The role of social support in health status and depressive symptoms after acute myocardial infarction: evidence for a stronger relationship among women

Sex differences in acute stroke metrics and outcome dependent on COVID status

BACKGROUND AND PURPOSE

Biological sex is known to have an impact on quality metrics of acute stroke. We aimed to determine whether COVID positivity accentuates this effect and constitutes worse outcome.

METHODS

The present analysis was based on the Global COVID-19 Stroke Registry, a retrospective, international, cohort study of consecutive ischemic stroke patients receiving intravenous thrombolysis and/or endovascular thrombectomy between 1 March 2020 and 30 June 2021. We investigated differences between the sexes in patient characteristics, acute stroke metrics as well as post-stroke outcome in COVID-positive and COVID-negative stroke patients undergoing acute revascularization procedures.

RESULTS

A total of 15,128 patients from 106 centers were recorded in the Global COVID-19 Stroke Registry, 853 (5.6%) of whom were COVID-positive. Overall, COVID-positive individuals were treated significantly slower according to every acute stroke metric compared to COVID-negative patients. We were able to show that key quality indicators in acute stroke treatment were unfavorable for COVID-negative women compared to men (last-seen-well-to-door time + 11 min in women). Furthermore, COVID-negative women had worse 3-month outcomes (3-month modified Rankin Scale score [interquartile range] 3.0 [4.0] vs. 2.0 [3.0]; p < 0.01), even after adjusting for confounders. In COVID-positive individuals no such difference between the sexes, either in acute management metrics or in 3-month outcome, was seen.

CONCLUSION

Known sex-related differences in acute stroke management exist and extend to times of crisis. Nevertheless, if patients were COVID-19-positive at stroke onset, women and men were treated the same, which could be attributed to structured treatment pathways.

Predictors of Health-Related Quality of Life Among Women Participating in an Appointment-Based Cardiac Rehabilitation Program

BACKGROUND

An alternative patient-centered appointment-based cardiac rehabilitation (CR) program has led to significant improvements in health outcomes for patients with cardiovascular disease. However, less is known about the effects of this approach on health-related quality of life (HRQoL), particularly for women.

OBJECTIVE

We examined the effects of a patient-centered appointment-based CR program on HRQoL by sex and examined predictors of HRQoL improvements specifically for women.

METHODS

Data were used from an urban single-center CR program at Yale New Haven Health (2012-2017). We collected information on patient demographics, socioeconomic status, and clinical characteristics. The Outcome Short-Form General Health Survey (SF-36) was used to measure HRQoL. We evaluated sex differences in SF-36 scores using t tests and used a multivariate linear regression model to examine predictors of improvements in HRQoL (total SF-36 score) for women.

RESULTS

A total of 1530 patients with cardiovascular disease (23.7% women, 4.8% Black; mean age, 64 ± 10.8 years) were enrolled in the CR program. Women were more likely to be older, Black, and separated, divorced, or widowed. Although women had lower total SF-36 scores on CR entry, there was no statistically significant difference in CR adherence or total SF-36 score improvements between sexes. Women who were employed and those with chronic obstructive pulmonary disease were more likely to have improvements in total SF-36 scores.

CONCLUSION

Both men and women participating in an appointment-based CR program achieved significant improvements in HRQoL. This approach could be a viable alternative to conventional CR to optimize secondary outcomes for patients.

Positive psychosocial factors and the development of symptoms of depression and posttraumatic stress symptoms following acute myocardial infarction

Introduction

Acute myocardial infarction (MI) is a potentially fatal condition, leading to high psychological distress and possibly resulting in the development of depressive symptoms and posttraumatic stress symptoms (PTSS). The aim of this study was to investigate the association of clusters of positive psychosocial factors (resilience, task-oriented coping, positive affect and social support) with both MI-induced depressive symptoms and PTSS, independent of demographic factors.

Methods

We investigated 154 consecutive patients with MI, 3 and 12 months after hospital discharge. All patients completed the short version of the German Resilience Scale, the Coping Inventory for Stressful Situations (CISS), the Enriched Social Support Inventory (ESSI) and the Global Mood Scale (GMS). The level of interviewer-rated MI-induced posttraumatic stress disorder (PTSD) symptoms at 3- and 12-months follow-up was evaluated through the Clinician-Administered PTSD Scale (CAPS). Depressive symptoms were assessed at 3- and 12-month follow-up with the Beck Depression Inventory (BDI-II).

Results

Three different clusters were revealed: (1) lonely cluster: lowest social support, resilience and average task-oriented coping and positive affect; (2) low risk cluster: highest resilience, task-oriented coping, positive affect and social support; (3) avoidant cluster: lowest task-oriented coping, positive affect, average resilience and social support. The clusters differed in depressive symptoms at 3 months (F = 5.10; p < 0.01) and 12 months follow-up (F = 7.56; p < 0.01). Cluster differences in PTSS were significant at 3 months (F = 4.78, p < 0.05) and 12 months (F = 5.57, p < 0.01) follow-up. Differences in PTSS subscales were found for avoidance (F = 4.8, p < 0.05) and hyperarousal (F = 5.63, p < 0.05), but not re-experiencing, at 3 months follow-up. At 12 months follow-up, cluster differences were significant for re-experiencing (F = 6.44, p < 0.01) and avoidance (F = 4.02, p < 0.05) but not hyperarousal.

Discussion

The present study contributes to a better understanding of the relationships among different positive psychosocial factors, depressive symptoms and PTSS following acute MI. Future interventions may benefit from taking into account positive psychosocial factors to potentially reduce patients' depressive symptoms and PTSS after MI.

Health related quality of life of patients following mechanical valve replacement surgery for rheumatic mitral stenosis in Tanzania

BACKGROUND

The assessment of outcomes of interventions based on the patient's perspective using patient-reported outcome measures (PROMs) has been increasingly highlighted in clinical practice. However, health related quality of life (HRQoL), one of the common constructs measured by PROMs remain unknown among patients after heart valve replacement (HVR) in Tanzania.

OBJECTIVES

To assess the HRQoL amongst patients operated on for rheumatic mitral stenosis at Jakaya Kikwete Cardiac Institute (JKCI).

METHODS

A prospective study of patients operated on due to rheumatic mitral stenosis at JKCI from January 2020 to April 2021 was undertaken. The HRQoL was assessed by using the MacNew questionnaire, addressing three domains (physical, emotional, and social function); the score ranges from 0 to 7. We categorized HRQoL as low (mean score ≤ 4.9), moderate (5-6) and high (> 6). We analysed several sociodemographic and clinical variables for HRQoL.

RESULTS

Out of 54 patients, there were 34 females and 20 males. Their mean (± SD) age was 37.98 (± 12.58) years. The reliability of translated Kiswahili version of MacNew was good. The mean (± SD) global scores were 3.47 ± 0.59, 4.88 ± 0.71 and 6.14 ± 0.50 preoperatively, at 3 months and 6 months respectively (p-values < 0.001 preoperatively vs. 3 months, preoperatively vs. 6 months and at 3 months vs. 6 months). The median of individual mean difference HRQoL score pre-operatively and at 6 months was 2.67. The preoperative and 6 months mean difference HRQoL scores were higher among patients with vs. without atrial fibrillation (2.95 ± 0.59 vs. 2.45 ± 0.53, p = 0.003) and those on anticoagulants (preoperatively) vs. not on anticoagulants (3.14 ± 0.58 vs. 2.57 ± 0.57, 0.009). The mean difference HRQoL scores were similar for sociodemographic and other clinical parameters, including those with stroke vs. without stroke.

CONCLUSION

Six months after HVR the overall MacNew HRQoL scores improved markedly. This improvement in HRQoL was regardless of the presence of comorbidities (e.g. stroke and atrial fibrillation) which underscores the importance of considering valvular surgery if they fit the criteria. Clinicians and researchers in low-resource settings should collaborate to promote the utilization of PROMs in the routine care of patients.

Protocol for a feasibility randomized trial of a social support intervention plus usual care versus usual care, targeting patients treated for cardiac disease who experience loneliness

INTRODUCTION

In patients treated for cardiac disease, loneliness is known to contribute negatively to health behavior, health outcome, and increase risk of cardiac and all-cause mortality. Even so, in health care research, social support interventional studies targeting patients who experience loneliness are lacking.

AIM

To determine the feasibility of an individually structured social support intervention targeting patients treated for cardiac disease who experience loneliness.

