Cognitive-affective symptoms of depression after myocardial infarction: different prognostic importance across age groups

Time-dependent cognitive and somatic symptoms of depression as predictors of new cardiac-related events in at-risk patients: the UPBEAT-UK cohort

BACKGROUND

Evidence suggests that somatic rather than cognitive depressive symptoms are risk factors for recurrent cardiac events in at-risk patients. However, this has never been explored using a time-dependent approach in a narrow time-frame, allowing a cardiac event-free time-window.

METHODS

The analysis was performed on 595 participants [70.6% male, median age 72 (27-98)] drawn from the UPBEAT-UK heart disease patient cohort with 6-monthly follow-ups over 3 years. Depressive symptomatology was measured using the Patient Health Questionnaire-9 (PHQ-9) (four somatic, five cognitive items). New cardiac events (NCEs) including cardiac-related mortality were identified by expert examination of patient records. Analyses were performed using Cox proportional hazard models with delayed entry, with time-dependent depressive dimensions and covariates measured 12-18 months (median: 14.1, IQR: 3.5) prior to the event, with a 12-month cardiac event-free gap.

RESULTS

There were 95 NCEs during the follow-up [median time-to-event from baseline: 22.3 months (IQR: 13.4)]. Both the somatic (HR 1.12, 95% CI 1.05-1.20, p = 0.001) and cognitive dimensions (HR 1.11, 95% CI 1.03-1.18, p = 0.004) were time-dependent risk factors for an NCE in the multi-adjusted models. Specific symptoms (poor appetite/overeating for the somatic dimension, hopelessness and feeling like a failure for the cognitive dimension) were also significantly associated.

CONCLUSION

This is the first study of the association between depressive symptom dimensions and NCEs in at-risk patients using a time-to-event standardised approach. Both dimensions considered apart were independent predictors of an NCE, along with specific items, suggesting regular assessments and tailored interventions targeting specific depressive symptoms may help to prevent NCEs in at-risk populations.

Efficacy of Ethanolic Extract of Opuntia ficus-indica var. saboten Stems for Improving Cognitive Function in Elderly Subjects 55-85 Years of Age: A Randomized, Double-Blind, Placebo-Controlled Study

Many natural compounds have been reported to improve cognitive function in cell- and animal-based studies. In this clinical trial, we evaluated the efficacy of ethanolic extract of Opuntia ficus-indica var. saboten stem for improving cognitive function using a randomized, double-blind, placebo-controlled trial (n = 81) in aged people. After 12 weeks of administration of OFE (a mixture of ethanolic extract of O. ficus-indica var. Saboten stem and dextrin) or placebo, the effect on cognitive function was assessed. Overall, OFE did not show a significant difference from the placebo in terms of efficacy. However, the cognitive function significantly improved in the OFE group compared with the placebo group in the subgroup ≤70 years of age, which means that the effect of OFE administration exhibits an age-dependent effect. In addition, the safety of OFE was confirmed by analyzing blood test results, vital signs, and electrocardiograms. In conclusion, OFE administration in participants ≤70 years of age shows a positive effect on overall cognitive function. The trial was registered on CRIS (the Clinical Research Information Service), administered by the Korea Centers for Disease Control & Prevention (Registration Number: KCT0003766; URL: https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=12957).

The association of type D personality and depression with infertility in women

Purpose: Type D personality-defined as the presence of two personality characters, namely negative affectivity (NA) and social inhibition (SI)-is associated with various disorders. The 14-item Type D Scale (DS14), which consists of NA and SI subscales, can be used for the detection of the presence of Type D personality. The aim of our study was to investigate the association of Type D personality and depression with infertility in women.Method: A total of 324 women, 168 primary unexplained infertile women (92 patients undergoing in vitro fertilization (IVF) treatment and 76 undergoing intrauterine insemination (IUI) treatment) and 156 fertile controls were recruited. The 21-item Beck Depression Inventory (BDI-21) and DS14 were completed by all participants. The study was approved by Local Ethics Committee with the protocol number 72867572-050-218.Results: Depression and Type D personality were found to be significantly more prevalent in the infertile group than the fertile group. Type D was positively associated with infertility (OR = 2.34, 95% CI = 1.45-3.78, p < .0001), especially in the younger-aged (<35 years) population (OR = 2.59, 95% CI = 1.48-4.5, p = .001). After adjusting for the duration of marriage, age, obesity, educational level, and the same characteristics of the partner, the association between Type D personality and infertility persisted (OR = 2.56, 95% CI = 1.52-4.29, p < .001). The scores of the BDI-21 and NA subscale were found to be negatively correlated with age and partner's age. The BDI and SI scores, and the NA, SI, and Type D personality rates were similar between the IUI and the IVF groups; however, the NA score was higher, and depression was found to be more prevalent and severe in the IUI group than the IVF group.Conclusions: Type D personality could be positively associated with infertility, especially in younger-aged women.

