to examine whether psychological symptom profiles based on these components are differently associated with health status and cardiac rehospitalization.

METHODS

Consecutive CHF patients (N=381) were assessed for VE at baseline using the Maastricht Questionnaire and assessed for health status at 6-month follow-up using the Minnesota Living with Heart Failure Questionnaire. Information on cardiac rehospitalization was obtained from the patients' medical records.

RESULTS

Principal component analysis revealed four essential features of VE: fatigue, cognitive-affective depressive symptoms, sleep difficulties, and lack of concentration. Latent class cluster analysis using these components identified three subgroups with different symptom profiles: a subgroup without VE, a first vitally exhausted subgroup (VE1; fatigue and lack of concentration, but with a relative absence of cognitive-affective depressive symptoms and sleep difficulties), and a second more severe, vitally exhausted subgroup (VE2; elevated levels of all components). Both vitally exhausted subgroups were more likely to have impaired health status (VE1: beta=.36, P<.001; VE2: beta=.71, P<.001). VE2 was also associated with an increased risk of cardiac rehospitalization at 6-month follow-up (odds ratio=2.98; 95% confidence interval=1.01-8.83; P=.049).

CONCLUSIONS

VE in CHF comprised four components (fatigue, cognitive-affective depressive symptoms, sleep difficulties, and lack of concentration) from which three different symptom profiles were derived. Subgroups with symptoms of VE were associated with adverse clinical outcome in CHF. In clinical practice, these results may help identify distinct groups of patients with potentially differential risks of adverse health outcomes.

Vital exhaustion and cardiovascular disease: are circulating fibrinogen and D-dimer levels a plausible link?

Vital exhaustion has been implicated in the development and progression of cardiovascular disease. In addition, elevated levels of fibrinogen and D-dimer have been associated with an increased risk of cardiovascular disease. Some studies have suggested that fibrinogen and D-dimer are associated with acute, chronic, and perceived stress. In this issue, Kudielka et al examine the relationship between circulating fibrinogen and D-dimer levels and vital exhaustion in a cross-sectional study of middle-aged teachers in Germany, to examine the plausible link between chronic stress and the development of cardiovascular disease. This commentary discusses the limited available evidence of the mechanisms responsible for the association between vital exhaustion and the development of cardiovascular disease and highlights the limitations of previous research and discusses future directions.

Circulating fibrinogen but not D-dimer level is associated with vital exhaustion in school teachers

Meta-analyses have established elevated fibrinogen and D-dimer levels in the circulation as biological risk factors for the development and progression of coronary artery disease (CAD). Here, we investigated whether vital exhaustion (VE), a known psychosocial risk factor for CAD, is associated with fibrinogen and D-dimer levels in a sample of apparently healthy school teachers. The teaching profession has been proposed as a potentially high stressful occupation due to enhanced psychosocial stress at the workplace. Plasma fibrinogen and D-dimer levels were measured in 150 middle-aged male and female teachers derived from the first year of the Trier-Teacher-Stress-Study. Log-transformed levels were analyzed using linear regression. Results yielded a significant association between VE and fibrinogen (p = 0.02) but not D-dimer controlling for relevant covariates. Further investigation of possible interaction effects resulted in a significant association between fibrinogen and the interaction term "VE x gender" (p = 0.05). In a secondary analysis, we reran linear regression models for males and females separately. Gender-specific results revealed that the association between fibrinogen and VE remained significant in males but not females. In sum, the present data support the notion that fibrinogen levels are positively related to VE. Elevated fibrinogen might be one biological pathway by which chronic work stress may impact on teachers' cardiovascular health in the long run.

Spousal caregivers of patients with Alzheimer's disease show longitudinal increases in plasma level of tissue-type plasminogen activator antigen

OBJECTIVE

To determine if caregivers of spouses with Alzheimer's disease demonstrate greater increase in tissue plasminogen activator (t-PA) antigen relative to noncaregiving controls. Caring for a spouse with Alzheimer's disease has been associated with increased mortality and reduced time to developing cardiovascular disease (CVD), possibly due to impaired fibrinolysis resulting from chronic stress.

