Neuropsychiatric effects of cardiovascular drug therapy

Evaluation of Ouabain's Tissue Distribution in C57/Black Mice Following Intraperitoneal Injection, Using Chromatography and Mass Spectrometry

Cardiotonic steroids (CTSs), such as digoxin, are used for heart failure treatment. However, digoxin permeates the brain-blood barrier (BBB), affecting central nervous system (CNS) functions. Finding a CTS that does not pass through the BBB would increase CTSs' applicability in the clinic and decrease the risk of side effects on the CNS. This study aimed to investigate the tissue distribution of the CTS ouabain following intraperitoneal injection and whether ouabain passes through the BBB. After intraperitoneal injection (1.25 mg/kg), ouabain concentrations were measured at 5 min, 15 min, 30 min, 1 h, 3 h, 6 h, and 24 h using HPLC-MS in brain, heart, liver, and kidney tissues and blood plasma in C57/black mice. Ouabain was undetectable in the brain tissue. Plasma: Cmax = 882.88 ± 21.82 ng/g; Tmax = 0.08 ± 0.01 h; T1/2 = 0.15 ± 0.02 h; MRT = 0.26 ± 0.01. Cardiac tissue: Cmax = 145.24 ± 44.03 ng/g (undetectable at 60 min); Tmax = 0.08 ± 0.02 h; T1/2 = 0.23 ± 0.09 h; MRT = 0.38 ± 0.14 h. Kidney tissue: Cmax = 1072.3 ± 260.8 ng/g; Tmax = 0.35 ± 0.19 h; T1/2 = 1.32 ± 0.76 h; MRT = 1.41 ± 0.71 h. Liver tissue: Cmax = 2558.0 ± 382.4 ng/g; Tmax = 0.35 ± 0.13 h; T1/2 = 1.24 ± 0.7 h; MRT = 0.98 ± 0.33 h. Unlike digoxin, ouabain does not cross the BBB and is eliminated quicker from all the analyzed tissues, giving it a potential advantage over digoxin in systemic administration. However, the inability of ouabain to pass though the BBB necessitates intracerebral administration when used to investigate its effects on the CNS.

Considerations Regarding Management of Heart Failure in Older Adults

Understanding noncardiovascular comorbidities and geriatric syndromes in elderly patients with heart failure (HF) is important as the average age of the population increases. Healthcare professionals need to consider these complex dynamics when managing older adults with HF, especially those older than 80. A number of small studies have described associations between HF and major geriatric domains. With information on patients' cognitive, functional decline, and ability to adhere to therapy, physicians can plan for individualized treatment goals and recommendations for these patients.

Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications.

METHODS

Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing.

RESULTS

Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes.

CONCLUSIONS

Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.

Na+,K+-ATPase and Cardiotonic Steroids in Models of Dopaminergic System Pathologies

In recent years, enough evidence has accumulated to assert that cardiotonic steroids, Na⁺,K⁺-ATPase ligands, play an integral role in the physiological and pathophysiological processes in the body. However, little is known about the function of these compounds in the central nervous system. Endogenous cardiotonic steroids are involved in the pathogenesis of affective disorders, including depression and bipolar disorder, which are linked to dopaminergic system dysfunction. Animal models have shown that the cardiotonic steroid ouabain induces mania-like behavior through dopamine-dependent intracellular signaling pathways. In addition, mutations in the alpha subunit of Na⁺,K⁺-ATPase lead to the development of neurological pathologies. Evidence from animal models confirms the neurological consequences of mutations in the Na⁺,K⁺-ATPase alpha subunit. This review is dedicated to discussing the role of cardiotonic steroids and Na⁺,K⁺-ATPase in dopaminergic system pathologies-both the evidence supporting their involvement and potential pathways along which they may exert their effects are evaluated. Since there is an association between affective disorders accompanied by functional alterations in the dopaminergic system and neurological disorders such as Parkinson's disease, we extend our discussion to the role of Na⁺,K⁺-ATPase and cardiotonic steroids in neurodegenerative diseases as well.

Associations between β-blockers and psychiatric and behavioural outcomes: A population-based cohort study of 1.4 million individuals in Sweden

BACKGROUND

β-blockers are widely used for treating cardiac conditions and are suggested for the treatment of anxiety and aggression, although research is conflicting and limited by methodological problems. In addition, β-blockers have been associated with precipitating other psychiatric disorders and suicidal behaviour, but findings are mixed. We aimed to examine associations between β-blockers and psychiatric and behavioural outcomes in a large population-based cohort in Sweden.

