Association Between Depressive Symptoms and Exercise Capacity in Patients With Heart Disease: A META-ANALYSIS

Association of depressive symptoms and engagement in physical activity with event-free survival in patients with heart failure

BACKGROUND

Heart failure (HF) subtype, depressive symptoms, and physical inactivity independently contribute to survival outcomes, but the effect of the interaction of these variables on survival outcomes remains unknown.

OBJECTIVES

We aimed to determine whether depressive symptoms and engagement in physical activity differentially interact to predict the combined endpoint of all-cause death or rehospitalization among patients with HF and reduced (HFrEF) or preserved ejection fraction (HFpEF).

METHODS

This study was a secondary analysis. The sample was categorized by the presence or absence of depressive symptoms, and engagement or non-engagement in physical activity. Cox proportional hazard modeling was used to predict the combined endpoint of all-cause death or rehospitalization.

RESULTS

A total of 1002 patients with HF were included (mean age 64.3 ± 12.7 years; 637 males [64 %]; 844 White [84 %]). Among them, 35.3 % did not engage in physical activity, while 64.7 % engaged in any level of physical activity, and 29.7 % had depressive symptoms. In both subtypes, depressive symptoms were associated with the highest risk of all-cause death or rehospitalization. Among patients with HFrEF, those with depressive symptoms who did not engage in physical activity were associated with a 136 % higher risk of the combined endpoint, while among those with HFpEF, depressive symptoms and engagement in physical activity were associated with a 78 % higher risk.

CONCLUSIONS

Depressive symptoms and lack of physical activity predicted the combined endpoint of all-cause death or rehospitalization among patients with HFrEF, while depressive symptoms alone were the strongest predictor among patients with HFpEF.

Remission from depression is associated with improved quality of life and preserved exercise capacity in adults with congenital heart disease

Aims

Improved long-term survival has widened the treatment goals for adults with congenital heart disease (ACHD) by addressing parameters that impact mental well-being and exercise capacity. Depression, a frequent co-morbidity in ACHD, is linked to both. Whether successful treatment of depression also affects cardiac parameters is a matter of debate.

Methods

This prospective, cross-sectional, longitudinal study included N = 150 ACHD (mean age 35.2 ± 11.3 years, 57% male) at baseline (t0) and N = 114 at follow-up (mean follow-up: 4.8 ± 0.6 years; t1). Patients were interviewed using a structured clinical interview, and severity of depression was assessed using the Montgomery-Asperg Depression Scale (MADRS). Additional testing was performed using self-rating questionnaires concerning depression, anxiety and quality of life (QoL). Exercise capacity (VO2max) was assessed by symptom limited exercise testing.

Results

Of N = 33 patients diagnosed with depression at t0, N = 18 patients remitted and N = 15 were non-remitters. Remitters displayed significantly decreased anxiety (P = 0.013), improved global QoL (P = 0.002), and preserved VO2max (P = 0.958) at t1 compared to t0. This was associated with favourable health behaviour at t1 and stable body-mass-index. Contrarily, non-remitters reported further increased anxiety (P = 0.021) and no significant improvement in QoL (P = 0.405). VO2max declined significantly (P = 0.006) and body-mass-index increased (P = 0.004). Never-depressed patients showed no significant changes in anxiety (P = 0.415) or QoL (P = 0.211). VO2max decreased significantly (P < 0.001).

Conclusion

In ACHD, remission from depression is associated with better physical functioning, mental health, and QoL. The assessment and treatment of depression in ACHD emerges as an important clinical goal that should be included in a comprehensive multimodal treatment plan.

Depression is Associated with the Increase Risk of Multimorbidity Among the General Population in Indonesia

Purpose

Depression is common among patients with chronic disease. However, little is known about the association between depression and the risk of developing multimorbidity. This study aims to identify the association between depression and the incidence of multimorbidity among the general population in Indonesia.

Patients and Methods

The national cross-sectional population-based survey used publicly available data from the Indonesian Family Life Survey (IFLS-5) for 2014 among respondents aged ≥15 years. Depression was assessed using the Center for Epidemiologic Studies-Depression (CES-D) scale. The number of chronic diseases and amount of sociodemographic information were obtained from self-reported data. A logistic regression analysis was used to assess the association between depression and multimorbidity, adjusting for confounders. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

Results

The study recruited 2222 respondents; the majority of them were male (68.0%) and aged 55–64 years (34.7%). Of the total number of respondents, 69.6% have depression and 36.5% have multimorbidity. The prevalence of depression in respondents increases with age. Depressive symptoms were more likely to report multimorbidity (OR 2.05, 95% CI: 1.66–2.52).