Persistent emotional distress after a first-time myocardial infarction and its association to late cardiovascular and non-cardiovascular mortality

BACKGROUND

Patients with symptoms of depression and/or anxiety - emotional distress - after a myocardial infarction (MI) have been shown to have worse prognosis and increased healthcare costs. However, whether specific subgroups of patients with emotional distress are more vulnerable is less well established. The purpose of this study was to identify the association between different patterns of emotional distress over time with late cardiovascular and non-cardiovascular mortality among first-MI patients aged <75 years in Sweden.

METHODS

We utilized data on 57,602 consecutive patients with a first-time MI from the national SWEDEHEART registers. Emotional distress was assessed using the anxiety/depression dimension of the European Quality of Life Five Dimensions questionnaire two and 12 months after the MI, combined into persistent (emotional distress at both time-points), remittent (emotional distress at the first follow-up only), new (emotional distress at the second-follow up only) or no distress. Data on cardiovascular and non-cardiovascular mortality were obtained until the study end-time. We used multiple imputation to create complete datasets and adjusted Cox proportional hazards models to estimate hazard ratios.

RESULTS

Patients with persistent emotional distress were more likely to die from cardiovascular (hazard ratio: 1.46, 95% confidence interval: 1.16, 1.84) and non-cardiovascular causes (hazard ratio: 1.54, 95% confidence interval: 1.30, 1.82) than those with no distress. Those with remittent emotional distress were not statistically significantly more likely to die from any cause than those without emotional distress.

DISCUSSION

Among patients who survive 12 months, persistent, but not remittent, emotional distress was associated with increased cardiovascular and non-cardiovascular mortality. This indicates a need to identify subgroups of individuals with emotional distress who may benefit from further assessment and specific treatment.

Individual depressive symptoms and all-cause mortality In 6673 patients with myocardial infarction: Heterogeneity across age and sex subgroups

BACKGROUND

Depression predicts poor prognosis in patients with myocardial infarction (MI). However, individual depressive symptoms may have different prognostic value, and age and sex could be important effect modifiers. This study compared the prognostic value of individual depressive symptoms across age and sex subgroups in post-MI patients.

METHODS

Individual patient-data were compiled for 6673 post-MI patients from seven studies. Depressive symptoms were measured with 10 items of the Beck Depression Inventory (BDI10). The endpoint was all-cause mortality (mean=3.8 years). Multilevel multivariable Cox regression analysis was used to estimate the mortality risk across age groups (≤55, 56-69 and ≥70 years) and sex for symptoms that potentially interacted with age and sex.

RESULTS

At follow-up, 995 (15%) post-MI patients had died. BDI10 depression scores were associated with an increased mortality risk (HR:1.20;95%CI:1.11-1.28,p<.001). Negative self-image (HR:1.53;1.06-2.21;p=.022) and indecisiveness (HR:1.53;1.15-2.04;p=.003) were associated with increased mortality in men <55. Dissatisfaction was associated with increased mortality in men aged 56-69 (HR:1.35;1.07-1.71;p=. 011), and dissatisfaction (HR:1.34;1.10-1.63;p=.003) and fatigue (HR:1.45;1.20-1.74;p<.001) in men >70. Fatigue was associated with mortality in women aged 56-69 (HR:1.54;1.09-2.15;p=.012), and suicidal ideation in women aged >70 (HR:1.58;1.03-2.43;p=.037). Left-ventricular ejection fraction (LVEF) accounted for much of the associations in men ≤55 years and women ≥70 years.

LIMITATIONS

Findings are sample-specific and need replication in future research; BDI10 items were derived from the original BDI assessment.

CONCLUSIONS

There is large heterogeneity in the prognostic value of individual depressive symptoms in post-MI patients across sex and age subgroups. LVEF partially explained the depression-prognosis association in specific subgroups.