DESIGN

A feasibility study based on randomized clinical trial design with 1:1 randomization to a 6-month social support program, plus usual care (intervention) versus usual care, (i.e., regular guidelines-based follow-up).

INTERVENTION

Patients classified as high risk lonely according to the High Risk Loneliness tool will be provided with an informal caregiver in the 6 months rehabilitation phase following cardiac disease treatment. The informal caregiver will be designated by the patient from the existing social network or a peer, depending on patients' preferences. The core content of the intervention is through nurse consultations at baseline and 1, 3, and 6 months, to enhance and reinforce the informal caregiver's competences to be a social support resource. The theoretical framework of the nurse consultations will be based on middle-range theory of self-care.

OUTCOME

Feasibility will be evaluated in terms of acceptability and adherence according to predefined feasibility criteria. The preliminary effect of the intervention on patient-reported outcomes, health behaviors, and health outcomes will be evaluated in the intervention and the control group at baseline and 1, 3, 6, and 12 months.

DISCUSSION

The present study will contribute with knowledge on how to implement a feasible social support intervention targeting patients treated for cardiac disease who experience loneliness and, furthermore, investigate the preliminary effect on health behavior and health outcome in the early rehabilitation period.

TRIAL REGISTRATION

The trial is registered on clinicaltrials.gov (NCT05503810) 18.08.2022.

Association of Sociodemographic Characteristics With 1-Year Hospital Readmission Among Adults Aged 18 to 55 Years With Acute Myocardial Infarction

Importance

Among younger adults, the association between Black race and postdischarge readmission after hospitalization for acute myocardial infarction (AMI) is insufficiently described.

Objectives

To examine whether racial differences exist in all-cause 1-year hospital readmission among younger adults hospitalized for AMI and whether that difference retains significance after adjustment for cardiac factors and social determinants of health (SDOHs).

Design, Setting, and Participants

The VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study was an observational cohort study of younger adults (aged 18-55 years) hospitalized for AMI with a 2:1 female-to-male ratio across 103 US hospitals from January 1, 2008, to December 31, 2012. Data analysis was performed from August 1 to December 31, 2021.

Main Outcomes and Measures

The primary outcome was all-cause readmission, defined as any hospital or observation stay greater than 24 hours within 1 year of discharge, identified through medical record abstraction and clinician adjudication. Logistic regression with sequential adjustment evaluated racial differences and potential moderation by sex and SDOHs. The Blinder-Oaxaca decomposition quantified how much of any racial difference was explained and not explained by covariates.

Results

This study included 2822 participants (median [IQR] age, 48 [44-52] years; 1910 [67.7%] female; 2289 [81.1%] White and 533 [18.9%] Black; 868 [30.8%] readmitted). Black individuals had a higher rate of readmission than White individuals (210 [39.4%] vs 658 [28.8%], P < .001), particularly Black women (179 of 425 [42.1%]). After adjustment for sociodemographic characteristics, cardiac factors, and SDOHs, the odds of readmission were 34% higher among Black individuals (odds ratio [OR], 1.34; 95% CI, 1.06-1.68). The association between Black race and 1-year readmission was positively moderated by unemployment (OR, 1.68; 95% CI, 1.09- 2.59; P for interaction = .02) and fewer number of working hours per week (OR, 1.01; 95% CI, 1.00-1.02; P for interaction = .01) but not by sex. Decomposition indicates that 79% of the racial difference in risk of readmission went unexplained by the included covariates.

Conclusions and Relevance

In this multicenter study of younger adults hospitalized for AMI, Black individuals were more often readmitted in the year following discharge than White individuals. Although interventions to address SDOHs and employment may help decrease racial differences in 1-year readmission, more study is needed on the 79% of the racial difference not explained by the included covariates.

Social support, psychosocial risks, and cardiovascular health: Using harmonized data from the Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America Study, and Multi-Ethnic Study of Atherosclerosis

Purpose

Social support may have benefits on cardiovascular health (CVH). CVH is evaluated using seven important metrics (Life's Simple 7; LS7) established by the American Heart Association (e.g., smoking, diet). However, evidence from longitudinal studies is limited and inconsistent. The objective of this study is to examine the longitudinal relationship between social support and CVH, and assess whether psychosocial risks (e.g., anger and stress) modify the relationship in a racially/ethnically diverse population.

Methods

Participants from three harmonized cohort studies - Jackson Heart Study, Mediators of Atherosclerosis in South Asians Living in America, and Multi-Ethnic Study of Atherosclerosis - were included. Repeated-measures modified Poisson regression models were used to examine the overall relationship between social support (in tertiles) and CVH (LS7 metric), and to assess for effect modification by psychosocial risk.

Results

Among 7724 participants, those with high (versus low) social support had an adjusted prevalence ratio (aPR) and 95% confidence interval (CI) for ideal or intermediate (versus poor) CVH of 0.99 (0.96-1.03). For medium (versus low) social support, the aPR (95% CI) was 1.01 (0.98-1.05). There was evidence for modification by employment and anger. Those with medium (versus low) social support had an aPR (95% CI) of 1.04 (0.99-1.10) among unemployed or low anger participants. Corresponding results for employed or high anger participants were 0.99 (0.94-1.03) and 0.97 (0.91-1.03), respectively.

Conclusion

Overall, we observed no strong evidence for an association between social support and CVH. However, some psychosocial risks may be modifiers. Prospective studies are needed to assess the social support-CVH relationship by psychosocial risks in racially/ethnically diverse populations.

Peer-support interventions for women with cardiovascular disease: protocol for synthesising the literature using an evidence map

INTRODUCTION

The leading cause of death for women is cardiovascular disease (CVD), including ischaemic heart disease, stroke and heart failure. Previous literature suggests peer support interventions improve self-reported recovery, hope and empowerment in other patient populations, but the evidence for peer support interventions in women with CVD is unknown. The aim of this study is to describe peer support interventions for women with CVD using an evidence map. Specific objectives are to: (1) provide an overview of peer support interventions used in women with ischaemic heart disease, stroke and heart failure, (2) identify gaps in primary studies where new or better studies are needed and (3) describe knowledge gaps where complete systematic reviews are required.

METHODS AND ANALYSIS

We are building on previous experience and expertise in knowledge synthesis using methods described by the Evidence for Policy and Practice Information (EPPI) and the Coordinating Centre at the Institute of Education. Seven databases will be searched from inception: CINAHL, Embase, MEDLINE, APA PsycINFO, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials, and Scopus. We will also conduct grey literature searches for registered clinical trials, dissertations and theses, and conference abstracts. Inclusion and exclusion criteria will be kept broad, and studies will be included if they discuss a peer support intervention and include women, independent of the research design. No date or language limits will be applied to the searches. Qualitative findings will be summarised narratively, and quantitative analyses will be performed using R.

ETHICS AND DISSEMINATION

The University of Toronto's Research Ethics Board granted approval on 28 April 2022 (Protocol #42608). Bubble plots (ie, weighted scatter plots), geographical heat/choropleth maps and infographics will be used to illustrate peer support intervention elements by category of CVD. Knowledge dissemination will include publication, presentation/public forums and social media.

Severity of psychological distress over five years differs as a function of sex and presence of coronary artery disease

BACKGROUND

Psychological distress is more prevalent and severe among patients with coronary artery disease (CAD) compared to healthy individuals. Little is known regarding its time course, and whether these differences extend to individuals with non-cardiovascular (CV) illnesses. This study examined the presence, severity, and time course of psychological distress in men and women with CAD and those of similarly aged individuals suffering from non-CV conditions.

METHODS

1229 individuals (61% men; mean_age = 60.4 ± 7.0 years) with stable CAD or non-CV illnesses reported on social support, hostility, stress, anxiety and depression at baseline as well as 4.8 ± 0.8 years later. Analyses involved mixed (Sex*CAD status*Time) repeated measures analyses (controlling for relevant covariates), as well as Chi-square and McNemar analyses.

RESULTS

Women with CAD reported more symptoms of depression compared to other participants at both evaluations (p's < 0.01), and reported more symptoms of anxiety and stress compared to others at T1 (p's < 0.05). At T2, perceived stress remained significantly greater among women with CAD compared to men (p's < 0.01), though differences in anxiety were no longer significant. Men reported more hostility than women (p = 0.001). CAD women fell within the clinical range for depression (p < 0.001), anxiety (p = 0.001), and stress (p = 0.030) more frequently compared to others at T1, and for depression (p = 0.009) and stress (p = 0.002) at T2.