METHODS

Annual in-home assessments of plasma t-PA antigen were collected from 165 participants (112 caregivers and 53 noncaregivers) enrolled in the University of California, San Diego Alzheimer caregiver study. Participants were married, living with their spouses, at least 55 years of age, and free of serious medical conditions (e.g., cancer). Caregivers provided in-home care for their spouse with Alzheimer's disease at the time of enrollment. Exclusion criteria included taking anticoagulant medication or evidenced severe hypertension (>200/120 mm Hg). Mixed (random effects) regression was used to assess slopes for t-PA antigen over the study period at the same time controlling for medical and demographic characteristics associated with t-PA antigen.

RESULTS

Caregivers demonstrated significantly greater increases in t-PA antigen over the 5-year study period compared with noncaregiving controls (p = .02), even when controlling for body mass index, mean blood pressure, age, gender, and use of CVD medication.

CONCLUSIONS

The accelerated rate of developing a prothrombotic environment including elevated t-PA antigen may provide one mechanism by which caregiving is associated with greater morbidity and mortality and the development of CVD.

Relation of morning serum cortisol to prothrombotic activity in women with stable coronary artery disease

BACKGROUND

Increased circulating cortisol levels have been associated with severity of atherosclerosis. Low-grade systemic thrombogenicity plays a major role in the initiation and progression of coronary disease. We hypothesized a direct relationship between cortisol and hemostasis factors related to a prothrombotic state in coronary artery disease.

METHODS

We measured morning serum cortisol and activated clotting factor VII, fibrinogen, von Willebrand factor antigen, and plasminogen activator inhibitor-1 activity in 285 women (56 +/- 7 years) between 3 and 6 months after an acute coronary event. To test whether the relationship between cortisol and hemostasis factors would be independent, statistical adjustment was made for demographic, biomedical, life style, and psychosocial variables.

RESULTS

Higher serum cortisol levels predicted higher fibrinogen (beta = .17, P = .001) and higher von Willebrand factor (beta = .16, P = .008), all independently of covariates, including C-reactive protein, which was also an independent predictor of fibrinogen (beta = .20, P = .001) and von Willebrand factor (beta = .16, P = .004). Higher levels of vital exhaustion were associated with higher levels of activated clotting factor VII independently of covariates and depression (beta = .18, P = .045). Cortisol showed crude correlations with vital exhaustion (r = .14, P = .022) and with depression (r = .13, P = .043) but did not mediate the relationship between psychosocial variables and hemostatic factors.

CONCLUSIONS

Morning serum cortisol showed a modest but independent association with prothrombotic activity in women with coronary artery disease suggesting that increased cortisol levels might contribute to atherosclerosis via eliciting a hypercoagulable state.

Acute depressed mood as a trigger of acute coronary syndromes

BACKGROUND

Some cases of acute coronary syndrome (ACS) may be triggered by emotional states such as anger, but it is not known if acute depressed mood can act as a trigger.

METHODS

295 men and women with a verified ACS were studied. Depressed mood in the two hours before ACS symptom onset was compared with the same period 24 hours earlier (pair-matched analysis), and with usual levels of depressed mood, using case-crossover methods.

RESULTS

46 (18.2%) patients experienced depressed mood in the two hours before ACS onset. The odds of ACS following depressed mood were 2.50 (95% confidence intervals 1.05 to 6.56) in the pair-matched analysis, while the relative risk of ACS onset following depressed mood was 4.33 (95% confidence intervals 3.39 to 6.11) compared with usual levels of depressed mood. Depressed mood preceding ACS onset was more common in lower income patients (p = .032), and was associated with recent life stress, but was not related to psychiatric status.

CONCLUSIONS

Acute depressed mood may elicit biological responses that contribute to ACS, including vascular endothelial dysfunction, inflammatory cytokine release and platelet activation. Acute depressed mood may trigger potentially life-threatening cardiac events.