METHODS AND FINDINGS

We conducted a population-based longitudinal cohort study using Swedish nationwide high-quality healthcare, mortality, and crime registers. We included 1,400,766 individuals aged 15 years or older who had collected β-blocker prescriptions and followed them for 8 years between 2006 and 2013. We linked register data on dispensed β-blocker prescriptions with main outcomes, hospitalisations for psychiatric disorders (not including self-injurious behaviour or suicide attempts), suicidal behaviour (including deaths from suicide), and charges of violent crime. We applied within-individual Cox proportional hazards regression to compare periods on treatment with periods off treatment within each individual in order to reduce possible confounding by indication, as this model inherently adjusts for all stable confounders (e.g., genetics and health history). We also adjusted for age as a time-varying covariate. In further analyses, we adjusted by stated indications, prevalent users, cardiac severity, psychiatric and crime history, individual β-blockers, β-blocker selectivity and solubility, and use of other medications. In the cohort, 86.8% (n = 1,215,247) were 50 years and over, and 52.2% (n = 731,322) were women. During the study period, 6.9% (n = 96,801) of the β-blocker users were hospitalised for a psychiatric disorder, 0.7% (n = 9,960) presented with suicidal behaviour, and 0.7% (n = 9,405) were charged with a violent crime. There was heterogeneity in the direction of results; within-individual analyses showed that periods of β-blocker treatment were associated with reduced hazards of psychiatric hospitalisations (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.91 to 0.93, p < 0.001), charges of violent crime (HR: 0.87, 95% CI: 0.81 to 0.93, p < 0.001), and increased hazards of suicidal behaviour (HR: 1.08, 95% CI: 1.02 to 1.15, p = 0.012). After stratifying by diagnosis, reduced associations with psychiatric hospitalisations during β-blocker treatment were mainly driven by lower hospitalisation rates due to depressive (HR: 0.92, 95% CI: 0.89 to 0.96, p < 0.001) and psychotic disorders (HR: 0.89, 95% CI: 0.85 to 0.93, p < 0.001). Reduced associations with violent charges remained in most sensitivity analyses, while associations with psychiatric hospitalisations and suicidal behaviour were inconsistent. Limitations include that the within-individual model does not account for confounders that could change during treatment, unless measured and adjusted for in the model.

CONCLUSIONS

In this population-wide study, we found no consistent links between β-blockers and psychiatric outcomes. However, β-blockers were associated with reductions in violence, which remained in sensitivity analyses. The use of β-blockers to manage aggression and violence could be investigated further.

Impact of delirium on mortality in patients hospitalized for heart failure

OBJECTIVE

Heart Failure (HF) is one of the leading causes of hospitalization in the United States accounting for ≈800,000 hospital discharges and $11 billion in annual costs. Delirium occurs in approximately 30% of elderly hospitalized patients and its incidence is significantly higher among those admitted to the critical care units. Despite this, there has been limited exploration of the clinical and economic impact of delirium in patients hospitalized with acute HF. We hypothesized that delirium in HF is associated with excess mortality and hospital costs.

METHODS

We queried the 2001-2014 Nationwide Inpatient Sample to identify hospitalizations that included a primary discharge diagnosis of HF (ICD-9-CM: 428.xx) and stratified them by presence or absence of delirium (ICD-9-CM: 239.0, 290.41, 293.0, 293.1, 348.31). Differences in in-hospital mortality, length of stay (LOS), and hospital costs were assessed using propensity-score matched cohorts.

RESULTS

Major predictors of delirium included advanced age, Caucasian race, underlying dementia or psychiatric diagnoses, higher Elixhauser Comorbidity Index, renal failure, cardiogenic shock, and coronary artery bypass surgery. In the propensity-score matched analysis of 76,411 hospitalization with delirium compared to 76,612 without delirium, in-hospital mortality (odds ratio: 1.67, 95% CI: 1.51-1.77), LOS (rate ratio [RR]: 1.47, 95% CI: 1.45-1.51), and hospital costs (RR: 1.44, 95% CI: 1.41-1.48) were all statistically higher in the presence of delirium (all p < 0.001).

CONCLUSION

In patients hospitalized with HF, delirium is an independent predictor of increased in-hospital mortality, longer LOS, and excess hospital costs despite adjustment for baseline characteristics.

The association between cardiovascular drugs and depression/anxiety in patients with cardiovascular disease: A meta-analysis

This study aimed to investigate the association between cardiovascular drugs and depression/anxiety in patients with cardiovascular disease (CVD). This meta-analysis was registered in PROSPERO (International Prospective Register of Systematic Reviews; CRD42020197839) and conducted in accordance with the MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. The PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP databases were systematically searched to identify all available studies on this topic. Random-effects multivariate meta-regression was performed to investigate the sources of study heterogeneity. Review Manager version 5.3 and Stata 12.0 were used for data analyses. This meta-analysis included 54 studies with a total number of 212,640 patients. Overall, in patients with CVD, aspirin (odds ratio [OR]:0.91, 95% confidence interval [CI]:0.86-0.96, P = 0.02) was associated with a lower risk of depression, while calcium channel blockers (CCB) (OR:1.21, 95%CI:1.05-1.38, P = 0.008), diuretics (OR:1.34, 95%CI:1.14-1.58, P = 0.0005), and nitrate esters (OR:1.32, 95%CI:1.08-1.61, P = 0.006) were associated with a higher risk of depression, additionally, statin (OR:0.79, 95%CI:0.71-0.88, P < 0.0001) was associated with a lower risk of anxiety, but diuretics (OR:1.39, 95%CI:1.26-1.52, P < 0.00001) was associated with a higher risk of anxiety. Subgroup analysis presented that, in patients with hypertension, β-blockers were associated with a higher risk of depression (OR:1.45, 95%CI:1.26-1.67, P < 0.00001); in patients with coronary artery disease (CAD), statin (OR:0.77, 95%CI:0.59-0.99, P = 0.04), and aspirin (OR:0.85, 95%CI:0.75-0.97, P = 0.02) were associated with a lower risk of depression, while CCB (OR:1.32, 95%CI:1.15-1.51, P < 0.0001) and diuretics (OR:1.36, 95%CI:1.12-1.64, P = 0.002) were associated with a higher risk of depression, additionally, diuretics was associated with a higher risk of anxiety (OR:1.41, 95%CI:1.28-1.55, P < 0.00001); in patients with heart failure, nitrate esters (OR:1.93, 95%CI:1.19-3.13, P = 0.007), and diuretics (OR:1.58, 95%CI: 1.02-2.43, P = 0.04) were associated with a higher risk of depression. The use of cardiovascular drugs should be considered when evaluating depression or anxiety in patients with CVD to improve the care and treatment of these patients.