Conclusion

Depression is associated with the increased risk of multimorbidity among the general population in Indonesia. Therefore, screening for and treatment of depression for those at risk of developing multimorbidity are urgently needed.

Depressive Symptoms After Acute Myocardial Infarction and Its Association With Low Functional Capacity and Physical Activity

PURPOSE

Depressive symptoms after acute myocardial infarction (AMI) are related with adverse health outcomes. However, the risk factors and course of depressive symptoms after AMI have not been widely investigated, especially in Asian populations. We aimed to evaluate changes in the prevalence of depressive symptoms and the associated risk factors at 3 mo after AMI. We also investigated the associations among functional capacity, physical activity (PA), and depressive symptoms.

METHODS

This cross-sectional study was conducted for 1545 patients who were admitted for AMI and referred to cardiac rehabilitation (CR) between August 2015 and March 2019. Of these patients, 626 patients completed the Patient Health Questionnaire-9 (PHQ-9), the Korean Activity Scale Index (KASI), and the International Physical Activity Questionnaire (IPAQ) 3 mo following AMI. A PHQ-9 score of ≥5 was considered to indicate depressive symptoms.

RESULTS

The prevalence of depressive symptoms was 30% at baseline and decreased to 12% at 3 mo after AMI. Depressive symptoms were significantly associated with low functional capacity (OR = 2.20, P = .004) and unemployment status (OR = 1.82, P = .023). After adjusting for variables including functional capacity, depressive symptoms exhibited a significant relationship with low PA after AMI (OR = 1.80, P = .023).

CONCLUSION

Systematic screening and treatment for depressive symptoms and efforts to promote CR may help to improve PA and functional capacity in Korean patients with AMI. Such efforts may aid in reducing the depressive symptoms and related adverse outcomes.

Relationship between physical capacity and depression in heart failure patients undergoing hybrid comprehensive telerehabilitation vs. usual care: subanalysis from the TELEREH-HF Randomized Clinical Trial

AIMS

The hybrid comprehensive telerehabilitation (HCTR) consisting of telecare (with psychological telesupport), telerehabilitation, and remote monitoring of cardiovascular implantable electronic devices might be an option to improve both physical capacity and depressive symptoms. The aim of the study was to investigate the influence of HCTR on depressive symptoms and physical capacity in heart failure (HF) patients in comparison with usual care (UC).

METHODS AND RESULTS

The present analysis formed part of a multicentre, randomized trial that enrolled 850 HF patients (New York Heart Association I-III, left ventricular ejection fraction ≤ 40%). Patients were randomized 1:1 to HCTR or UC. Patients underwent an HCTR programme (1 week in hospital and 8 weeks at home; exercise training 5 times weekly) or UC with observation. The Beck Depression Inventory II (BDI-II) score (cut point for depression ≥ 14) was used to assess depression and the physical capacity was measured by peak oxygen consumption (peak VO2; mL/kg/min). Measurements were made before and after 9-week intervention/observation (HCTR/UC group). Both groups were comparable in terms of demographic and clinical characteristics. In HCTR group, at entry, 23% of the sample obtained BDI-II scores ≥14 vs. 27.5% in UC group. There were no significant differences between groups regarding ΔBDI-II score (P = 0.992) after 9-week HCTR/UC. There was a significant improvement in physical capacity only in the HCTR group in both patients with (P = 0.033) and without (P < 0.001) depression.

CONCLUSIONS

In HF patients, HCTR provided similar reduction of depressive symptoms as UC. HCTR resulted in a significant improvement in physical capacity in patients with and without depression.

Physical activity and aerobic fitness in children with inherited cardiac diseases

BACKGROUND

Because of sports and exercise restrictions, children with inherited cardiac disease are at risk of physical deconditioning. Guidelines on sports participation in cardiovascular disease have become less restrictive over time, but their real-life application and behavioural impact have seldom been evaluated in children.

AIMS

We aimed to evaluate adherence to the 2020 European Society of Cardiology guidelines on sports and exercise in children with inherited cardiac arrhythmia and inherited cardiomyopathy; we also sought to evaluate their aerobic fitness, and the behavioural impact of inherited cardiac diseases on physical activity in children.