Linking stress to inflammation

There is ample evidence for the influence of central nervous system modulation through inflammatory cellular reactions under psychosocial stress. These inflammatory reflexes might be of major influence not only for metabolic and vascular disease but also for many autoimmune diseases for which stress has been reported as a risk factor. In prospective trials on the influence of risk factors for the occurrence of cardiovascular events, both psychosocial stress and autonomic nervous control of the cardiovascular system were shown to have a major impact on event rates. The underlying cause of these findings seems to be explained in part by the direct influences of autonomic reflexes, potentially induced by psychosocial tasks, on the progression of atherosclerosis. Hence, future prospective studies that aim at deciphering the influence of chronic psychosocial stress and autonomic function on the pathogenesis of inflammatory and metabolic disease will need to include neurophysiologic, molecular, and clinical parameters. Because the neuroimmunologic axis can be seen as a system connecting mental states with inflammatory reactions, pro-inflammatory mediators and anti-inflammatory strategies should be studied as such in experimental settings.

Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions

Burnout is characterized by emotional exhaustion, physical fatigue, and cognitive weariness, resulting from prolonged exposure to work-related stress. The authors review the accumulated evidence suggesting that burnout and the related concept of vital exhaustion are associated with increased risk of cardiovascular disease and cardiovascular-related events. The authors present evidence supporting several potential mechanisms linking burnout with ill health, including the metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis along with sympathetic nervous system activation, sleep disturbances, systemic inflammation, impaired immunity functions, blood coagulation and fibrinolysis, and poor health behaviors. The association of burnout and vital exhaustion with these disease mediators suggests that their impact on health may be more extensive than currently indicated.

Fatigue et maladies cardiovasculaires

Fatigue is a frequent complaint during cardiovascular disease and can sometimes constitute the first clinical manifestation of this disease. It is responsible for deterioration of the quality of life and prognosis. Although physical and mental fatigue are often intimately interrelated, these two aspects of fatigue correspond to different pathophysiological mechanisms and different clinical features and the neurobiological links between the two are only just beginning to be studied. Physical fatigue is related to loss of efficacy of the effector muscle, due to multiple causes: mismatch of cardiac output during exercise, muscle and microcirculatory deconditioning, neuroendocrine dysfunction, associated metabolic disorders. Mental fatigue corresponds to predominantly depressive mood disorders with a particular entity, vital exhaustion. The diagnostic approach is designed to eliminate other organic causes of fatigue. Functional tests investigating physical (exercise capacity) and mental dimensions (mood disorders) can be used to analyse their respective roles and to propose personalized management, in which rehabilitation has an essential place due to its global approach. The objective of this reduction of fatigue is threefold: to improve independence, to improve quality of life and to limit morbidity and mortality.

Relation of depressive mood to plasminogen activator inhibitor, tissue plasminogen activator, and fibrinogen levels in patients with versus without coronary heart disease

The increased risk of coronary heart disease (CHD) associated with depression is well documented. We hypothesized that impaired fibrinolysis is involved in this link. To explore the association of depressive mood and/or vital exhaustion with various measurements of fibrinolysis activity, 231 men (40 to 65 years old; 123 without CHD and taking no medication and 108 with documented CHD), completed the Center of Epidemiologic Studies Depression Scale and the Maastricht Questionnaire for vital exhaustion. Using classic cut-off points (Center of Epidemiologic Studies Depression Scale score >or=17, Maastricht Questionnaire score >or=8), 6.5% and 9.8% of subjects without CHD and 38% and 48.1% of those with CHD were classified as depressed and exhausted, respectively. Patients with CHD were older, had a higher body mass index, and higher levels of total cholesterol, glucose, plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (t-PA) antigen, and fibrinogen; 47% were treated for hypertension. Depressed subjects had higher levels of PAI-1 activity (p = 0.006) and exhausted patients had higher levels of PAI-1 activity (p = 0.011) and fibrinogen (p = 0.009). After adjusting for clinical condition (with or without CHD), smoking, hypertension, triglyceride concentration, and body mass index, PAI-1 activity remained higher in depressed subjects (p = 0.03). This association persisted after further adjustment for vital exhaustion or for t-PA antigen and fibrinogen levels. t-PA antigen and fibrinogen levels were not associated with depressive mood in multivariate analyses. No fibrinolytic variable was associated with vital exhaustion in multivariate analyses. In conclusion, depressive mood, but not vital exhaustion, is associated with higher levels of PAI-1 activity, suggesting a possible impairment of fibrinolysis and indicating a potential additional mechanism by which depressive mood may act as a cardiovascular risk factor.