Two-year prognosis after acute coronary syndrome in younger patients: Association with feeling depressed in the prior year, and BDI-II score and Endothelin-1

OBJECTIVE

To examine the effects of depressive symptoms and Endothelin (ET)-1 on 2-year prognosis in younger patients with acute coronary syndrome (ACS). Depression is associated with poor post-ACS prognosis; however, few investigations have focused on younger patients. Importantly, the studies that did emphasize younger patients suggested that the influence of depression on prognosis could be more robust in younger subgroups. The particular links between depression and poor prognosis in younger patients have yet to be definitively determined. ET-1 is a potent endogenous vasoconstrictor that has been previously linked to adverse post-ACS outcomes.

METHODS

The sample (n=153) included male (age≤50years) and female (age≤55years) ACS patients. Blood samples for ET-1 assessment were collected within 2-3h of ACS hospital admission. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) II within 2-5days of admission. The primary outcome was defined as a composite of major adverse cardiovascular events (MACE), including recurrent myocardial infarction, emergent coronary revascularization, and all-cause mortality within 2years after index admission.

RESULTS

During the follow-up period, 23 patients experienced MACE. Neither the BDI-II score nor ET-1 predicted MACE in unadjusted analyses or in analyses adjusted for demographic characteristics, comorbidities and troponin levels. In the supplementary analyses, feeling depressed in the year preceding ACS predicted MACE.

CONCLUSIONS

In this cohort of younger ACS patients, feeling depressed in the year preceding ACS admission predicted MACE in the 2years after baseline ACS event, while neither the BDI-II score, nor circulating ET-1 level predicted this outcome.

Association Between Depressive Disorders and Incident Acute Myocardial Infarction in Human Immunodeficiency Virus-Infected Adults: Veterans Aging Cohort Study

Importance

With the advent of highly effective antiretroviral therapy and improved survival, human immunodeficiency virus (HIV)-infected people are living longer and are now at an increased risk for cardiovascular disease (CVD). There is an urgent need to identify novel risk factors and primary prevention approaches for CVD in HIV. Although depression is prevalent in HIV-infected adults and is associated with future CVD in the general population, its association with CVD events has not been examined in the HIV-infected population.

Objective

To examine whether depressive disorders are prospectively associated with incident acute myocardial infarction (AMI) in a large cohort of adults with HIV.

Design, Setting, and Participants

Included in this cohort study were 26 144 HIV-infected veterans without CVD at baseline (1998-2003) participating in the US Department of Veterans Affairs Veterans Aging Cohort Study from April 1, 2003, through December 31, 2009. At baseline, 4853 veterans (19%) with major depressive disorder (MDD; International Classification of Diseases, Ninth Revision [ICD-9] codes 296.2 and 296.3) and 2296 (9%) with dysthymic disorder (ICD-9 code 300.4) were identified. The current analysis was conducted from January 2015 to November 2015.

Main Outcomes and Measures

Incident AMI (defined by discharge summary documentation, enzyme/electrocardiography evidence of AMI, inpatient ICD-9 code for AMI (410), or AMI as underlying cause of death [International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code 121]) between the enrollment date and December 31, 2009.

Results

The mean (SD) age of those with MDD was 47.3 (7.9) years and for those without MDD was 48.2 (9.7) years. During 5.8 years of follow-up, 490 AMI events (1.9%) occurred. Baseline MDD was associated with incident AMI after adjusting for demographics (hazard ratio [HR], 1.31; 95% CI, 1.05-1.62), CVD risk factors (HR, 1.29; 95% CI, 1.04-1.60), and HIV-specific factors (HR, 1.30; 95% CI, 1.05-1.62). Further adjustment for hepatitis C, renal disease, substance abuse, and hemoglobin level (HR, 1.25; 95% CI, 1.00-1.56) and antidepressant use (HR, 1.12; 95% CI, 0.87-1.42) attenuated associations. Baseline dysthymic disorder was not associated with incident AMI.

Conclusions and Relevance

We report novel evidence that HIV-infected adults with MDD have a 30% increased risk for AMI than HIV-infected adults without MDD after adjustment for many potential confounders. Our findings raise the possibility that MDD may be independently associated with incident atherosclerotic CVD in the HIV-infected population.

Explaining heterogeneity in the predictive value of Type D personality for cardiac events and mortality

BACKGROUND

Type D personality has been associated with adverse outcomes in patients with coronary artery disease (CAD). However, large heterogeneity exists between Type D studies, including some studies reporting null-findings.

OBJECTIVES

The aim of this study was to examine i) choice of endpoint and ii) age as two study characteristics that may partly explain this large heterogeneity in the Type D associated prognostic effect.