METHODS

Children aged 6-18 years with inherited cardiomyopathy or inherited cardiac arrhythmia were eligible for this cross-sectional study. Clinical, demographic and qualitative data were analysed.

RESULTS

A total of 32 children were included in the study (mean age 12.7±3.5 years). Most children (81.3%) complied with the 2020 European Society of Cardiology guidelines; they were physically active and had good overall aerobic fitness, with a mean peak oxygen uptake (VO₂) value of 36.5±8.0mL/kg/min (84.0±17.2% of theoretical value). As a result of personal or parental behaviour, some children at risk of sudden cardiac death did not comply with the recommended upper limit of physical activity intensity, whereas others at low risk did not comply with the lower limit.

CONCLUSION

Most children with inherited cardiac arrhythmia or inherited cardiomyopathy complied with current 2020 European Society of Cardiology guidelines on sports cardiology and exercise in cardiovascular disease.

Health-related quality of life and physical activity in children with inherited cardiac arrhythmia or inherited cardiomyopathy: the prospective multicentre controlled QUALIMYORYTHM study rationale, design and methods

Background

Advances in paediatric cardiology have improved the prognosis of children with inherited cardiac disorders. However, health-related quality of life (QoL) and physical activity have been scarcely analysed in children with inherited cardiac arrhythmia or inherited cardiomyopathy. Moreover, current guidelines on the eligibility of young athletes with inherited cardiac disorders for sports participation mainly rely on expert opinions and remain controversial.

Methods

The QUALIMYORYTHM trial is a multicentre observational controlled study. The main objective is to compare the QoL of children aged 6 to 17 years old with inherited cardiac arrhythmia (long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, or arrhythmogenic right ventricular dysplasia), or inherited cardiomyopathy (hypertrophic, dilated, or restrictive cardiomyopathy), to that of age and gender-matched healthy subjects. The secondary objective is to assess their QoL according to the disease’s clinical and genetic characteristics, the level of physical activity and motivation for sports, the exercise capacity, and the socio-demographic data. Participants will wear a fitness tracker (ActiGraph GT3X accelerometer) for 2 weeks. A total of 214 children are required to observe a significant difference of 7 ± 15 points in the PedsQL, with a power of 90% and an alpha risk of 5%.

Discussion

After focusing on the survival in children with inherited cardiac disorders, current research is expanding to patient-reported outcomes and secondary prevention. The QUALIMYORYTHM trial intends to improve the level of evidence for future guidelines on sports eligibility in this population.

Trial registration ClinicalTrials.gov Identifier: NCT04712136, registered on January 15th, 2021 (https://clinicaltrials.gov/ct2/show/NCT04712136).

Changes in Physical Performance and Their Association With Health-Related Quality of Life in a Mixed Nonischemic Cardiac Population That Participates in Rehabilitation

PURPOSE

Exercise-based cardiac rehabilitation improves physical performance and health-related quality of life (HRQoL). However, whether improvements in physical performance are associated with changes in HRQoL has not been adequately investigated in a nonischemic cardiac population.

METHODS

Patients who were ablated for atrial fibrillation, who underwent heart valve surgery or who were treated for infective endocarditis, and who participated in 1 of 3 randomized controlled rehabilitation trials were eligible for the current study. Change in physical performance and HRQoL were measured before and after a 12-wk exercise intervention. Physical performance was assessed using a cardiopulmonary exercise test, a 6-min walk test, and a sit-to-stand test. Health-related quality of life was assessed using the generic 36-Item Short Form Health Survey and the disease-specific HeartQoL questionnaire. Spearman correlation coefficient (ρ) and linear regressions quantified the association between changes in physical outcome measures and changes in HRQoL.

RESULTS

A total of 344 patients were included (mean age: 60.8 ± 11.6 yr and 77% males). Associations between changes in physical outcome measures and HRQoL ranged from very weak to weak (ρ = -0.056 to 0.228). The observed associations were more dominant within physical dimensions of the HRQoL compared with mental or emotional dimensions. After adjusting for sex, age, and diagnosis, changes in physical performance explained no more than 20% of the variation in the HRQoL.

CONCLUSION

The findings show that the positive improvement in HRQoL from exercise-based cardiac rehabilitation cannot simply be explained by an improvement in physical performance.