The association between burnout, depression, anxiety, and inflammation biomarkers: C-reactive protein and fibrinogen in men and women

Following the demonstrated association of employee burnout or vital exhaustion with several risk factors for cardiovascular disease (CVD) and CVD risk, the authors investigated the possibility that one of the mechanisms linking burnout with CVD morbidity is microinflammation, gauged in this study by high-sensitivity C-reactive protein (hs-CRP) and fibrinogen concentrations. Their sample included 630 women and 933 men, all apparently healthy, who underwent periodic health examinations. The authors controlled for possible confounders including 2 other negative affective states: depression and anxiety. In women, burnout was positively associated with hs-CRP and fibrinogen concentrations, and anxiety was negatively associated with them. In men, depression was positively associated with hs-CRP and fibrinogen concentrations, but not with burnout or anxiety. Thus, burnout, depression, and anxiety are differentially associated with microinflammation biomarkers, dependent on gender.

Negative affect states and cardiovascular disorders: a review and the proposal of a unifying biopsychosocial concept

AIM

The purpose of this review was to study the relationships between negative affect states and cardiovascular disorders.

PROCEDURE

The phenomenology of the negative affect states of depression, helplessness, hopelessness, vital exhaustion and grief is described. Their correlations with morbidity and mortality are analyzed. The physiological correlates of the affect states are pointed out. Finally, the reaction pattern of conservation-withdrawal according to Schmale and Engel and its ontogenesis are outlined. This is a disengaging behavior pattern as opposed to the engaging fight-flight reaction pattern of Cannon. The giving up complex, with its affects of helplessness and hopelessness, is explained.

CONCLUSIONS

The giving up complex in the context of the conservation-withdrawal pattern presents a biologically and developmentally sound conceptual basis for the understanding of the relationships of the negative affect states with cardiovascular disorders. This enables the integration of the concept of vital exhaustion, which has become the most promising operationalized instrument in psychosocial cardiovascular research.

Effects of treating exhaustion in angioplasty patients on new coronary events: results of the randomized Exhaustion Intervention Trial (EXIT)

BACKGROUND

Extreme fatigue is a common complaint in percutaneous coronary intervention (PCI) patients, and is associated with an increased risk for new cardiac events. The objective of the Exhaustion Intervention Trial (EXIT) was to determine whether a behavioral intervention on exhaustion reduces the risk of a new coronary event after PCI.

METHODS AND RESULTS

Seven hundred ten consecutive patients, ages 35 to 68 years, who felt exhausted after PCI were randomized into an intervention group and a usual-care group. The intervention was based on group therapy focusing on stressors leading to exhaustion, and on support for recovery by promoting rest and making rest more efficient. One month after PCI, 50% of the patients felt exhausted. The intervention reduced the odds of remaining exhausted at 18 months by 56% in those without a previous history of coronary artery disease (CAD) (OR = 0.44; 95% CI 0.29-0.66), but had no effect on exhaustion in those with a history of CAD (OR = 0.93; 95% CI 0.56-1.55; p = .78). The intervention did not reduce the risk of a new coronary event within 2 years (RR = 1.14; 95%CI 0.82-1.57). Post-hoc analyses suggest that the effect of the intervention was limited by a positive history of CAD, the presence of a chronic, painful condition (especially rheumatism), and by opposite effects on early and late cardiac events.

CONCLUSION

A behavioral intervention in PCI patients has a beneficial effect on feelings of exhaustion. It could not be demonstrated that the intervention reduces the risk of a new coronary event within 2 years.

Overcommitment to work is associated with vital exhaustion

OBJECTIVES

Vital exhaustion has been shown to predict the progression and manifestation of cardiovascular disease. Little is known about the relationship between vital exhaustion and overcommitment, the inability to withdraw from obligations at work. The aim of this study was to explore the relationship between vital exhaustion and overcommitment at work, as measured by the intrinsic-effort scale of the effort-reward model after consideration of other potentially salutogenetic and pathogenetic working conditions.