Delirium and Its Pharmacological Causes in Older People, Part Three

Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people. Parts two and three continued to review the pharmacological classes of medications that cause or contribute to delirium in older people.

Added value of anxiolytic benzodiazepines in predictive models on severe delirium in patients with acute decompensated heart failure: A retrospective analysis

Background

Delirium in patients with acute decompensated heart failure (ADHF) is associated with poor clinical outcomes. Although some medications have been reported as risk factors for delirium, their impact on patients with ADHF is still unclear. This study aimed to determine the association of specific medication use with delirium and their additive predictive value in models based on conventional risk factors.

Methods and results

In this single-center, retrospective study, 650 patients treated for ADHF were included. Fifty-nine patients (9.1%) had delirium. In multivariate analysis, anxiolytic benzodiazepines [odds ratio (OR): 6.4, 95% confidence interval (CI): 2.8–15], mechanical ventilation or noninvasive positive pressure ventilation (OR: 6.0, 95% CI: 2.9–12), depression (OR: 3.2, 95% CI: 1.5–6.5), intensive care or high care unit admission (OR: 2.9, 95% CI: 1.5–5.6), male sex (OR: 2.0, 95% CI: 1–3.7), and age (OR: 1.1, 95% CI: 1–1.1) were independently associated with severe delirium. The predictive model that included anxiolytic benzodiazepines had a significantly better discriminatory ability for the incidence of severe delirium than the conventional model.

Conclusions

The use of anxiolytic benzodiazepines was independently correlated with severe delirium, and their use in models based on conventional risk factors had an additive value for predicting delirium in patients with ADHF.

Efficacy and safety of propranolol for treatment of temporomandibular disorder pain: a randomized, placebo-controlled clinical trial

Propranolol is a nonselective beta-adrenergic receptor antagonist. A multicenter, randomized, double-blind, placebo-controlled, parallel-group, phase 2b trial enrolled participants aged 18 to 65 years with temporomandibular disorder myalgia to evaluate efficacy and safety of propranolol compared with placebo in reducing facial pain. Participants were randomized 1:1 to either extended-release propranolol hydrochloride (60 mg, BID) or placebo. The primary endpoint was change in facial pain index (FPI = facial pain intensity multiplied by facial pain duration, divided by 100). Efficacy was analyzed as a mean change in FPI from randomization to week 9 and as the proportion of participants with ≥30% or ≥50% reductions in FPI at week 9. Regression models tested for treatment-group differences adjusting for study site, sex, race, and FPI at randomization. Of 299 participants screened, 200 were randomized; 199 had at least one postrandomization FPI measurement and were included in intention-to-treat analysis. At week 9, model-adjusted reductions in mean FPI did not differ significantly between treatment groups (-1.8, 95% CL: -6.2, 2.6; P = 0.41). However, the proportion with a ≥30% reduction in FPI was significantly greater for propranolol (69.0%) than placebo (52.6%), and the associated number-needed-to-treat was 6.1 (P = 0.03). Propranolol was likewise efficacious for a ≥50% reduction in FPI (number-needed-to-treat = 6.1, P = 0.03). Adverse event rates were similar between treatment groups, except for more frequent fatigue, dizziness, and sleep disorder in the propranolol group. Propranolol was not different from placebo in reducing mean FPI but was efficacious in achieving ≥30% and ≥50% FPI reductions after 9 weeks of treatment among temporomandibular disorder participants.

Do β-Blockers Cause Depression?: Systematic Review and Meta-Analysis of Psychiatric Adverse Events During β-Blocker Therapy

[Figure: see text].

Neuropsychiatric Consequences of Lipophilic Beta-Blockers

Beta-blockers are a class of drugs with important benefits in cardiovascular pathology. In this paper, we aim to highlight their adverse and therapeutic effects in the neuropsychiatric field. With respect to permeability, we would like to mention that most beta-blockers are lipophilic and can cross the blood–brain barrier. Observational studies show the presence of neuropsychiatric side effects when taking beta-blockers, and is the reason for which caution is recommended in their use in patients with depressive syndrome. From a therapeutic point of view, most current evidence is for the use of beta-blockers in migraine attacks, essential tremor, and akathisia. Beta-blockers appear to be effective in the treatment of aggressive behavior, beneficial in the prevention of posttraumatic stress syndrome and may play a role in the adjuvant treatment of obsessive–compulsive disorder, which is refractory to standard therapy. In conclusion, the relationship between beta-blockers and the central nervous system appears as a two-sided coin. Summarizing the neuropsychiatric side effects of beta-blockers, we suggest that clinicians pay special attention to the pharmacological properties of different beta-blockers.