CONCLUSIONS

The evolution of patient distress differed as a function of the measure examined, their sex, and/or CV status. While psychological distress was prevalent among these patients with diverse health conditions, women with CAD were particularly and chronically vulnerable.

Who Cares? Perception of Loneliness in Patients Treated for Coronary Heart DiseaseHvem bekymrer sig? Oplevelsen af ensomhed hos patienter med iskæmisk hjertesygdom

Social support is known to be essential to cope with the physical and psychological aftermath following coronary heart disease treatment. Consequently, patients experiencing loneliness may be placed in a vulnerable situation. The aim of this study was to provide insight into the nuances and complexity of loneliness and its impact on health behaviour in the early rehabilitation period following treatment. The study used a hermeneutic philosophical approach. Patients classified as lonely were interviewed in either a focus group ( n = 7) or in an individual interview ( n = 10). We analysed the empirical material using inductive content analysis. The analysis illuminated various dimensions of patients’ perceived loneliness; ‘Loneliness as an emotional pain’, ‘A changed, but unmet need for social support’ and ‘Striving for symmetry in relationships’. Loneliness negatively influenced patients’ ability to adapt to the critical event and manage health behaviour changes. Insight into the mechanisms that aggravate loneliness may inform future social support interventions.

Social støtte er beskrevet som essentiel i forbindelse med håndteringen af de fysiske og psykiske følger af iskæmisk hjertesygdom. Derfor kan patienter som oplever ensomhed være i en særlig sårbar situation. Formålet med dette kvalitative studie var at opnå en nuanceret indsigt i patients oplevelse af ensomhed, samt hvordan ensomhed influerer på sundhedsadfærd i den tidlige rehabiliteringsperiode efter behandlingen for iskæmisk hjertesygdom. I studiet havde vi en hermeneutisk filosofisk tilgang. Patienter klassificeret som ensomme blev interviewet enten individuelt (n = 10) eller i fokusgruppe (n = 7). Vi analyserede det empiriske materiale med induktiv indholdsanalyse. Analysen tydeliggjorde forskellige dimensioner af patienternes oplevede ensomhed: ”Ensomhed som en emotionel smerte”, ”Et ændret, men ikke imødekommet behov for social støtte”, Stræben efter symmetri i relationer”. Ensomhed havde en negativ indflydelse på patienternes mulighed for at håndtere den kritiske hændelse og på sundhedsadfærd. En øget indsigt i de mekanismer som forværrer ensomhed, har relevans ved udarbejdelsen af fremtidige sociale støtteinterventioner.

Sex-differences in psychosocial sequelae after spontaneous cervical artery dissection

Short- to mid-term functional outcome in spontaneous cervical artery dissection is favorable, but the concomitant psychosocial impact is underreported. We aimed to determine these possible sequelae, with a special focus on sex differences, in our cohort of spontaneous cervical artery dissection subjects. During a standardized prospective in-house follow-up visit we, among other values, evaluated functional outcome (modified Rankin Scale [mRS]), psychosocial measures (return to work-, divorce rate) and health-related quality of life (WHO-QoL-BREF and SF-36-questionnaires). 145 patients participated in the long-term prospective follow-up. Median follow-up time was 6.5 years and excellent functional outcome (mRS ≤ 1) was achieved in 89.0% subjects. 87.6% returned to work and 17.6% married patients had a divorce during follow-up. Even though relevant baseline-/discharge characteristics and functional outcome did not differ between the sexes, women were less likely to return to work compared to men (79.7% vs. 93.8%; P = 0.010) and divorce rate was considerably higher in women (30.2% vs. 9.2%; P = 0.022). Health related quality of life did not differ significantly between the sexes, but women consistently reported lower values. Even though functional outcome is beneficial in most patients, measures to prevent poor psychosocial outcome should be considered in the long-term care of patients with spontaneous cervical artery dissection, especially women.

One size does not fit all: A qualitative study exploring preferences and barriers towards the design of a loneliness reduction intervention in patients with coronary heart disease

Aim

To explore preferences and barriers towards the design of a loneliness reduction intervention in patients treated for coronary heart disease who experience loneliness.

Design

A qualitative study using patient involvement methodology.

Methods

Seventeen patients participated in either focus groups or individual interview sessions. The interview guide was based on patient involvement methodology. Interviews were analysed using deductive content analysis.

Results

Four overall findings emerged as follows: (a) An intervention involving a social network member must comply with patients perceived social norms; (b) An intervention involving a peer provides benefits from reciprocity and shared experiences, but also requires surplus mental energy; (c) The history of an existing relationship can act as both provider and barrier for confidentiality and (d) Start‐up, timeframe and structure of the intervention should be individually tailored to the patient's preferences. Findings illuminated preferences and barriers towards the design of a loneliness reduction intervention in patients with coronary heart disease.

Variations in Quality of Care by Sex and Social Determinants of Health Among Younger Adults With Acute Myocardial Infarction in the US and Canada

IMPORTANCE

Quality of care of young adults with acute myocardial infarction (AMI) may depend on health care systems in addition to individual-level factors such as biological sex and social determinants of health (SDOH).

OBJECTIVE

To examine whether the quality of in-hospital and postacute care among young adults with AMI differs between the US and Canada and whether female sex and adverse SDOH are associated with a low quality of care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis used data from 2 large cohorts of young adults (aged ≤55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Data were collected from August 21, 2008, to April 30, 2013, and analyzed from July 12, 2019, to March 10, 2021.

EXPOSURES

Sex, SDOH, and health care system.

MAIN OUTCOMES AND MEASURES

Opportunity-based quality-of-care score (QCS), determined by dividing the total number of quality indicators of care received by the total number for which the patient was eligible, with low quality of care defined as the lowest tertile of the QCS.

RESULTS

A total of 4048 adults with AMI (2345 women [57.9%]; median age, 49 [interquartile range, 44-52] years; 3004 [74.2%] in the US) were included in the analysis. Of 3416 patients with in-hospital QCS available, 1061 (31.1%) received a low QCS, including more women compared with men (725 of 2007 [36.1%] vs 336 of 1409 [23.8%]; P < .001) and more patients treated in the US vs Canada (962 of 2646 [36.4%] vs 99 of 770 [12.9%]; P < .001). Conversely, low quality of post-AMI care (748 of 2938 [25.5%]) was similarly observed for both sexes, with a higher prevalence in the US (678 of 2346 [28.9%] vs 70 of 592 [11.8%]). In adjusted analyses, female sex was not associated with low QCS for in-hospital (odds ratio [OR], 1.05; 95% CI, 0.87-1.28) and post-AMI (OR, 1.07; 95% CI, 0.88-1.30) care. Conversely, being treated in the US was associated with low in-hospital (OR, 2.93; 95% CI, 2.16-3.99) and post-AMI (OR, 2.67; 95% CI, 1.97-3.63) QCS, regardless of sex. Of all SDOH, only employment was associated with higher quality of in-hospital care (OR, 0.72; 95% CI, 0.59-0.88). Finally, only in the US, low quality of in-hospital care was associated with a higher 1-year cardiac readmissions rate (234 of 962 [24.3%]).

CONCLUSIONS AND RELEVANCE

These findings suggest that beyond sex, health care systems and SDOH that depict social vulnerability are associated with quality of AMI care. Taking into account SDOH among young adults with AMI may improve quality of care and reduce readmissions, especially in the US.

Impact of Race on the In-Hospital Quality of Care Among Young Adults With Acute Myocardial Infarction

Background The extent to which race influences in-hospital quality of care for young adults (≤55 years) with acute myocardial infarction (AMI) is largely unknown. We examined racial disparities in in-hospital quality of AMI care and their impact on 1-year cardiac readmission. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolling young Black and White US adults with AMI (2008-2012). An in-hospital quality of care score (QCS) was computed (standard AMI quality indicators divided by the total a patient is eligible for). Multivariable logistic regression was performed to identify factors associated with the lowest QCS tertile, including interactions between race and social determinants of health. Among 2846 young adults with AMI (median 48 years [interquartile range 44-52], 67.4% women, 18.8% Black race), Black individuals, especially women, exhibited a higher prevalence of cardiac risk factors and social determinants of health and were more likely to experience a non-ST-segment-elevation myocardial infarction than White individuals. Black individuals were more likely in the lowest QCS tertile than White individuals (40.8% versus 34.7%; P=0.003). The association between Black race and low QCS (odds ratio [OR], 1.25; 95% CI, 1.02-1.54) was attenuated by adjustment for confounders. Employment was independently associated with better QCS, especially among Black participants (OR, 0.76; 95% CI, 0.62-0.92; P-_interaction=0.02). Black individuals experienced a higher rate of 1-year cardiac readmission (29.9% versus 20.0%; P<0.0001). Conclusions Black individuals with AMI received lower in-hospital quality of care and exhibited a higher rate of cardiac readmissions than White individuals. Black individuals had a lower quality of care if unemployed, highlighting the intersection of race and social determinants of health.