METHODS

This cross-sectional study is based on a stratified random sample of 634 employees (mean age 39.9 years, standard deviation 10.7 years) from a manufacturing and assembly plant for aeroplane parts. Participants completed a questionnaire, which included the nine-item shortened Maastricht exhaustion questionnaire to score the dependent variable exhaustion, and the six-item short form of the intrinsic-effort scale ("immersion") of the effort-reward-imbalance model as the primary independent variable. Perceived work stress was assessed by Siegrist's effort-reward-imbalance questionnaire and the 52-item, 13 subscale salutogenetic subjective work assessment (SALSA) questionnaire, which focuses on indicators of perceived work stress in terms of pathogenetic and salutogenetic descriptors of decision latitude, psychological job demands, and social support. Additional candidate covariates included depression, anxiety and type-D personality.

RESULTS

In regression analysis, overcommitment (r=0.516; P<0.0001) was independently associated with vital exhaustion. Multivariable linear regression analysis showed that overcommitment explained 27% of the variance of vital exhaustion.

CONCLUSIONS

Overcommitment, indicating an exhaustive work-related coping style, is independently associated with vital exhaustion. It appears to be an important personality trait that may contribute to feelings of exhaustion at times of increased job strain.

Exaggerated Plasma Fibrin Formation (D-Dimer) in Elderly Alzheimer Caregivers as Compared to Noncaregiving Controls

BACKGROUND

The chronic stress of providing care for a spouse suffering from Alzheimer's disease has been associated with an increased risk for coronary artery disease and overall mortality. Procoagulant changes are kindled by mental stress, and they are prospectively associated with atherothrombotic events.

OBJECTIVE

To examine whether dementia caregivers would show greater coagulation activity and less fibrinolytic capacity than noncaregiving controls.

METHODS

Subjects were 48 (30 female and 18 male) elderly (mean age +/- SD, 72 +/- 9 years) community-dwelling spousal Alzheimer caregivers and 20 noncaregiving age- and gender-matched controls. Plasma levels of thrombin-antithrombin III, fibrin D-dimer, von Willebrand factor, tissue-type plasminogen activator, and plasminogen activator inhibitor 1 were measured.

RESULTS

D-dimer, a marker of fibrin formation and degradation, was significantly higher in caregivers than in controls (688 +/- 575 vs. 406 +/- 157 ng/ml, p = 0.021). Plasma levels of the four other hemostasis variables were not significantly different between the two groups. Controlling for the classic cardiovascular risk factors body mass index, hypertension status, smoking status, hypercholesterolemia, type II diabetes, and medication potentially affecting hemostasis did not change results.

CONCLUSION

The findings suggest that Alzheimer caregivers have an increased fibrin turnover as compared to noncaregiving controls independent of common confounders of hemostasis. Such an elevated clotting diathesis might contribute to increased cardiovascular risk and overall mortality with dementia caregiving strain.

Exhaustion and coronary heart disease: the history of a scientific quest

This paper describes the development of the concept "vital exhaustion", the epidemiological evidence that this state belongs to the precursors of different manifestations of coronary artery disease, and the biological plausibility of the association between exhaustion and coronary artery disease. It further describes the main results of a randomized, controlled trial designed to determine whether a behavioural intervention reduces the risk of a new coronary event.

Regulation of Hemostasis by the Sympathetic Nervous System: Any Contribution to Coronary Artery Disease?