METHODS

We used four existing data cohorts of 1503 CAD patients (89% male, mean age=57.2±9.1) with baseline measures of Type D and endpoints >5years follow-up: major adverse cardiac events (MACE), cardiac death/MI, and non-cardiac death. Patients were classified in 4 age categories: <50y, 50-59y, 60-69y and ≥70y. Multiple logistic regression models included age, sex, and clinical covariates.

RESULTS

At follow-up, there were 295 events, including 116 cardiac death/MI, and 37 non-cardiac deaths. Both continuous and categorical measures of Type D predicted adverse events. Type D was independently associated with MACE (OR=1.82; 95%CI 1.33-2.50) and cardiac death/MI (OR=2.49; 95%CI 1.55-3.99). However, Type D was not associated with non-cardiac death (OR=1.23; 95%CI 0.57-2.69). Regarding age, Type D consistently predicted MACE in the lower age groups (all ORs≥2.20, all ps≤.004), but not in patients aged ≥70y (OR=1.43, p=.57).

CONCLUSIONS

Choice of endpoint and age modulated the risk conferred by Type D personality. Type D was associated with an increased risk of cardiac events, but not with non-cardiac death, or with events in patients aged ≥70y. Research on psychosocial risk in CAD should account for different sources of heterogeneity in study characteristics.

Base Rates of Depressive Symptoms in Patients with Coronary Heart Disease: An Individual Symptom Analysis

Background

Major depression is common in coronary heart disease (CHD) but challenging to diagnose. Instead of focusing on the overall diagnosis of depression, base rates of depressive symptoms could facilitate screening and management of psychopathology in CHD. The present study investigates the frequency of individual depressive symptoms in CHD and their impact on cardiac and subjective health.

Methods

In total, 1337 in- and outpatients with CHD were screened for depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9) at three different cardiac treatment sites. Tables stratified by age and gender were designed to illustrate base rates of depressive symptoms. Multiple regression analyses adjusted for sociodemographic and clinical data were conducted to test associations between individual depressive symptoms and quality of life as well impairment caused angina pectoris and dyspnea.

Results

During the last 14 days, more than half of patients reported a loss of energy (74.9%, 95% Confidence Interval (CI): 70.6–79.2), sleeping problems (69.4%, 95% CI: 64.9–74.0), loss of interest (55.7%, 95% CI: 50.8–60.7). In contrast, psychomotor change (25.6%, 95%CI: 21.3–30.0), feelings of failure (21.9%, 95%CI: 17.7–26.0), suicidal ideations (14.1%, 95%CI: 10.7–17.6) were less frequently reported. Depending on the outcome, only particular depressive symptoms were highly associated with low quality of life and impairment caused by angina pectoris and dyspnea. Loss of energy was the only depressive symptom that reliably predicted all three outcomes.

Conclusions

Depressive symptoms in CHD are frequent but vary widely in terms of frequency. Findings underline the differential effects of individual depressive symptoms on cardiac health. Presented base rates of depressive symptoms offer clinicians a new way to judge the severity of individual depressive symptoms and to communicate individual PHQ-9 profiles with patients with respect to gender, age, cardiac symptoms and quality of life.

Association between Ideal Cardiovascular Health Metrics and Depression in Chinese Population: A Cross-sectional Study

The study aimed to examine the association between ideal cardiovascular health (CVH) metrics and depression. We conducted a population-based, cross-sectional study of 6,851 participants aged 20 years or older (3,525 men and 3,326 women) living in Tangshan City, China. Information on the seven CVH metrics (including smoking, body mass index, dietary intake, physical activity, blood pressure, total cholesterol and fasting blood glucose) was collected via questionnaires, physical examination and laboratory test. Depression status was assessed using the Epidemiologic Studies Depression Scale (CES-D) and a score of 16 or above was considered depression. The relationship between CVH metrics and depression was analyzed using logistic regression. Of the 6,851 participants, 525 (7.7%) were in depression status. After adjustment for potential confounders, men in the highest quartile of ideal CVH metric summary score had a reduced likelihood of having depression compared to those in the lowest quartile (adjusted odds ratio (AOR): 0.46, 95% confidence interval (CI): 0.28-0.75, p = 0.002). A similar trend was found among women, even though the association was not significant (AOR = 0.74, 95%CI: 0.46-1.18, p = 0.211). This study suggested that better CVH status is associated with a lower risk of depression especially in Chinese male and young population.