Younger Women Living with Chronic Disease: Comparative Challenges, Resiliencies, and Needs in Heart Disease and Breast Cancer

Background: Younger women with chronic disease (<60 years of age), especially women with stereotypically "men's" heart disease (HD), are understudied. Unique difficulties may occur with HD, which is less commonly associated with women, compared with breast cancer (BC). Similarities may also exist across younger women, as chronic disease is less normative in younger people. Intersections of gender, age, and the specific disease experience require greater attention for improving women's health. This exploratory qualitative study compared younger women's experiences of HD or BC. Methods: Semistructured interviews with 20 women (n = 10 per disease) were analyzed using applied thematic analysis. Results: Amidst building careers, intimate relationships, and families, women felt thwarted by disease-related functional problems. Cognitive-behavioral coping strategies spurred resilience, including integrating the illness experience with self-identity. Barriers arose when medical professionals used representativeness heuristics (e.g., chronic disease occurs in older age). Important experiences in HD included worsened self-image from disability, negative impact of illness invisibility, and persisting isolation from lacking peer availability. Initial medical care reported by women with HD may reflect gender biases (e.g., HD missed in emergency settings and initial diagnostics). New information provided by the younger women includes limited illness-related optimism in women with HD facing age and gender stereotypes, as well as the advantages and disadvantages of peer availability in BC. Conclusions: Greater public awareness of younger women with chronic disease, alongside structural support and connection with similarly challenged peers, is suggested. As advocacy for BC awareness and action has strengthened over past decades, similar efforts are needed for younger women with HD.

Impact of community engagement and social support on the outcomes of HIV-related meningitis clinical trials in a resource-limited setting

BACKGROUND

Clinical trials remain the cornerstone of improving outcomes for HIV-infected individuals with cryptococcal meningitis. Community engagement aims at involving participants and their advocates as partners in research rather than merely trial subjects. Community engagement can help to build trust in communities where these trials are conducted and ensure lasting mutually beneficial relationships between researchers and the community. Similarly, different studies have reported the positive effects of social support on patient's outcomes. We aimed to describe our approach to community engagement in Uganda while highlighting the benefits of community engagement and social support in clinical trials managing patients co-infected with HIV and cryptococcal meningitis.

METHODS

We carried out community engagement using home visits, health talks, posters, music and drama. In addition, social support was given through study staff individually contributing to provide funds for participants' food, wheel chairs, imaging studies, adult diapers, and other extra investigations or drugs that were not covered by the study budget or protocol. The benefits of this community engagement and social support were assessed during two multi-site, randomized cryptococcal meningitis clinical trials in Uganda.

RESULTS

We screened 1739 HIV-infected adults and enrolled 934 with cryptococcal meningitis into the COAT and ASTRO-CM trials during the period October 2010 to July 2017. Lumbar puncture refusal rates decreased from 31% in 2010 to less than 1% in 2017. In our opinion, community engagement and social support played an important role in improving: drug adherence, acceptance of lumbar punctures, data completeness, rate of screening/referrals, reduction of missed visits, and loss to follow-up.

CONCLUSIONS

Community engagement and social support are important aspects of clinical research and should be incorporated into clinical trial design and conduct.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT01075152 and NCT01802385.

Stress, sex hormones, inflammation, and major depressive disorder: Extending Social Signal Transduction Theory of Depression to account for sex differences in mood disorders

Social Signal Transduction Theory of Depression is a biologically plausible, multi-level theory that describes neural, physiologic, molecular, and genomic mechanisms that link experiences of social-environmental adversity with internal biological processes that drive depression pathogenesis, maintenance, and recurrence. Central to this theory is the hypothesis that interpersonal stressors involving social threat (e.g., social conflict, evaluation, rejection, isolation, and exclusion) upregulate inflammatory processes that can induce several depressive symptoms, including sad mood, anhedonia, fatigue, psychomotor retardation, and social-behavioral withdrawal. The original article describing this formulation (Psychol Bull 140:774-815, 2014) addressed critical questions involving depression onset and recurrence, as well as why depression is strongly predicted by early life stress and comorbid with anxiety disorders and certain physical disease conditions, such as asthma, rheumatoid arthritis, chronic pain, and cardiovascular disease. Here, we extend the theory to help explain sex differences in depression prevalence, which is a defining feature of this disorder. Central to this extension is research demonstrating that ovarian hormone fluctuations modulate women's susceptibility to stress, brain structure and function, and inflammatory activity and reactivity. These effects are evident at multiple levels and are highly context-dependent, varying as a function of several factors including sex, age, reproductive state, endogenous versus exogenous hormones, and hormone administration mode and dose. Together, these effects help explain why women are at greater risk for developing inflammation-related depressed mood and other neuropsychiatric, neurodevelopmental, and neurodegenerative disorders during the reproductive years, especially for those already at heightened risk for depression or in the midst of a hormonal transition period.

Gender differences in psychosocial outcomes of psychotherapy trial in patients with depression and coronary artery disease

INTRODUCTION

The biological and psychosocial risk profile differs between women and men with coronary artery disease (CAD). Depressive symptoms and Vital Exhaustion (VE) predict an unfavourable course of CAD. The secondary analysis of the SPIRR-CAD trial offered the possibility to examine gender as exposure variable of the clinical and psychological situation at baseline and in a variety of psychosocial measures as outcomes.

METHODS

In this trial, 450 men (78.9%) and 120 women (21.1%) with CAD (age ≤ 75 y), with mild to moderate depression (scoring ≥8 on the HADS), were randomized to usual care with or without a stepwise psychotherapy intervention. Beside clinical measures exhaustion and other indicators of depressive symptoms were collected at baseline and 18-month follow up.

RESULTS

Men had more signs and symptoms of heart disease at baseline, whereas women had higher psychosocial burden (e.g. negative affect). Women were more likely to live alone, had lower educational levels and employment rates and higher levels of depression and exhaustion. The psychotherapy intervention differed as a function of gender: In women, VE decreased from 29.4 ± 8.1 to 22.1 ± 11.7 in the intervention group (IG) and from 29.2 ± 8.2 to 25.1 ± 11.3 in the control group (CG). In men VE decreased from 23.3 + -10.8 to 21.2 ± 9.7 in the IG and from 23.6 ± 10.7 to 19.3 ± 11.3 in the CG (time x intervention x gender; F = 4.97; p = .026).

DISCUSSION

Women had a higher psychosocial burden than men. VE compared to other rating instruments of depressive symptoms suggested a stronger response to the intervention in women. VE may help to understand gender differences in psychotherapeutic treatment studies of CAD.

ISRCTN

76240576; clinicaltrials.gov.

Measures of Patient Activation and Social Support in a Peer-Led Support Network for Women With Cardiovascular Disease

PURPOSE

Social support has been associated with beneficial effects on many disease states and overall health and well-being. However, there is limited research exploring the impact of peer-led support models among women living with coronary heart disease. This study describes the structure of peer-led support groups offered by WomenHeart (WH): The National Coalition for Women Living with Heart Disease, and assesses WH participants' quality of life and social, emotional, and physical health.

METHODS

Participants were recruited from 50 WH groups. A 70-item online survey was administered, and the main analytic sample included 157 women. Multivariate logistic regression was used to examine the association between patient activation levels (lower activation levels: 1, 2 vs higher activation levels: 3, 4) and social support scores (range: lowest 8 to highest 34), adjusting for age.

RESULTS

High levels of social support, patient activation, physical activity, and low levels of stress, anxiety, and depression were reported. Those who were at or above the median for the social support measures (indicating high levels of social support) had greater odds of high levels of patient activation (level 3 or 4) than individuals reporting low levels of social support (OR = 2.23; 95% CI, 1.04-4.76; P = .012).