Within the last two decades, hemostasis factors have emerged as 'new' risk factors for coronary artery disease. Historical studies on the physiology of the sympathetic nervous system (SNS) attributed accelerated blood clotting to the components of the fight-flight response. Although this has not been demonstrated, exaggerated clotting related to SNS hyperactivity might confer an increased arterial thrombotic risk. This review outlines the effects of sympathetic activation as mimicked by adrenergic infusions and as elicited by mental stress and physical exercise, and the molecular mechanisms involved. A selective review of the pertinent literature was undertaken. Sympathetic activation provokes a simultaneous increase in molecules of both the coagulation and fibrinolysis pathways within minutes, resulting in net hypercoagulability as a part of normal human physiology. Catecholamines and adrenergic receptors interact to mediate hemostatic changes. Exaggerated procoagulant changes in individuals with a preexistent atherosclerotic disease, in those experiencing ongoing stressful life circumstances and in the physically untrained might confer a thrombotic threat with sympathetic activation. Initial evidence suggests that nonselective β-adrenergic blockade may attenuate clotting acceleration upon SNS activation. Prospective studies are needed to demonstrate whether exaggerated clotting as elicited by the SNS is associated with an increased risk of cardiovascular morbidity and mortality. If confirmed, intervention studies targeted at reducing this risk, for example with drugs, psychotherapy (including stress management) and regular physical exercise, would be warranted.

Elevated Plasma C-reactive protein in chronically distressed subjects who carry the A allele of the TNF-alpha -308 G/A polymorphism

OBJECTIVE

Sustained psychological stress may result in a state operationalized as "vital exhaustion." Exhaustion predicted coronary artery disease (CAD) events whereby increased inflammatory activity might mediate this link. Moreover, there is an emerging importance of gene-environmental interactions in CAD. We investigated the effect of exhaustion severity on plasma levels of C-reactive protein (CRP) and whether exhaustion might regulate CRP levels via the -308G/A polymorphism of the tumor necrosis factor (TNF)-alpha gene.

METHODS

We assessed exhaustion in 275 industrial employees (mean age +/- SD, 41 +/- 9 years, 88% men) using the Maastricht Questionnaire. Subjects were stratified as per exhaustion severity: none (N = 80), moderate (N = 128), and severe (N = 67). The TNF-alpha polymorphism was determined by real-time polymerase chain reaction, and plasma CRP levels were measured by a high-sensitivity immunoassay.

RESULTS

There was a significant interaction between exhaustion and the TNF-alpha polymorphism, explaining 4.5% in the variance of plasma CRP values (F(5,271) = 2.47, p =.033); the result held after controlling for classic cardiovascular risk factors. Adjusted mean CRP levels across exhaustion strata in GA (N = 70) and AA (N = 3) carriers combined were 0.91 mg/l (none), 1.78 mg/l (moderate), and 2.61 mg/l (severe) as compared with 1.24 mg/l, 1.61 mg/l, and 1.36 mg/l for the GG wild-type (N = 202).

CONCLUSION

The findings suggest that the A allele of the TNF-alpha -308 G/A polymorphism may mediate inflammation with exhaustion in a dose-response relationship, while with the GG wild-type exhaustion severity seems unrelated to CRP levels. The finding provides a rationale for gene-environmental interactions by which psychosocial factors may promote atherosclerosis and CAD.

Synergism between smoking and vital exhaustion in the risk of Ischemic stroke: evidence from the ARIC study

PURPOSE

To examine the synergism between vital exhaustion and cigarette smoking in producing ischemic stroke. Vital exhaustion (VE), a state characterized by unusual fatigue, irritability, and feelings of demoralization, is measured by the Maastricht questionnaire (MQ), a 21-item inventory of symptoms.

METHODS

The Atherosclerosis Risk in Communities (ARIC) Study is an ongoing cohort study, initiated in 1987. The MQ was administered at the second follow-up visit (1990-1992), and participants were subsequently followed for an average of 6.27 years. Four US communities (Minneapolis, Minnesota; Washington County, Maryland; Forsyth County, North Carolina; and Jackson, Mississippi). 13,066 participants aged 48 to 67 years at baseline (Visit 2) with no history of stroke. Validated hospitalized ischemic stroke.

RESULTS

During the follow-up period, there were 202 incident ischemic strokes. After multivariate adjustment, current smoking, and high VE were independent risk factors for incident stroke: (smoking vs. non-smoking HR=1.76, p < 0.01; high VE vs. low VE HR=1.94, p < 0.01). For persons with both VE and smoking vs. persons with neither, HR=2.71 (p < 0.001). The proportion of stroke disease burden due to VE and smoking that could be attributed to their interaction was 81 to 93 percent.