Unmet challenges in treating hypertension in patients with borderline personality disorder: A systematic review

BACKGROUND

Caregivers encounter serious and substantial challenges in managing hypertension in patients with subclinical or clinical borderline personality disorder (BPD). These challenges include therapeutic conflicts resulting from harmful drug-drug, and drug-disease interactions. Current guidelines provide no recommendations for concurrent psychotropic and antihypertensive treatment of hypertensive BPD patients who are at even greater cardiovascular risk.

METHODS

We conducted a systematic literature review to assess the extent of available evidence on prevalence rates, cardiovascular risk factors, therapeutic conflicts, and evidence-based treatment recommendations for patients with co-occurring hypertension and BPD. Search terms were combined for hypertension and BPD in PubMed, MEDLINE, EMBASE, Cochrane, and PsycINFO databases.

RESULTS

We included 11 articles for full-text evaluation and found a very high prevalence of hypertension and substantial cardiovascular risk in studies on co-occurring BPD and hypertension. However, we identified neither studies on harmful drug-drug and drug-disease interactions nor studies with treatment recommendations for co-occurring hypertension and BPD.

CONCLUSIONS

Increased prevalence of hypertension in BPD patients, and therapeutic conflicts of psychotropic agents strongly suggest careful evaluation of treatment strategies in this patient group. However, no studies or guidelines recommend specific therapies or strategies to resolve therapeutic conflicts in patients with hypertension and BPD. This evidence gap needs attention in this population at high risk for cardiovascular disease.

Psychopathy in the Medical Emergency Department

Psychopathy is a personality disorder representing an admixture of a fearless and dominant temperament with an impulsive and antisocial orientation. A sample of 1,026 participants in the waiting room of the medical emergency department of a city hospital exhibited levels of fearless dominance similar to university undergraduates and federal inmates; their levels of impulsive antisociality fell between those of federal and state inmates. Both psychopathy factors were correlated with male gender, younger age, and more frequent average alcohol consumption. Fearless dominance was associated with agentic success (e.g., being employed, higher household income), fewer psychological problems, and less use of psychotropic medications, including anxiolytics. Impulsive antisociality was negatively related to both agentic and communal (e.g., ever being married) success and positively correlated with substance use and self-reported bipolar, ADHD, and psychotic psychiatric conditions. Further, only impulsive antisociality was associated with presenting to the emergency department for physical injury or psychological disturbance.

Prevalence of depression and anxiety among participants with glaucoma in a population-based cohort study: The Gutenberg Health Study

Background

To investigate the prevalence of depression and anxiety among subjects with self-reported glaucoma and the association between self-reported glaucoma and depression respectively anxiety in a European cohort.

Methods

A study sample of 14,657 participants aged 35 to 74 years was investigated in a population-based cohort study. All participants reported presence or absence of glaucoma. Ophthalmological examinations were carried out in all participants and demographic and disease related information were obtained by interview. Depression was assessed with the Patient Health Questionnaire (PHQ-9), and generalized anxiety with the two screening items (GAD-2) of the short form of the GAD-7 (Generalized Anxiety Disorder-7 Scale). Prevalence of depression and generalized anxiety were investigated for subjects with and without self-reported glaucoma. Logistic regression analyses with depression, respectively anxiety as dependent variable and self-reported glaucoma as independent variable were conducted and adjusted for socio-demographic factors, systemic comorbidities (arterial hypertension, myocardial infarction, stroke, diabetes mellitus, chronic obstructive pulmonary disease, cancer), ocular diseases (cataract, macular degeneration, corneal diseases, diabetic retinopathy), visual acuity, intraocular pressure, antiglaucoma eye drops (sympathomimetics, parasympathomimetics, carbonic anhydrase inhibitors, beta-blockers, prostaglandins) and general health status.

Results

293 participants (49.5% female) reported having glaucoma. Prevalence of depression among participants with and without self-reported glaucoma was 6.6% (95%-CI 4.1–10.3) respectively 7.7% (95%-CI 7.3–8.2), and for anxiety 5.3% (95%-CI 3.1–8.7) respectively 6.6% (95%-CI 6.2–7.1). Glaucoma was not associated with depression (Odds ratio 1.10, 95%-CI 0.50–2.38, p = 0.80) or anxiety (1.48, 95%-CI 0.63–3.30, p = 0.35) after adjustment for socio-demographic factors, ocular/systemic diseases, ocular parameters, antiglaucoma drugs and general health status. A restriction to self-reported glaucoma cases either taking topical antiglaucoma medications or having a history of glaucoma surgery did not alter the result.

Conclusions

This is the first study analyzing both depression and anxiety among glaucoma patients in a European cohort. Subjects with and without self-reported glaucoma had a similar prevalence of depression and anxiety in our population-based sample. Self-reported glaucoma was not associated with depression or anxiety. A lack of a burden of depressive symptoms may result from recruitment from a population-based sample as compared to previous study groups predominantly recruited from tertiary care hospitals.

Cognitive decline in heart failure

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.

Pharmacological Hypotension as a Cause of Delirious Mania in a Patient with Bipolar Disorder

Delirious mania is a severe but often underrecognized syndrome characterized by rapid onset of delirium, mania, and psychosis, not associated with a prior toxicity, physical illness, or mental disorder. We discuss the case of a delirious mania potentially triggered and maintained by a systemic hypotension induced by antihypertensive drugs. Symptoms recovered completely after the discontinuation of antihypertensive medications and the normalization of blood pressure levels.