CONCLUSIONS

Women who regularly attended a support group by a trained peer leader were highly engaged in their health care and had low levels of stress, anxiety, and depression. These findings lend credibility to the value of the peer support model and could potentially be replicated in other disease states to enhance patient care.

Role of Depression and Social Isolation at Time of Waitlisting for Survival 8 Years After Heart Transplantation

Background

We evaluated depression and social isolation assessed at time of waitlisting as predictors of survival in heart transplant (HTx) recipients.

Methods and Results

Between 2005 and 2006, 318 adult HTx candidates were enrolled in the Waiting for a New Heart Study, and 164 received transplantation. Patients were followed until February 2013. Psychosocial characteristics were assessed by questionnaires. Eurotransplant provided medical data at waitlisting, transplantation dates, and donor characteristics; hospitals reported medical data at HTx and date of death after HTx. During a median follow‐up of 70 months (<1–93 months post‐HTx), 56 (38%) of 148 transplanted patients with complete data died. Depression scores were unrelated to social isolation, and neither correlated with disease severity. Higher depression scores increased the risk of dying (hazard ratio=1.07, 95% confidence interval, 1.01, 1.15, P=0.032), which was moderated by social isolation scores (significant interaction term; hazard ratio = 0.985, 95% confidence interval, 0.973, 0.998; P=0.022). These findings were maintained in multivariate models controlling for covariates (P values 0.020–0.039). Actuarial 1‐year/5‐year survival was best for patients with low depression who were not socially isolated at waitlisting (86% after 1 year, 79% after 5 years). Survival of those who were either depressed, or socially isolated or both, was lower, especially 5 years posttransplant (56%, 60%, and 62%, respectively).

Conclusions

Low depression in conjunction with social integration at time of waitlisting is related to enhanced chances for survival after HTx. Both factors should be considered for inclusion in standardized assessments and interventions for HTx candidates.

Another Chance at Life: Jordanian Patients' Experience of Going Through a Myocardial Infarction

BACKGROUND AND PURPOSE

Myocardial infarction (MI) is a life-threatening health condition that has physical, spiritual, emotional, and social changes. Understanding feelings and thoughts of patients who suffered MI attacks is essential to recovery. Among Jordanian patients who suffered an acute attack of MI, the aim of the study was to describe the experiences and the varied meanings that they assign to their experiences.

METHODS

A qualitative hermeneutic phenomenological research design was used. Five participants were engaged in in-depth semistructured interviews. The participants were identified using a purposeful sampling technique, after being admitted at a coronary care unit in a university hospital located in Amman, the capital city of Jordan. The hospital provides a full range of cardiovascular medical and surgical care for patients admitted from different socioeconomic levels. Transcribed data were analyzed following inductive qualitative content analysis method.

RESULTS

The experience of MI was a traumatizing event characterized by life-threatening symptoms, and participants feared they would not come back home. However, cultural values and religiosity among the Jordanian patients played a major role in facilitating their positive coping during and after the MI attack. The participants' recount of their experience was summed-up into 5 major themes: frightening experience, needed support, religiosity, experiencing changes, and lifestyle modifications. After the MI attack, most of the participants felt that they had given another chance to live, showing a pressing need to make healthier lifestyle modifications to avoid another MI attack.

IMPLICATIONS FOR PRACTICE

Health care workers should need not only pay attention on physical and physiological caring aspects but should also consider other patients' needs, while supporting the patients and their family members.

Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis

OBJECTIVES

Patients with rheumatoid arthritis (RA) have an excess risk of cardiovascular disease (CVD). We aimed to assess the impact of CVD risk factors, including potential sex differences, and RA-specific variables on CVD outcome in a large, international cohort of patients with RA.

METHODS

In 13 rheumatology centres, data on CVD risk factors and RA characteristics were collected at baseline. CVD outcomes (myocardial infarction, angina, revascularisation, stroke, peripheral vascular disease and CVD death) were collected using standardised definitions.

RESULTS

5638 patients with RA and no prior CVD were included (mean age: 55.3 (SD: 14.0) years, 76% women). During mean follow-up of 5.8 (SD: 4.4) years, 148 men and 241 women developed a CVD event (10-year cumulative incidence 20.9% and 11.1%, respectively). Men had a higher burden of CVD risk factors, including increased blood pressure, higher total cholesterol and smoking prevalence than women (all p<0.001). Among the traditional CVD risk factors, smoking and hypertension had the highest population attributable risk (PAR) overall and among both sexes, followed by total cholesterol. The PAR for Disease Activity Score and for seropositivity were comparable in magnitude to the PAR for lipids. A total of 70% of CVD events were attributable to all CVD risk factors and RA characteristics combined (separately 49% CVD risk factors and 30% RA characteristics).

CONCLUSIONS

In a large, international cohort of patients with RA, 30% of CVD events were attributable to RA characteristics. This finding indicates that RA characteristics play an important role in efforts to reduce CVD risk among patients with RA.

How does social support affect functional impairment in late life? Findings of a multicenter prospective cohort study in Germany

Objective

to investigate how social support affects functional impairment (FI) in late life in a longitudinal approach.

Methods

in a multicenter prospective cohort study, subjects in old age (≥75 years at baseline) were interviewed every 1.5 years. Social support was quantified in the follow-up (FU) Waves 2 and 4 (FU Wave 2: n = 2,349; FU Wave 4: n = 1,484). FI was assessed by using the Lawton and Brody Instrumental Activities of Daily Living scale.

Results

fixed effects regressions showed that a decrease in social support is associated with FI in the total sample and in both sexes. The effect on FI was most pronounced with the dimension social integration, whereas changes in practical support only affected FI in the total sample and changes in emotional support only affected FI in men.

Conclusions

our findings emphasise the importance of social support for functional status in late life. Thus, strengthening social support in old age might be effective in maintaining functional abilities.

The association between supportive relatives and lower occurrence of anxiety and depression in heart patients: Results from a nationwide survey

BACKGROUND

Approximately 30-40% of heart patients develop anxiety and/or depression, which might influence recovery and long-term survival. Research has suggested that support from relatives may decrease anxiety and depression among heart patients; however, the results are inconsistent and often based on small study populations.

AIM

The paper aimed to investigate the association between having supportive relatives and the occurrence of anxiety and depression in heart patients.

METHODS

A population-based cross-sectional study among Danish patients diagnosed with ischemic heart disease, atrial fibrillation, heart failure, or heart valve disease. Presence of supportive relatives was measured as the degree to which the patients felt that they had relatives they could count on, while symptoms of anxiety and depression were measured by the Hospital Anxiety and Depression Scale (HADS). Multiple logistic regression analyses accounting for confounders were used to examine the association between supportive relatives and anxiety/depression.

RESULTS

The questionnaire was answered by 2496 heart patients, corresponding to 50% of the invited population. Patients with low or some degree of supportive relatives had a higher odds ratio (OR) of anxiety than patients with a high degree (OR = 2.20, 95% confidence interval (CI): 1.28-2.37; OR = 1.75, 95% CI: 1.57-3.08, respectively). Likewise, patients with low or some degree of supportive relatives had a higher OR of depression than patients with a high degree (OR = 1.96, 95% CI: 1.40-2.66; OR = 1.93, 95% CI: 1.37-2.60, respectively).

CONCLUSIONS

The presence of supportive relatives was found to be associated with lower occurrence of anxiety and depression. Health professionals should focus on including relatives in the treatment and rehabilitation of heart patients.

Women's Heart Health: Knowledge, Beliefs, and Practices of Canadian Physicians

BACKGROUND

Heart disease is a leading cause of morbidity and mortality in women. To date, the majority of knowledge regarding heart disease is based on research conducted in men. As a result, a male-oriented model of heart disease constitutes the basis for diagnostic and therapeutic strategies for both sexes. This article reports findings from the first survey of Canadian physicians to examine their knowledge, beliefs, and practices regarding heart disease in women.

MATERIALS AND METHODS

This cross-sectional survey, adapted from an instrument used in the United States, was undertaken in the spring of 2015. A sample of 504 physicians from a randomly selected sample of online responses was produced.

RESULTS

Overall, physician responses demonstrate a general lack of awareness regarding the prevalence and approaches to the identification of, and treatments for, heart disease in women. In addition, physicians did not provide high ratings of their own effectiveness in supporting female patients to prevent or manage heart disease. The barriers that physicians face and the strategies to support them in improving women's heart health were explored.