CONCLUSIONS

The combination of cigarette smoking and VE is synergistic in the production of stroke.

Vital exhaustion as a risk factor for ischaemic heart disease and all-cause mortality in a community sample. A prospective study of 4084 men and 5479 women in the Copenhagen City Heart Study

BACKGROUND

Vital exhaustion, a psychological measure characterized by fatigue and depressive symptoms, has been suggested to be an independent risk factor for ischaemic heart disease (IHD) but the generality of the phenomenon remains in question. The aim of this study is to describe prevalence of these symptoms in a community sample and determine whether they prospectively predict increased risk of IHD and all-cause mortality in men and women.

METHODS

The study base was 4084 men and 5479 women aged 20-98 free of IHD examined in 1991-1993 in the Copenhagen City Heart Study. Events were ascertained through record linkage until 1998 for IHD and September 2000 for all-cause mortality. There were 483 first hospital admissions and deaths caused by IHD and 1559 deaths from all causes during follow-up.

RESULTS

The 17 items on the vital exhaustion questionnaire were frequently endorsed with prevalence ranging from 6 to 47 per cent, higher in women. All but 4 of the 17 items were significantly associated with IHD with significant relative risks (RR) ranging between 1.36 (95% CI: 1.08, 1.72) and 2.10 (95% CI: 1.63, 2.71). Associations with all-cause mortality were also observed, but were weaker. RR of both IHD and all-cause mortality increased with increasing item sum score and were similar in men and women. For IHD, RR reached a maximum of 2.57 (95% CI: 1.65, 4.00) for subjects endorsing >9 items. The similar RR for all-cause mortality was 2.50 (95% CI: 2.09, 2.99). Multivariate adjustment for biological, behavioural, and socioeconomic risk factors did not substantially affect the association for IHD but attenuated the association with all-cause mortality.

CONCLUSIONS

Measures of fatigue and depression were common symptoms in this population sample and convey increased risk of IHD and of all-cause mortality. We propose this knowledge begin to be implemented in risk assessment in clinical practice.

Vital exhaustion in relation to lifestyle and lipid profile in healthy women

"Vital exhaustion," characterized by fatigue, irritability, and demoralization, precedes new and recurrent coronary events. Biological mechanisms explaining this association are not fully understood. The objective was to investigate the relationship between vital exhaustion, lifestyle, and lipid profile. Vital exhaustion, smoking, body mass index (BMI), alcohol consumption, exercise capacity, and serum lipids were determined in 300 healthy women, aged 56.4 +/- 7.1 years. No statistically significant associations were found between vital exhaustion and lifestyle variables. Divided into quartiles, vital exhaustion was inversely related to high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1 in a linear fashion after adjustment for age, BMI, exercise capacity, and alcohol consumption. A multivariate-adjusted vital exhaustion-score in the top quartile, as compared to one in the lowest, was associated with 12% lower HDL-C and 8% lower apolipoprotein A1 (p < .05). In conclusion, alterations in lipid metabolism may be a possible mediating mechanism between vital exhaustion and coronary heart disease. The impact of lifestyle variables was weak.

Herpes viruses, cytokines, and altered hemostasis in vital exhaustion

OBJECTIVE

Infections with herpes viruses have been implicated in the pathogenesis of atherosclerosis. We tested the hypothesis that vital exhaustion (VE) is associated with multiple herpesvirus infections, such as herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus, and with an increase in pathogen burden (ie, the aggregated seropositivity to immunoglobulin G antibodies for herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus). In addition, we examined the association of VE and pathogen burden with measures of hemostasis and inflammation.

METHODS

Blood samples were drawn from 29 men with VE and 30 male control subjects, all healthy and nonsmokers, to assess serological evidence of infection and measures of hemostasis and inflammation.