Effect of Preoperative Beta-Blocker Use on Outcomes Following Cardiac Surgery

Recent studies suggest that the use of preoperative β blockers in cardiac surgery may not provide improved mortality rates and may even contribute to negative clinical outcomes. We therefore assessed the role of β blockers on several outcomes after cardiac surgery (delirium, acute kidney injury [AKI], stroke, atrial fibrillation (AF), mortality, and hospital length of stay) in 4,076 patients who underwent elective coronary artery bypass grafting, coronary artery bypass grafting + valve, or valve cardiac surgery from November 1, 2009, to September 30, 2015, at Vanderbilt Medical Center. Clinical data from 2 prospectively collected datasets at our institution were reviewed: the Cardiac Surgery Perioperative Outcomes Database and the Society of Thoracic Surgeons Database. Preoperative β-blocker use was defined by Society of Thoracic Surgeons guidelines as patients receiving a β blocker within 24 hours preceding surgery. Of the included patients, 2,648 (65.0%) were administered a β blocker within 24 hours before surgery. Adjusting for possible confounders, preoperative β-blocker use was associated with increased odds of AKI stage 2 (odds ratio 1.96, 95% confidence interval 1.19 to 3.24, p <0.01). There was no evidence that β-blocker use had an independent association with postoperative delirium, AKI stages 1 and 3, stroke, AF, mortality, or prolonged length of stay. A secondary propensity score analysis did not show a marginal association between β-blocker use and any outcome. In conclusion, we did not find significant evidence that preoperative β-blocker use was associated with postoperative delirium, AF, AKI, stroke, or mortality.

The sensitivity of Na+, K+ ATPase as an indicator of blood diseases

BACKGROUND

Blood-related hereditary diseases are widespread in Eastern and SouthWestern regions of Saudi Arabia until recently. In this study, we used Na⁺, K⁺ATPase as an enzymatic indicator for the diagnosis of the diseases.

MATERIALS AND METHODS

Individuals with different blood diseases (iron deficiency (n=13), anemia (n=14), thalassemia (n=16) and sickle cell anemia (n=12) were studied for Na⁺, K⁺-ATPase activity in the plasma membrane of red blood cell and compared with those of the healthy ones (n=20) of the same age and gender living in Jeddah, Saudi Arabia.

RESULTS

There was a significant elevation in the specific activity of Na⁺, K⁺ATPase in individuals with anemia compared with those of control (0.0094 + 0.001 nmol / mg protein/min versus 0.0061 ± 0.001). On the other hand, there was a significant reduction in enzyme activity in thalassemia (0.0028 ± 0.002 nmol / mg protein/min) and sickle cell anemia cases (0.0042 ±0.001 nmol / mg protein/min) compared to the control group. The cut off value for Na⁺, K⁺ATPase activity is 0.005 µmol Pi/min-showing 94% sensitivity and 93% specificity for the differentiation of blood abnormality.

CONCLUSION

It can be recommended that the activity of Na⁺, K⁺-ATPase can be used for the diagnosis of individuals with blood diseases/disorders.

Risk factors for depressive symptoms in glaucoma patients: a nationwide case-control study

PURPOSE

The purpose was to investigate the risk factors for depressive symptoms in glaucoma patients.

METHODS

From the Longitudinal Health Insurance Database in Taiwan, we included 1190 glaucoma patients with subsequent depression diagnoses in the case group and randomly selected 4673 glaucoma patients without depression diagnoses as the control group, matched by age, sex, and time of glaucoma diagnosis. The age-adjusted Charlson comorbidity index (ACCI) score was used to compute the burden of comorbidity for each patient. Current use (past 6 months) of topical antiglaucoma medications and systemic medications was identified. Multivariate regression was used to analyze the risk factors for depression.

RESULTS

The mean age for glaucoma patients was 61.88 years. Patients with depressive symptoms had significantly higher ACCI scores (P < .0001). The current use of any topical antiglaucoma medications was not associated with an increased risk for depression. However, higher ACCI scores (P < .0001), cerebrovascular diseases (odds ratio [OR] = 1.324, 95 % confidence interval [CI] = 1.118--1.568), dementia (OR = 2.647, 95 % CI = 2.142-3.270), thyroid diseases (OR = 1.720, 95 % CI = 1.366-2.165), headaches (OR = 1.299, 95 % CI = 1.112-1.518), and current use of systemic β-blockers (OR = 1.782, 95 % CI = 1.538-2.065) and calcium channel blockers (OR = 1.396, 95 % CI, 1.197-1.629) were found to increase the risk of depression in glaucoma patients.

CONCLUSIONS

In this study, a comorbidity burden was a significant risk factor for depression in glaucoma patients, particularly for those currently using systemic β-blockers and calcium channel blockers.

[Anxiogenic and depressogenic side-effects of non-psychiatric drugs]

Although medications such as anticancer, antimicrobial, immunomodulatory, neurological or hormonal therapies may have a negative impact on mood, adequate attention was not paid until the withdrawal of rimonabant in 2008. In the present study the authors review full spectrum of currently available medications discussing anxiety and depression as possible adverse effects of treatment. A relatively high risk of depression should always be considered when pharmacotherapy applied, especially if current depressive episodes, positive family history, or neurotic personality traits increasing susceptibility to depressogenic effects. Prior to start of medical treatment, the potential effectiveness of the given drug should be precisely evaluated, and alternative medical and non-medical treatment options should also be carefully considered. In addition, monitoring patients during treatment for signs of depressive or anxious symptoms is necessary.