CONCLUSIONS

There is a clear need to educate physicians about heart disease in women and its prevention and management. More female-specific research, prevention, and clinical programs will enhance our ability to significantly improve cardiovascular health in Canadian women.

Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study

BACKGROUND

Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI.

METHODS

We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction.

RESULTS

One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women.

CONCLUSIONS

Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Practical Care Support During the Early Recovery Period After Acute Coronary Syndrome

OBJECTIVE

To describe the prevalence and predictors of receipt of practical support among acute coronary syndrome (ACS) survivors during the early post-discharge period.

METHOD

406 ACS patients were interviewed about receipt of practical (instrumental and informational) support during the week after discharge. Demographic, clinical, functional, and psychosocial predictors of instrumental and informational practical support were examined.

RESULTS

81% of participants reported receiving practical support during the early post-discharge period: 75% reported receipt of instrumental support and 51% reported receipt of informational support. Men were less likely to report receiving certain types of practical support, whereas married participants and those with higher education, impaired health literacy, impaired activities of daily living, and in-hospital complications were more likely to report receiving certain types of practical support.

CONCLUSION

Receipt of practical support is very common among ACS survivors during the early post-discharge period, and type of support received differs according to patient characteristics.

Sexual Activity and Function in the Year After an Acute Myocardial Infarction Among Younger Women and Men in the United States and Spain

Importance

Most younger adults who experience an acute myocardial infarction (AMI) are sexually active before the AMI, but little is known about sexual activity or sexual function after the event.

Objective

To describe patterns of sexual activity and function and identify indicators of the probability of loss of sexual activity in the year after AMI.

Design, Setting, and Participants

Data from the prospective, multicenter, longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study (conducted from August 21, 2008, to January 5, 2012) were assessed at baseline, 1 month, and 1 year. Participants were from US (n = 103) and Spanish (n = 24) hospitals and completed baseline and all follow-up interviews. Data analysis for the present study was conducted from October 15, 2014, to June 6, 2016. Characteristics associated with loss of sexual activity were assessed using multinomial logistic regression analyses.

Main Outcomes and Measures

Loss of sexual activity after AMI.

Results

Of the 2802 patients included in the analysis, 1889 were women (67.4%); median (25th-75th percentile) age was 49 (44-52) years (range, 18-55 years). At all time points, 637 (40.4%) of women and 437 (54.9%) of men were sexually active. Among people who were active at baseline, men were more likely than women to have resumed sexual activity by 1 month (448 [63.9%] vs 661 [54.5%]; P < .001) and by 1 year (662 [94.4%] vs 1107 [91.3%]; P = .01) after AMI. Among people who were sexually active before and after AMI, women were less likely than men to report no sexual function problems in the year after the event (466 [40.3%] vs 382 [54.8%]; P < .01). In addition, more women than men (211 [41.9%] vs 107 [30.5%]; P < .01) with no baseline sexual problems developed 1 or more incident problems in the year after the AMI. At 1 year, the most prevalent sexual problems were lack of interest (487 [39.6%]) and trouble lubricating (273 [22.3%]) among women and erectile difficulties (156 [21.7%]) and lack of interest (137 [18.8%]) among men. Those who had not communicated with a physician about sex in the first month after AMI were more likely to delay resuming sex (adjusted odds ratio [AOR], 1.51; 95% CI, 1.11-2.05; P = .008). Higher stress levels (AOR, 1.36; 95% CI, 1.01-1.83) and having diabetes (AOR, 1.90; 95% CI, 1.15-3.13) were significant indicators of the probability of loss of sexual activity in the year after the AMI.

Conclusions and Relevance

Impaired sexual activity and incident sexual function problems were prevalent and more common among young women than men in the year after AMI. Attention to modifiable risk factors and physician counseling may improve outcomes.

Unique Aspects of Coronary Artery Disease in Indian Women

PURPOSE

Epidemiologic and clinical research suggests important gender-related differences in the prevalence, presentation, associated conventional and non-conventional risk factors, management and outcomes of coronary heart disease (CHD) patients. Adequate data is not available for Indian population where prevalence of CHD and depression is high.

METHOD

We conducted an observational, single-center, study from January 2010 to December 2011 on 10450 consecutive patients visiting a tertiary care center, Ahmedabad, Gujarat, India who presented with complaints related to CHD.

RESULTS

Of these, 6867 patients had coronary artery disease (CAD) as confirmed by angiographic investigation; 5678 were males, and 1189 were females with similar mean age. As compared to males, females had higher prevalence of hypertension, diabetes and obesity while males had higher prevalence of smoking. Invasive treatment options like Coronary Artery Bypass Grafting (p < 0.001) and Percutaneous Coronary Intervention (p = 0.001) were used less often to treat females, and medical therapy (p < 0.001) was the preferred treatment option irrespective of the contributing risk factors/extent of CAD. Depression was observed in 39.8% of acute coronary syndrome patients (n = 1648) as assessed by MARDS scale. It was higher in female patients and in low socioeconomic strata (p < 0.001).At 12 and 36 months, rates of revascularization (p < 0.001) and mortality (p < 0.005) were higher with poor quality of life (QoL) (P < 0.001) in depressed CAD patients.

CONCLUSION

In India, women appear to have a higher prevalence of hypertension, diabetes, obesity, and family history of CHD. Yet women get invasive treatments less often than men. Depression is also more common in women and is associated with poor QoL and early mortality than men.

Gender differences following supervised exercise therapy in patients with intermittent claudication

OBJECTIVE

Prevalence of peripheral arterial disease is equal in men and women. However, women seem to suffer more from the burden of disease. Current studies on gender-related outcomes following supervised exercise therapy (SET) for intermittent claudication (IC) yield conflicting results.

METHODS

A follow-up analysis was performed on data from the 2010 Exercise Therapy in Peripheral Arterial Disease (EXITPAD) study, a multicenter randomized controlled trial including IC patients receiving SET or a walking advice. The SET program was supervised by physiotherapists and included interval-based treadmill walking approximating maximal pain combined with activities such as cycling and rowing. Patients usually started with three 30-minute sessions a week. Training frequency was adapted during the following year on the basis of individual needs. The primary outcome was gender differences regarding the change in absolute claudication distance (ACD) after SET. ACD was defined as the number of meters that a patient had covered just before he or she was forced to stop walking because of intolerable pain. Secondary outcomes were gender differences in change of functional walking distance, quality of life, and walking (dis)ability after SET. Walking distances were obtained by standardized treadmill testing according to the Gardner-Skinner protocol. Quality of life was measured by the 36-Item Short Form Health Survey, and walking (dis)ability was determined by the Walking Impairment Questionnaire (WIQ). Measurements were performed at baseline and after 3, 6, 9, and 12 months. Only patients who met the 12-month follow-up measure were included in the analysis.

RESULTS

A total of 113 men and 56 women were available for analysis. At baseline, groups were similar in terms of clinical characteristics and ACD walking distances (men, 250 meters; women, 270 meters; P = .45). ACD improved for both sexes. However, ACD increase was significantly lower for women than for men during the first 3 months of SET (Δ 280 meters for men vs Δ 220 meters for women; P = .04). Moreover, absolute walking distance was significantly shorter for women compared with men after 1 year (565 meters vs 660 meters; P = .032). Women also reported less on several WIQ subdomains, although total WIQ score was similar (0.69 for men vs 0.61 for women; P = .592). No differences in quality of life after SET were observed.

CONCLUSIONS

Women with IC benefit less during the first 3 months of SET and have lower absolute walking distances after 12 months of follow-up compared with men. More research is needed to determine whether gender-based IC treatment strategies are required.

Biopsychosocial health disparities among young women enrolled in cardiac rehabilitation

PURPOSE

Our aim was to compare the biopsychosocial characteristics of young women with those of older women who were enrolled in cardiac rehabilitation (CR). The baseline characteristics of women who prematurely terminated CR participation were also explored.

METHODS

Baseline physiological and psychosocial indices of women ≤ 55 years compared with older women eligible for CR were evaluated 1 week before enrolling in either a traditional CR or a gender-specific, motivationally enhanced CR.

RESULTS

A greater proportion of young women (n = 65) compared with their older counterparts (n = 187) were diagnosed with acute myocardial infarction during their index hospitalization. They demonstrated lower high-density lipoprotein cholesterol, higher total cholesterol/high-density lipoprotein cholesterol ratios, and greater body weight compared with older women and were more likely to be active smokers. Young women compared with older women reported significantly worse health perceptions, quality of life, optimism, hope, social support, and stress and significantly more symptoms of depression and anxiety. Women who prematurely terminated CR participation were younger, more obese, with worse quality of life, and greater symptoms of depression and anxiety compared with women completing CR.