RESULTS

VE is associated with a relatively high pathogen burden, altered hemostasis, and higher levels of cytokines, such as interleukin-6. Across all subjects, a relatively high pathogen burden was also associated with altered hemostasis but not with increased cytokine levels. The interaction of VE with pathogen burden revealed significant linear increases in measures of hemostasis and inflammation. Finally, immunoglobulin G antibody titer levels of individual herpesvirus infections were not associated with hemostatic measures or with cytokines.

CONCLUSIONS

We conclude that stress-related alterations in hemostasis and inflammation are not necessarily linked to one particular herpesvirus infection but rather to an increase in aggregated seropositivity to herpesvirus infections.

The concept of allostasis in biology and biomedicine

Living organisms have regular patterns and routines that involve obtaining food and carrying out life history stages such as breeding, migrating, molting, and hibernating. The acquisition, utilization, and storage of energy reserves (and other resources) are critical to lifetime reproductive success. There are also responses to predictable changes, e.g., seasonal, and unpredictable challenges, i.e., storms and natural disasters. Social organization in many populations provides advantages through cooperation in providing basic necessities and beneficial social support. But there are disadvantages owing to conflict in social hierarchies and competition for resources. Here we discuss the concept of allostasis, maintaining stability through change, as a fundamental process through which organisms actively adjust to both predictable and unpredictable events. Allostatic load refers to the cumulative cost to the body of allostasis, with allostatic overload being a state in which serious pathophysiology can occur. Using the balance between energy input and expenditure as the basis for applying the concept of allostasis, we propose two types of allostatic overload. Type 1 allostatic overload occurs when energy demand exceeds supply, resulting in activation of the emergency life history stage. This serves to direct the animal away from normal life history stages into a survival mode that decreases allostatic load and regains positive energy balance. The normal life cycle can be resumed when the perturbation passes. Type 2 allostatic overload begins when there is sufficient or even excess energy consumption accompanied by social conflict and other types of social dysfunction. The latter is the case in human society and certain situations affecting animals in captivity. In all cases, secretion of glucocorticosteroids and activity of other mediators of allostasis such as the autonomic nervous system, CNS neurotransmitters, and inflammatory cytokines wax and wane with allostatic load. If allostatic load is chronically high, then pathologies develop. Type 2 allostatic overload does not trigger an escape response, and can only be counteracted through learning and changes in the social structure.

Inflammation and coagulation factors in persons > 65 years of age with symptoms of depression but without evidence of myocardial ischemia

Depression is associated with increased cardiovascular disease, but the underlying mechanisms are not well understood. This study examines associations of depressive symptoms with inflammation and coagulation factors in persons aged > 65 years. Blood samples were obtained from 4,268 subjects free of cardiovascular disease (age 72.4 +/- 5.5 years, 2,623 women). Inflammation markers were C-reactive protein (CRP), white blood cell (WBC) count, total platelet count, and albumin; coagulation factors included factors VIIc and VIIIc and fibrinogen. Depression was assessed with the Center for Epidemiologic Studies Depression scale, and states of energy depletion with a validated exhaustion index. Statistical adjustments were made for risk factors (age, sex, race, systolic blood pressure, smoking status, diabetes mellitus) and physical measures of frailty (isometric handgrip, timed 15-feet walk test, activity level). Depression was associated with elevated CRP (3.31 +/- 0.10 vs 3.51 +/- 0.21 mg/L), WBC (6.14 +/- 0.03 vs 6.43 +/- 0.11 10(6)/L), fibrinogen (319 +/- 1 vs 326 +/- 3 mg/dl), and factor VIIc (124.6 +/- 0.6% vs 127.2 +/- 1.3%; all p <0.05). Exhaustion also was related to elevated inflammation and coagulation markers (p < 0.05). Exhausted men had markedly elevated CRP levels (6.82 +/- 2.10 mg/L) versus nonexhausted men (3.05 +/- 0.16: p = 0.007). After adjustment for control variables, exhaustion remained associated with albumin (p = 0.033), fibrinogen (p = 0.017), CRP (p = 0.066), and WBC (p = 0.060), whereas associations of depressive symptoms with biochemistry measures lost statistical significance. Thus, depression and exhaustion are associated with low-grade inflammation and elevated coagulation factors in persons aged > 65 years.