Factors That Predispose Women to Greater Depressive Symptoms: A Sex-, Age-, and Diagnosis-Matched Cardiac Rehabilitation Cohort

BACKGROUND

Depressive symptoms (DS) disproportionately affect women with cardiac disease; however, no analyses have been conducted that would allow for focused sex-specific interventions.

METHODS

Consecutively enrolled women (n = 663) were matched with men postcardiac revascularization at cardiac rehabilitation (CR) entry by primary diagnosis, age, and year of CR entry from database records (2006 to 2017). Multivariate analyses were conducted to determine predictors of DS (≥16 on the Center for Epidemiologic Studies Depression Scale) in all patients and men and women separately.

RESULTS

In bivariate analysis, women were more likely than men to have DS (30.2% vs 19.3%; P < 0.001) in the matched cohort. A greater proportion of women than men had DS in all 10-year age categories (P < 0.05) except youngest (<50 years; 37% vs 30.4%; P = 0.7) and oldest (≥80; 12.3% vs 10.3%; P = 0.8). DS peaked in women aged 50 to 59 (42.5%) and men <50 years (30.4%). In all patients, independent predictors of DS were younger age, lower cardiorespiratory fitness (VO_2peak), being unemployed, greater comorbidities, smoking, anxiolytics, antidepressants, not being married, but not sex. Shared predictors in women-only and men-only analyses were younger age, lower VO_2peak, antidepressants, and being unemployed. Unique predictors for women were obesity, smoking, and delayed CR entry and, for men, hypertension, myocardial infarction, anxiolytics, and not being married.

CONCLUSIONS

Despite matching for age and diagnosis, women were more likely to have DS than men. However, sex was not a predictor of DS in multivariate analyses. This suggests that the profile of women predisposes them to greater DS. Obesity, smoking, and greater delayed CR entry were unique correlates for women and targets for intervention.

Depression and multimorbidity: Considering temporal characteristics of the associations between depression and multiple chronic diseases

OBJECTIVES

Depression frequently co-occurs with multiple chronic diseases in complex, costly, and dangerous patterns of multimorbidity. The field of health psychology may benefit from evaluating the temporal characteristics of depression's associations with common diseases, and from determining whether depression is a central connector in multimorbid disease clusters. The present review addresses these issues by focusing on 4 of the most prevalent diseases: hypertension, ischemic heart disease, arthritis, and diabetes.

METHOD

Study 1 assessed how prior chronic disease diagnoses were associated with current depression in a large, cross-sectional, population-based study. It assessed depression's centrality using network analysis accounting for disease prevalence. Study 2 presents a systematic scoping review evaluating the extent to which depression was prospectively associated with the onset of the 4 prevalent chronic diseases.

RESULTS

In Study 1 depression had the fourth highest betweenness centrality ranking of 26 network nodes and centrally connected many existing diseases and unhealthy behaviors. In Study 2 depression was associated with subsequent incidence of ischemic heart disease and diabetes across multiple meta-analyses. Insufficient information was available about depression's prospective associations with incident hypertension and arthritis.

CONCLUSIONS

Depression is central in patterns of multimorbidity and is associated with incident disease for several of the most common chronic diseases, justifying the focus on screening and treatment of depression in those at risk for developing chronic disease. Future research should investigate the mediating and moderating roles of health behaviors in the association between depression and the staggered emergence over time of clusters of multimorbid chronic diseases. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The effect of diet, lifestyle and psychological factors in the prognosis of ischemic heart failure

Background/Objective

Dietary patterns may play an important role in the prognosis of heart failure.

Methods

Dietary habits, sleeping habits, physical activity and anxiety and depression status were recorded in 326 patients (90 females, mean age 73.45 ± 10.9 years) with ischemic heart failure prospectively followed for 30 months.

Results

Lower ΗADS-depression scores (p = 0.03), a low-fat meat diet (p = 0.035) and moderate coffee consumption (p = 0.005) were associated with better prognosis. Non-significant differences were recorded in outcomes with regard to consumption of other dietary categories.

Conclusions

A balanced diet as well as emphasis on the treatment of depression may improve outcomes in ischemic heart failure.

•

Coffee consumption is associated with better outcomes in ischemic heart failure.

•

A low fat meat diet is associated with better outcomes in ischemic heart failure.

•

High ΗADS depression score is related to worst prognosis in ischemic heart failure.

•

Sedentary lifestyle is related to worst outcomes in ischemic heart failure.