CONCLUSIONS

Notable differences in physiological and psychosocial profiles of young women compared with older women enrolled in CR were evident, placing them at high risk for nonadherence to secondary prevention interventions as well as increased risk for disease progression and subsequent cardiac adverse events. Continued existence of these health differentials represents an important public health problem and warrants further research to address these age-related and sex-specific health disparities among women with coronary heart disease.

Influence of Sociodemographic and Stroke-related Factors on Availability of Social Support among Nigerian Stroke Survivors

Background:

Availability of social support has been identified as an important prerequisite for positive outcomes after stroke. There is however, little information on variables that influence the availability of social support after stroke.

Aim:

This study explored the influence of selected sociodemographic and clinical variables on social support of stroke survivors in Nigeria.

Subjects and Methods:

One hundred stroke survivors undergoing rehabilitation at two tertiary-care hospitals in Northern Nigeria participated in the study. Data on age, gender, living arrangement, marital, education and prestroke employment status, and time after stroke were obtained through interview, while poststroke disability was evaluated with the modified Rankin Scale. Social support was assessed with the multidimensional scale of perceived social support (MSPSS). Univariate and multiple linear regression analyses were conducted. A P value of less than 0.05 is considered as significant.

Results:

Univariate analysis showed that gender, education, and prestroke employment status were significantly associated with the availability of social support. In a regression model that accounted for 11 % of the variance in social support, prestroke employment was the only variable that independently influenced availability of social support (β = −0.33, P < 0.01) with previously employed stroke survivors having higher MSPSS score (5.28 [0.98]) compared to the unemployed (4.57 [0.82]).

Conclusion:

Employment is a known significant contributor to social network and was also found to influence significantly, the availability of poststroke social support in this study. Further studies are required to identify factors that more substantially influence the availability of social support after stroke.

Sex Differences in Depression: Does Inflammation Play a Role?

Women become depressed more frequently than men, a consistent pattern across cultures. Inflammation plays a key role in initiating depression among a subset of individuals, and depression also has inflammatory consequences. Notably, women experience higher levels of inflammation and greater autoimmune disease risk compared to men. In the current review, we explore the bidirectional relationship between inflammation and depression and describe how this link may be particularly relevant for women. Compared to men, women may be more vulnerable to inflammation-induced mood and behavior changes. For example, transient elevations in inflammation prompt greater feelings of loneliness and social disconnection for women than for men, which can contribute to the onset of depression. Women also appear to be disproportionately affected by several factors that elevate inflammation, including prior depression, somatic symptomatology, interpersonal stressors, childhood adversity, obesity, and physical inactivity. Relationship distress and obesity, both of which elevate depression risk, are also more strongly tied to inflammation for women than for men. Taken together, these findings suggest that women's susceptibility to inflammation and its mood effects may contribute to sex differences in depression. Depression continues to be a leading cause of disability worldwide, with women experiencing greater risk than men. Due to the depression-inflammation connection, these patterns may promote additional health risks for women. Considering the impact of inflammation on women's mental health may foster a better understanding of sex differences in depression, as well as the selection of effective depression treatments.

Can Anyone Hear Me? Does Anyone See Me? A Qualitative Meta-Analysis of Women's Experiences of Heart Disease

Female heart patients are underdiagnosed and undertreated. The purpose of this qualitative meta-data-analysis was to explain how societal expectations related to gender and the treatment environment influence women's experiences and can inform optimal care. The authors used grounded theory methodology and a social constructionist gender lens to analyze 43 studies (1993-2012) of women's experiences of heart disease. The analysis illustrates how social expectations within both medical and relational contexts led to women experiencing barriers to diagnosis and treatment and inadvertent minimization of their experience and knowledge. Women's descriptions of their experiences suggest three kinds of health care strategies that have the potential to increase women's engagement with heart disease treatment and rehabilitation: (a) support give and take in relational connections, (b) identify and acknowledge unique health-promoting behavior, and (c) focus on empowerment. These findings have interdisciplinary implications for practice with women with heart disease.

Sex differences in perceived stress and early recovery in young and middle-aged patients with acute myocardial infarction

BACKGROUND

Younger age and female sex are both associated with greater mental stress in the general population, but limited data exist on the status of perceived stress in young and middle-aged patients presenting with acute myocardial infarction.

METHODS AND RESULTS

We examined sex difference in stress, contributing factors to this difference, and whether this difference helps explain sex-based disparities in 1-month recovery using data from 3572 patients with acute myocardial infarction (2397 women and 1175 men) 18 to 55 years of age. The average score of the 14-item Perceived Stress Scale at baseline was 23.4 for men and 27.0 for women (P<0.001). Higher stress in women was explained largely by sex differences in comorbidities, physical and mental health status, intrafamily conflict, caregiving demands, and financial hardship. After adjustment for demographic and clinical characteristics, women had worse recovery than men at 1 month after acute myocardial infarction, with mean differences in improvement score between women and men ranging from -0.04 for EuroQol utility index to -3.96 for angina-related quality of life (P<0.05 for all). Further adjustment for baseline stress reduced these sex-based differences in recovery to -0.03 to -3.63, which, however, remained statistically significant (P<0.05 for all). High stress at baseline was associated with significantly worse recovery in angina-specific and overall quality of life, as well as mental health status. The effect of baseline stress on recovery did not vary between men and women.

CONCLUSIONS

Among young and middle-aged patients, higher stress at baseline is associated with worse recovery in multiple health outcomes after acute myocardial infarction. Women perceive greater psychological stress than men at baseline, which partially explains women's worse recovery.

Effect of low perceived social support on health outcomes in young patients with acute myocardial infarction: results from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study

Background

Social support is an important predictor of health outcomes after acute myocardial infarction (AMI), but social support varies by sex and age. Differences in social support could account for sex differences in outcomes of young patients with AMI.

Methods and Results

Data from the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, an observational study of AMI patients aged ≤55 years in the United States and Spain, were used for this study. Patients were categorized as having low versus moderate/high perceived social support using the ENRICHD Social Support Inventory. Outcomes included health status (Short Form‐12 physical and mental component scores), depressive symptoms (Patient Health Questionnaire), and angina‐related quality of life (Seattle Angina Questionnaire) evaluated at baseline and 12 months. Among 3432 patients, 21.2% were classified as having low social support. Men and women had comparable levels of social support at baseline. On average, patients with low social support reported lower functional status and quality of life and more depressive symptoms at baseline and 12 months post‐AMI. After multivariable adjustment, including baseline health status, low social support was associated with lower mental functioning, lower quality of life, and more depressive symptoms at 12 months (all P<0.001). The relationship between low social support and worse physical functioning was nonsignificant after adjustment (P=0.6). No interactions were observed between social support, sex, or country.

Conclusion

Lower social support is associated with worse health status and more depressive symptoms 12 months after AMI in both young men and women. Sex did not modify the effect of social support.

Psychosocial factors and medication adherence among patients with coronary heart disease: A text messaging intervention

OBJECTIVE

Medication adherence is a complex behavior that is influenced by numerous factors. Applying self-efficacy theory, the primary aim of this randomized controlled trial was to compare medication self-efficacy among patients with coronary heart disease who received: (a) text messages (TMs) for medication reminders and education, (b) TMs for education, or (c) no TMs. The second aim was to identify the personal (sociodemographic and clinical characteristics) and psychosocial factors that were associated with and predicted medication adherence.

METHODS

Customized TMs were delivered over 30 days. Repeated measures analysis of variance was used to analyze medication self-efficacy. A multiple regression analysis was performed at baseline and follow-up to determine variables that were associated with and predicted self-reported medication adherence.

RESULTS

Among 90 subjects with mean age 59.2 years (standard deviation (SD) 9.4, range 35-83), total scores for medication self-efficacy improved over 30 days; however, there was no significant difference in this improvement as a function of the different treatment groups (p=0.64). Controlling for other variables in the model (age, education, depression, and social support), less depression (p=0.004) and higher social support (p=0.02) positively predicted higher medication adherence in the final model.