Severe depressive symptoms are associated with elevated endothelin-1 in younger patients with acute coronary syndrome

OBJECTIVE

To explore the relationship of depressive symptom severity to circulating endothelin (ET)-1 in younger patients with acute coronary syndrome (ACS). Younger patients report greater depressive symptom severity, which predicts poorer post-ACS prognosis. The pathways linking depression to post-ACS prognosis require further elucidation. ET-1 is a potent endogenous vasoconstrictor which has been previously linked to adverse post-ACS outcomes.

METHODS

The sample (n=153) included males ≤ 50 years of age and females ≤ 55 years of age who participated in a larger study. Blood samples for ET-1 assessment were collected within 2-3h of ACS admission. Depressive symptoms were assessed with the Beck Depression Inventory (BDI) II within 2-5 days of admission. ET-1 was treated as a transformed continuous variable (ET-1T). BDI-II scores were classified into four categories using conventional thresholds demarcating mild, moderate, and severe levels of depressive symptoms. The relationship of classified BDI-II score to ET-1T was examined in simple and multivariable linear regression models.

RESULTS

Classified BDI-II score was related to ET-1T in both unadjusted (χ(2)=9.469, p=0.024) and multivariable (χ(2)=8.430, p=0.038) models, with ET-1T being significantly higher in patients with severe depressive symptoms than in those with mild and moderate depressive symptoms.

CONCLUSIONS

In this sample of younger post-ACS patients, severe depressive symptoms were associated with elevated ET-1. We acknowledge that the observed association could be eliminated by the inclusion of some unmeasured variable(s). Longitudinal research should examine whether ET-1 mediates the relationship of depressive symptoms to long-term post-ACS outcomes.

Predictive value of social inhibition and negative affectivity for cardiovascular events and mortality in patients with coronary artery disease: the type D personality construct

OBJECTIVE

Methodological considerations and selected null findings indicate the need to reexamine the Type D construct. We investigated whether associations with cardiac events in patients with coronary artery disease (CAD) involve the specific combination of negative affectivity (NA) and social inhibition (SI), or rather the main effect of either trait alone.

METHODS

In this 5-year follow-up of 541 patients with CAD, the Type D construct (14-item Type D Scale) was tested by examining a) the interaction of continuous NA and SI z scores and b) a four-group classification defined by low/high trait scores. End points were major adverse cardiac events (MACEs; death, myocardial infarction [MI], coronary revascularization) and cardiac death/MI.

RESULTS

At follow-up, 113 patients had a MACE, including 47 patients with cardiac death/MI. After adjustment for disease severity, age, sex, and main trait effects, the interaction of NA and SI z scores was associated with MACE (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.11-1.67). This continuous measure of Type D was also associated with cardiac death/MI (OR = 1.48, 95% CI = 1.11-1.96) and remained an independent predictor of events after adjustment for depressive symptoms. Using a cutoff of 10 on both NA and SI scales, Type D was associated with an adjusted OR of 1.74 (95% CI = 1.11-2.73) for MACE and an OR of 2.35 (95% CI = 1.26-4.38) for death/MI but was unrelated to noncardiac death. Patients with high NA or SI alone were not at increased risk.

CONCLUSIONS

Continuous (NA × SI interaction) and dichotomized measures of Type D were associated with cardiovascular events in patients with CAD. Research is needed to explore moderating factors that may alter this association.

Age-related differences in the effect of psychological distress on mortality: Type D personality in younger versus older patients with cardiac arrhythmias

Background. Mixed findings in biobehavioral research on heart disease may partly be attributed to age-related differences in the prognostic value of psychological distress. This study sought to test the hypothesis that Type D (distressed) personality contributes to an increased mortality risk following implantable cardioverter defibrillator (ICD) treatment in younger patients but not in older patients. Methods. The Type D Scale (DS14) was used to assess general psychological distress in 455 younger (≤70 y, m = 59.1) and 134 older (>70 y, m = 74.3) ICD patients. End points were all-cause mortality and cardiac death after a median follow-up of 3.2 years. Results. Older patients had more advanced heart failure and a higher mortality rate (n = 34/25%) than younger patients (n = 60/13%), P = 0.001. Cardiac resynchronization therapy (CRT), but not Type D personality, was associated with increased mortality in older patients. Among younger patients, however, Type D personality was associated with an adjusted hazard ratio = 1.91 (95% CI 1.09–3.34) and 2.26 (95% CI 1.16–4.41) for all-cause and cardiac mortality; other predictors were increasing age, CRT, appropriate shocks, ACE-inhibitors, and smoking. Conclusion. Type D personality was independently associated with all-cause and cardiac mortality in younger ICD patients but not in older patients. Cardiovascular research needs to further explore age-related differences in psychosocial risk.