Relationships between exercise capacity and anxiety, depression, and cognition in patients with heart failure

BACKGROUND

Symptoms of anxiety, depression, and cognitive impairment are common in heart failure (HF) patients, but there are inconsistencies in the literature regarding their relationship and effects on exercise capacity.

OBJECTIVES

The aim of this study was to explore the relationships between exercise capacity and anxiety, depression, and cognition in HF patients.

METHODS

This was a secondary analysis on the baseline data of the Italian subsample (n = 96) of HF patients enrolled in the HF-Wii study. Data was collected with the 6-minute walk test (6MWT), Hospital Anxiety and Depression Scale, and Montreal Cognitive Assessment.

RESULTS

The HF patients walked an average of 222 (SD 114) meters on the 6MWT. Patients exhibited clinically elevated anxiety (48%), depression (49%), and severe cognitive impairment (48%). Depression was independently associated with the distance walked on the 6MWT.

CONCLUSIONS

The results of this study reinforced the role of depression in relation to exercise capacity and call for considering strategies to reduce depressive symptoms to improve outcomes of HF patients.

Exercise for stroke prevention

We review evidence concerning exercise for stroke prevention. Plausible biological reasons suggest that exercise would be important in preventing stroke. While definitive randomised controlled trials evaluating the impact of physical activity (PA) and exercise on preventing stroke and mortality are lacking, observational studies, small randomised controlled trials and meta-analyses have provided evidence that PA and exercise favourably modify stroke risk factors, including hypertension, dyslipidaemia, diabetes, sedentary lifestyle, obesity, excessive alcohol consumption and tobacco use. It is, therefore, important to understand the factors associated with poststroke PA/exercise and cardiorespiratory fitness. Positively associated factors include self-efficacy, social support and quality of patients' relationships with health professionals. Negatively associated factors include logistical barriers, medical comorbidities, stroke-related deficits, negative exercise beliefs, fear of falling, poststroke fatigue, arthropathy/pain and depression. Definitive research is needed to specify efficacious behavioural approaches to increase poststroke exercise. Effective techniques probably include physician endorsement of exercise programmesto patients, enhancement of patient-professional relationships, providing patients an exercise rationale, motivational interviewing, collaborative goal-setting with patients, addressing logistical concerns, social support in programsmes, structured exercise programming, individualised behavioural instruction, behavioural diary recording, reviewing behavioural consequences of exercise efforts, reinforcing successful exercise performance. Exercise programming without counselling may increase short-term activity; simple advice or information-giving is probably ineffective. Older patients or those with cognitive impairment may need increased structure, with emphasis on behaviour per se, versus self-regulation skills. We support the latest American Heart Association/American Stroke Association guidelines (2014) recommending PA and exercise for stroke prevention, and referral to behaviourally oriented programmes to improve PA and exercise.

Depression, anxiety, and stress in patients with coronary heart disease

The analytical paper summarized the results of recent studies of an association of depression, anxiety, and stress with coronary heart disease (CHD). Mental disorders are shown to be associated with increased risk of CHD and to worsen the course of coronary disease. Antidepressants and psychotherapy improve the control of mental disorders, quality of life, and, in some cases, have a positive impact on the course of coronary disease.

[Cardiac rehabilitation for children and adults with congenital heart disease]

Advances in heart surgery over the past 30 years have significantly improved the prognosis of congenital heart diseases (CHD). Therefore, the epidemiology of CHD has changed dramatically with a shift of mortality from pediatrics to adulthood and an increased prevalence of complex CHD. Today, caregivers and patients focus their interests to new perspectives: improving the quality of life, practicing sports, improving psychosocial care. Cardiac rehabilitation is completely integrated in these new therapeutic strategies. The starting point is the cardiopulmonary exercise test (CPET), with the measurement of oxygen uptake, or "VO2". CPET is now recommended in the follow-up of the adults with CHD. Maximum oxygen uptake correlates to the quality of life of children and adults with CHD. The principles of the rehabilitation in patients with heart failure may usually be applied to CHD patients. Some studies in complex CHD showed improvement of VO2 and quality of life after rehabilitation, without any adverse events. However few physicians have the experience in rehabilitation among CHD patients, especially children. Randomized trials on cardiac rehabilitation in adult and pediatric CHD patients are essential to increase the level of evidence and lead to specific guidelines in this population.