CONCLUSIONS

TM medication reminders and/or health education did not improve medication self-efficacy. Further theory testing of current and future models and interventions are required to understand variables related to self-efficacy and medication adherence. Addressing psychosocial factors such as depression and social support should be a priority to improve medication adherence among patients with coronary heart disease.

Health-related quality of life in European women following myocardial infarction: a cross-sectional study

BACKGROUND

Coronary heart disease is a major contributor to women's health problems.

DESIGN

Self-perceived social support, well-being and health-related quality of life (HRQL) were documented in the cross-sectional HeartQoL survey of European women one and six months after a myocardial infarction.

METHODS

European women were recruited in 18 European countries and grouped into four geographical regions (Southern Europe, Northern Europe, Western Europe and Eastern Europe). Continuous socio-demographic variables and categorical variables were compared by age and region with ANOVA and χ(2), respectively; multiple regression models were used to identify predictors of social support, well-being and HRQL.

RESULTS

Women living in the Eastern European region rated social support, well-being and HRQL significantly lower than women in the other regions. Older women had lower physical HRQL scores than younger women. Eastern European women rated social support, well-being and HRQL significantly lower than women in the other regions. Prediction of the dependent variables (social support, well-being and HRQL) by socio-demographic factors varied by total group, in the older age group, and by region; body mass index and managerial responsibility were the most consistent significant predictors.

[Depression in Acute Coronary Syndromes: Application of the Beck Depression Inventory]

BACKGROUND

Depression has been related to the occurrence of cardiovascular diseases, and also appears to increase the risk of death from coronary artery disease. The presence of depression after the occurrence of an acute coronary syndrome (ACS) and its relationship with socioeconomic factors has not been studied in Colombia.

OBJECTIVE

To describe the frequency of depression and associated factors in patients hospitalized with an ACS.

METHODS

A cross-sectional study was carried out between April and May 2008 in three coronary care units in Santa Marta, Colombia. The presence of depression was evaluated with the Beck Depression Inventory (BDI). Depression was considered to be present if BDI was equal or greater than 10. The relationship between the presence of depression and demographic, clinic and laboratory characteristics was analyzed.

RESULTS

A BDI score ≥10 (any degree of depression) was seen in 21 (63.64%) of the patients. In 9 out of 10 (91.66%) patients without stable income had depression in contrast to 12 out of 23 (57.14%) with stable income (P=.037). Depression was found in in 8 of the 8 (100%) patients with electrocardiographic pathological T wave inversion, in contrast to 13 out of the 25 (52%) without changes in T wave (P=.014). Depression was detected in 17 of 22 (77.27%) patients who smoked cigarettes versus 4 of 11 (36.36%) of patients who have never smoked (P=.021).

CONCLUSIONS

Depressive symptoms are significantly present in patients suffering an acute coronary syndrome. Unemployment, pathological T wave inversion, and smoking seem to be associated with the presence of depressive symptoms after an acute coronary event.

Effects of social support and stressful life events on health-related quality of life in coronary artery disease patients

OBJECTIVE

The objective of this study was to examine the effects of social support and stressful life events on health-related quality of life (HRQoL) in coronary artery disease (CAD) patients.

METHODS

Five hundred sixty consecutive patients with CAD attending cardiac rehabilitation program were invited to participate in the study. Data on stressful life events, perceived social support, and HRQoL were collected from the self-administered questionnaires, Social Readjustment Rating Scale, Multidimensional Scale of Perceived Social Support, and 36-Item Short Form Medical Outcome Questionnaire, respectively.

RESULTS

In male patients, multivariate linear regression analyses revealed that physical domains of the HRQoL, specifically physical functioning, were associated with clinical aspects of the CAD, such as New York Heart Association class and angina pectoris class, and psychological domains of the HRQoL such as mental health, energy/vitality, and social functioning were associated with social characteristics such as stressful life events and perceived social support. In women, both physical and psychological domains of the HRQoL were associated only with social characteristics, especially with perceived social support.

CONCLUSION

Perceived social support and stressful life events have independent significant effects on the HRQoL in CAD patients, especially in female patients. When planning cardiac rehabilitation programs, special attention should be paid to patients who experience high levels of stress and have low social support.

Preventing cardiovascular disease in women: how can we do better?

PURPOSE OF REVIEW

This review highlights advances in the primary and secondary prevention of cardiovascular disease (CVD) in women in the preceding 12 months.

RECENT FINDINGS

The American Heart Association (AHA) has recently published guidelines on the prevention of CVD in women, which brought new attention to this important topic. Limited progress has been made regarding an awareness of CVD among women, and modest progress has been made on the creation of health behavior change programs that effectively reduce smoking, increase physical activity and improve nutrition. Preventive therapies have been demonstrated to improve outcomes in women with diagnosed disease, but more research that includes women is required to further assess the benefits of primary preventive strategies and therapies.

SUMMARY

A review of the literature from the past year confirms the recommendations and direction set in the AHA's updated prevention guidelines. This review illuminates promising new directions for practice and the need for future research focused on strategies to advance early and lasting lifestyle changes to promote cardiovascular health and the prevention of CVD. Adoption of and adherence to the guidelines, continued evaluation and publication of effective practice strategies, and ongoing research are critical to improve efforts to prevent CVD in women.

Review on depression and coronary heart disease

The impact of psychological factors on somatic disorders - and vice versa - and the involvement of biological mechanisms in psychic disorders have generated considerable interest in recent years, notably thanks to cutting-edge investigation techniques (immunohistochemistry, functional imaging, genetics, etc.). In the field of psychosomatics, coronary heart disease (CHD) is a frequent co-morbidity of mental disorders, particularly mood disorders. Indeed, there is a bidirectional relationship between CHD and mood disorders, with a strong co-occurrence of the two diseases accompanied by a reciprocal worsening of the prognosis for the two conditions. Various epidemiological studies have shown that depression is a psychic risk factor for CHD and that CHD is present in almost 30% of patients with affective disorders. In this review of the literature, we tackle the crucial question of the diagnosis of depression during myocardial infarction. This clinical approach is essential given the underevaluation of this psychic problem. Then, various psychological, biological and genetic arguments are presented in support of the hypothesis that various aetiological mechanisms of the two disorders are partly shared. We finally deal with the treatment of depression in the context of CHD with its pharmacological and psychological specificities. In conclusion, this review reiterates the need for a multidisciplinary approach, which is necessary to understand, diagnose and then treat this frequent co-morbid condition of heart disease and depression.

Depressive symptoms in people with chronic physical conditions: prevalence and risk factors in a Hong Kong community sample

BACKGROUND

Depression is predicted to become one of the two most burdensome diseases worldwide by 2020 and is common in people with chronic physical conditions. However, depression is relatively uncommon in Asia. Family support is an important Asian cultural value that we hypothesized could protect people with chronic physical conditions from developing depression. We investigated depressive symptom prevalence and risk factors in a Chinese sample with chronic medical conditions, focusing on the possible protective role of family relationships.

METHODS

Data were obtained from the Hong Kong Jockey Club FAMILY Project cohort study in 2009-2011, which included 6,195 participants (age ≥15) with self-reported chronic conditions. Depressive symptoms were recorded using the Patient Health Questionnaire-9 (PHQ-9). Demographic and lifestyle variables, stressful life events, perceived family support and neighborhood cohesion were assessed. Factors associated with a non-somatic (PHQ-6) depression score were also examined.

RESULTS

The prevalence of depressive symptoms (PHQ-9 scores ≥5) was 17% in those with one or more chronic conditions, and was more prevalent in women than in men (19.7% vs. 13.9%; p < 0.001). In multilevel analyses, life stress, number of chronic conditions and satisfaction with family support explained 43% of the variance in PHQ-9 scores (standardized regression coefficients of 0.46, 0.15, and -0.12 respectively, all p <0.001). Body mass index, problem alcohol drinking, physical activity, and unmarried status were significantly associated with PHQ-9 scores, although these associations were weak. Variables associated with depression explained 35% of the variance in non-somatic (PHQ-6) depression scores. Satisfaction with family support played a stronger protective role against depressive symptoms (both PHQ-9 and PHQ-6 scores) among women than men (p < 0.05).

CONCLUSIONS

Acute life stress and the number of chronic conditions, together with socio-demographic factors, explain most variance in depressive symptoms among chronically ill Chinese individuals. Somatic items in the PHQ-9 increased the depression scores but they did not alter the pattern of predictors. Family support appears to be an important protective factor in Chinese cultures for individuals with chronic conditions.