Autonomic and hemodynamic origins of pre-hypertension: central role of heredity

OBJECTIVES

The purpose of this study is to better understand the origins and progression of pre-hypertension.

BACKGROUND

Pre-hypertension is a risk factor for progression to hypertension, cardiovascular disease, and increased mortality. We used a cross-sectional twin study design to examine the role of heredity in likely pathophysiological events (autonomic or hemodynamic) in pre-hypertension.

METHODS

Eight hundred twelve individuals (337 normotensive, 340 pre-hypertensive, 135 hypertensive) were evaluated in a sample of twin pairs, their siblings, and other family members. They underwent noninvasive hemodynamic, autonomic, and biochemical testing, as well as estimates of trait heritability (the percentage of trait variance accounted for by heredity) and pleiotropy (the genetic covariance or shared genetic determination of traits) by variance components.

RESULTS

In the hemodynamic realm, an elevation of cardiac contractility prompted increased stroke volume, in turn increasing cardiac output, which elevated blood pressure into the pre-hypertension range. Autonomic monitoring detected an elevation of norepinephrine secretion plus a decline in cardiac parasympathetic tone. Twin pair variance components documented substantial heritability as well as joint genetic determination for blood pressure and the contributory autonomic and hemodynamic traits. Genetic variation at a pathway locus also indicated pleiotropic effects on contractility and blood pressure.

CONCLUSIONS

Elevated blood pressure in pre-hypertension results from increased cardiac output, driven by contractility as well as heart rate, which may reflect both diminished parasympathetic and increased sympathetic tone. In the face of increased cardiac output, systemic vascular resistance fails to decline homeostatically. Such traits display substantial heritability and shared genetic determination, although by loci not yet elucidated. These findings clarify the role of heredity in the origin of pre-hypertension and its autonomic and hemodynamic pathogenesis. The results also establish pathways that suggest new therapeutic targets for pre-hypertension, or approaches to its prevention.

[Neurological aspects of chronic heart failure]

Chronic heart failure (CHF) is one of the leading causes of hospitalization, morbidity and mortality. Moreover, there is a high rate of neurological as well as neuropsychological comorbidities, namely ischemic stroke, structural brain alterations, cognitive impairment, sleep apnea and possible side-effects of HF medication such as delirium or (intracerebral) hemorrhage. The higher stroke risk in patients with HF increases further with age, concomitant arterial hypertension or atrial fibrillation (AF). In women the stroke risk increases with reduced ejection fraction (EF). In general stroke in HF patients is associated with a poor outcome and higher mortality, which is increased more than 2-fold. Furthermore, approximately 25-80% of all patients with CHF experience cognitive impairments such as decreased attention and concentration, memory loss, diminished psychomotor reaction time and decreased executive functions. Cognitive impairment in patients with HF has been linked to losses in gray matter, (silent) ischemic strokes, decreased cerebral perfusion and higher mortality. Moreover, sleep apnea occurs in more than half of all patients with CHF and reduced EF. However, prospective studies are needed to test whether early detection and optimal treatment of HF reduces the burden of neurological and neuropsychological sequelae.

Substances used in completed suicide by overdose in Toronto: an observational study of coroner's data

OBJECTIVE

To identify the substances used by people who die from suicide by overdose in Toronto and to determine the correlates of specific categories of substances used.

METHOD

Coroner's records for all cases of suicide by overdose in Toronto, Ontario, during a 10-year period (1998 to 2007) were examined. Data collected included demographic data, all substances detected, and those determined by the coroner to have caused death. Logistic regression analyses were used to examine demographic and clinical factors associated with suicide by different drug types.

RESULTS

There were 397 documented suicides by overdose (mean age 49.1 years, 50% female). Most substances detected were psychotropic prescription medications (n = 245), followed by other prescription medications (n = 143) and over-the-counter (OTC) medications (n = 83). More than one-half of all suicides by overdose were determined to have only one specific substance as the cause of death (n = 206). In suicides where only one class of substance was present in lethal amounts, OTC medication (n = 48), opioid analgesics (n = 44), and tricyclic antidepressants (n = 44) were most common.

CONCLUSIONS

Suicides by overdose involved the use of different classes of substances, including psychotropic prescription medication, other prescription medications, as well as OTC medications. Physicians and pharmacists should be aware of commonly used prescription and OTC medications in overdose and exercise increased vigilance in prescribing or dispensing them to at-risk patients.

Mania-like behavior induced by genetic dysfunction of the neuron-specific Na+,K+-ATPase α3 sodium pump

Bipolar disorder is a debilitating psychopathology with unknown etiology. Accumulating evidence suggests the possible involvement of Na(+),K(+)-ATPase dysfunction in the pathophysiology of bipolar disorder. Here we show that Myshkin mice carrying an inactivating mutation in the neuron-specific Na(+),K(+)-ATPase α3 subunit display a behavioral profile remarkably similar to bipolar patients in the manic state. Myshkin mice show increased Ca(2+) signaling in cultured cortical neurons and phospho-activation of extracellular signal regulated kinase (ERK) and Akt in the hippocampus. The mood-stabilizing drugs lithium and valproic acid, specific ERK inhibitor SL327, rostafuroxin, and transgenic expression of a functional Na(+),K(+)-ATPase α3 protein rescue the mania-like phenotype of Myshkin mice. These findings establish Myshkin mice as a unique model of mania, reveal an important role for Na(+),K(+)-ATPase α3 in the control of mania-like behavior, and identify Na(+),K(+)-ATPase α3, its physiological regulators and downstream signal transduction pathways as putative targets for the design of new antimanic therapies.

Depressogenic effects of medications: a review

The literature is filled with reports that link medications with the onset or progression of depression. Because depression is so common in patients with medical illness, assessing whether a medication has in fact caused depression, or whether the relationship is coincidental, can be challenging. In this article, we review the literature on the association between medications and depression. For most agents, there are case reports or small studies linking the medication with the onset of depression, but more rigorous prospective studies are either lacking or found no association between the agent and depression. However, several medications, (eg, barbiturates, vigabatrin, topiramate, flunarizine, corticosteroids, mefloquine, efavirenz, and interferon-α) do appear to cause depression in some patients and should be used with caution in patients at risk for depression.

Delirium following vascular surgery: increased incidence with preoperative beta-blocker administration

PURPOSE

To determine if there is an association between perioperative administration of beta-blockers and postoperative delirium in patients undergoing vascular surgery.

METHODS

After Institutional Review Board approval, data were retrospectively collected on patients who underwent vascular surgery in an academic hospital during the period January 2006 to January 2007. Patients with preoperative altered level of consciousness, carotid endarterectomy, or discharge within 24 h of surgery were excluded from the study. Identification of delirium was based on evaluation of the level of consciousness with the NEECHAM Confusion Scale and/or a chart-based instrument for delirium. Multivariable logistic regression analysis was used to identify independent perioperative predictors of postoperative delirium. Beta-blockers were tested for a potential effect.

RESULTS

The incidence of postoperative delirium was 128/582 (22%). Independent predictors included age (OR 1.04, 95% CI [1.02-1.07]), history of cerebrovascular accident/transient ischemic attack (OR 2.64, 95% CI [1.57-4.55]), and depression (OR 3.56, 95% CI [1.53-8.28]). Open aortic reconstruction was associated with an OR of 5.34, 95% CI (2.54-11.2) and amputation with an OR of 4.66, 95% CI (1.96-11.09). Preoperative beta-blocker administration increased the odds of postoperative delirium 2.06 times (95% CI [1.18-3.6]). Statin administration reduced the odds of delirium by 44% (95% CI [0.37-0.88]). The model was reliable (Hosmer-Lemeshow test, P = 0.72) and discriminative (area under the receiver operating characteristic [ROC] curve = 0.729).

CONCLUSIONS

Preoperative administration of beta-blockers is associated with an increased risk of postoperative delirium after vascular surgery. Conversely, preoperative statin administration is associated with a lower risk of postoperative delirium. A randomized prospective controlled trial is required to validate these findings.

High impact of depression in heart failure: Early diagnosis and treatment options

Depressive syndromes in chronic heart failure (CHF) are common and are associated with a poorer prognosis, particularly with increased morbidity and mortality. CHF as a severe physical disorder may increase the risk of developing depressive syndromes or vice-versa as an interaction of possible common psycho-organic etiological aspects. Depression in CHF is associated with impaired NYHA status and daily activities, resulting in enhanced hospitalisation rates and medical costs with a great impact on long-term health. Only a fraction of comorbid patients receives antidepressants. Therefore, identification of risk factors and prevention by optimizing cardiological and psychiatric therapeutic strategies appear essential for these patients. Early diagnosis and treatment of both CHF and depression may prevent further pathophysiological effects on the heart and brain. This review gives a comprehensive overview of the occurrence, risk factors and shared pathophysiology of depression in CHF, and focuses on improving insufficient diagnosis and therapy of depression. Special attention is given on the cardiac effects of psychopharmacological and alternate non-pharmacological antidepressant therapy in CHF. Recommendations are made for treating depression in CHF patients for a better prevention of this disabling physical and psychosocial condition.

Neuropsychiatric consequences of cardiovascular medications

The use of cardiovascular medications can have a variety of neuropsychiatric consequences. Many cardiovascular agents cause higher rates of fatigue and sedation than placebo, and case reports of medication-induced mood syndromes, psychosis, and cognitive disturbances exist for many cardiovascular drugs. Depression has been associated with β-blockers, methyldopa, and reserpine, but more recent syntheses of the data have suggested that these associations are much weaker than originally believed. Though low cholesterol levels have been associated with depression and suicide, lipid-lowering agents have not been associated with these adverse effects. Finally, cardiovascular medications may have beneficial neuropsychiatric consequences; for example, the use of clonidine in patients with attention deficit-hyperactivity disorder, the use of prazosin for patients with post-traumatic stress disorder, and the use of propranolol for performance anxiety and akathisia.

Mania in a case of hyperparathyroidism

Psychiatric manifestations of primary hyperparathyroidism are mediated by hypercalcemia. To date, most evidence indicates that hypercalcemia and increased cerebrospinal-fluid calcium levels produce depression symptoms. Presented here is a case report of a 52-year-old woman in a manic state. She had no psychiatric history but had substantially elevated parathyroid hormone levels and hypercalcemia. On the basis of emerging evidence that calcium channel-blockers effectively treat mania, the authors propose that elevated calcium levels may act through multiple mechanisms or on various regions of the brain to produce a spectrum of psychiatric symptoms that should now include mania as a possibility.

Statin-associated adverse effects beyond muscle and liver toxicity

Randomized controlled trials with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) have consistently demonstrated significant reductions in cardiovascular morbidity and mortality. Statins are currently the most widely used drugs in many countries. The most important adverse effects are associated with muscle and liver toxicity. However, with increased use and dose of statins and their over-the-counter availability in some countries more cases of other rare side effects may be seen in clinical practice. In the present article we review the literature concerning the statin-related adverse effects other than muscle and liver injury and we provide insight into their clinical relevance and possible underlying mechanisms.

Association of Cardiac Drugs with Depression after Acute Coronary Syndrome

Background:

Depressive adverse effects of major cardiac medications in patients with cardiovascular disease have been suggested.

Objective:

To investigate the influence of the use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and/or β-blockers on subsequent depressive symptoms in patients hospitalized for acute coronary syndrome.

Methods:

A sample of 521 patients was followed for 8 months during 1,340 observations. Data were collected from structured telephone interviews and medical record chart reviews. Pooled time series generalized estimating equations regression models were used to evaluate depressive symptom scores, controlling for major clinical and sociodemographic patient characteristics.

Results:

No significant independent or interactive effects were found linking the use of these medications to subsequent depressive symptoms, despite changes in depressive symptoms over time. Factors that did affect subsequent depression included sociodemographic (eg, increased age, less education) and clinical characteristics (eg, higher composite comorbidity, prior history of depression and/or first myocardial infarction, higher postdischarge pain levels).

Conclusions:

Our results suggest that potential depressive adverse effects should not be considered a contraindication to the use of recommended cardiac medications. Observed increases in depressive symptoms after an acute cardiac injury will more likely be attributed to other patient characteristics independent of the use of major drug therapy prescribed to prevent further acute cardiac events.

Medications: a risk factor for periodontal disease diagnosis and treatment

Among the aging U.S. population, patients are taking significantly more medications than in the past. In view of this, dentists should take careful medical histories, including use of herbal agents, and be aware of medication-related problems and their potential effect on the diagnosis and treatment of periodontal disease. This review highlights major concerns about medications as a risk factor for periodontal therapy. Medications and their impact on periodontal disease can be categorized as those which affect oral hygiene, diagnosis, gingival and oral mucosa, and alveolar bone.

Amiodarone versus sotalol for atrial fibrillation

BACKGROUND

The optimal pharmacologic means to restore and maintain sinus rhythm in patients with atrial fibrillation remains controversial.

METHODS

In this double-blind, placebo-controlled trial, we randomly assigned 665 patients who were receiving anticoagulants and had persistent atrial fibrillation to receive amiodarone (267 patients), sotalol (261 patients), or placebo (137 patients) and monitored them for 1 to 4.5 years. The primary end point was the time to recurrence of atrial fibrillation beginning on day 28, determined by means of weekly transtelephonic monitoring.

RESULTS

Spontaneous conversion occurred in 27.1 percent of the amiodarone group, 24.2 percent of the sotalol group, and 0.8 percent of the placebo group, and direct-current cardioversion failed in 27.7 percent, 26.5 percent, and 32.1 percent, respectively. The median times to a recurrence of atrial fibrillation were 487 days in the amiodarone group, 74 days in the sotalol group, and 6 days in the placebo group according to intention to treat and 809, 209, and 13 days, respectively, according to treatment received. Amiodarone was superior to sotalol (P<0.001) and to placebo (P<0.001), and sotalol was superior to placebo (P<0.001). In patients with ischemic heart disease, the median time to a recurrence of atrial fibrillation was 569 days with amiodarone therapy and 428 days with sotalol therapy (P=0.53). Restoration and maintenance of sinus rhythm significantly improved the quality of life and exercise capacity. There were no significant differences in major adverse events among the three groups.

CONCLUSIONS

Amiodarone and sotalol are equally efficacious in converting atrial fibrillation to sinus rhythm. Amiodarone is superior for maintaining sinus rhythm, but both drugs have similar efficacy in patients with ischemic heart disease. Sustained sinus rhythm is associated with an improved quality of life and improved exercise performance.

Medications' impact on oral health

BACKGROUND

Over-the-counter and prescription drugs are used frequently, in large quantities and by many adults, particularly by those older than 65 years of age. A number of medications (prescription, over-the-counter, vitamins and minerals, herbal preparations) can affect oral health. With the population's aging, and as more drugs become available, dentists can expect to encounter medication-related oral side effects among their patients.

TYPES OF STUDIES REVIEWED

The author reviewed studies that ranged from case reports to randomly controlled, double-blinded studies. However, in view of the subject matter, the majority of findings are based on case reports.

CONCLUSIONS

Since many patients regularly take medications, both prescribed and nonprescribed, dentists always must take a thorough medical history so that they can be aware of medication-related problems and the impact of medications on diagnosis and treatment planning.

CLINICAL IMPLICATIONS

Dentists must be aware of the potential oral tissue complications that medications can create and develop appropriate treatment plans for their patients that consider the oral health impact of the medications they take.