Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association

Anxiety, depression, and Type D personality in ischaemic heart disease patients receiving treatment from outpatient clinics in a government hospital in Sri Lanka

BACKGROUND

Anxiety, depression, and Type D personality are strongly correlated with the prognosis of IHD and the effectiveness of therapy. The main purpose of this study was to assess the proportions and associations of anxiety, depression, and Type D personality among clinically stable IHD patients (aged 18-60) treated at an outpatient clinic operated by a government hospital in Sri Lanka, who were diagnosed with IHD within the preceding three months.

METHODS

A cross-sectional study design was analysed using SPSS® version 23.0. The validated Sinhalese version of the Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression, while the DS-14 was used to determine Type D personality traits.

RESULTS

Among the 399 patients, 29.8% (n = 119) had anxiety, 24.8% (n = 99) had depression, and 24.6% (n = 24.6) had Type D personality. The level of anxiety had a significant association with depression (p = 0.002) and Type D personality (p = 0.003). Furthermore, depression was significantly associated with ethnicity (p = 0.014), occupation (p = 0.010), and type D personality (p = 0.009). Type D personality was the strongest predictor of anxiety, with patients being 1.902 times more likely to experience anxiety (95% CI 1.149-3.148; p = 0.012). Anxiety was a significant predictor of depression, with patients being 1.997 times more likely to experience depression (95% CI 1.210-3.296; p = 0.007). Non-Sinhalese ethnic background was also a significant predictor of depression (OR: 0.240; 95% CI 0.073-0.785; p = 0.018). Anxiety increased the likelihood of having Type D personality traits by 1.899 times (95% CI 1.148-3.143; p = 0.013).

CONCLUSION

The current study recommends the importance of screening and treating the psychological risk factors of IHD patients parallel to their IHD treatment to improve their prognosis. These insights highlight the need for targeted interventions that address depression, anxiety and the impact of Type D personality traits in enhancing the overall management and prognosis of IHD.

Depression screening in patients with coronary heart disease : A narrative review of the current evidence

In view of the large and sometimes conflicting body of research, this narrative review summarizes the current evidence on depression screening in patients with coronary heart disease. Depression is a risk factor for development and progression of coronary heart disease. Consequently, many international cardiac guidelines recommend screening for depression in patients with coronary heart disease. However, the efficacy and implementation of these guidelines are debated due to the lack of empirical evidence supporting the benefits of routine depression screening. Studies conducted in cardiac routine care support this assumption: Patients with positive depression screens do not receive adequate follow-up care, which highlights gaps in the detection-to-treatment pathway. Barriers to effective screening and treatment include system-level factors, such as insufficient integration of mental health resources in cardiology, and patient-related factors like stigma and low acceptance of mental health treatment. Innovative interventions that address these barriers and involve patients as active partners in depression care should be developed through a theory-driven, transparent, multistage process involving key stakeholders such as patients, nurses, and cardiologists. A sound methodological evaluation of such multilevel interventions could answer the question of whether early detection of depression in patients with coronary heart disease would lead to health benefits.

Depression and Implantable Cardioverter-Defibrillator Implantation in Black Patients at Risk for Sudden Cardiac Death

BACKGROUND

Black patients meeting indications for implantable cardioverter-defibrillators (ICDs) have lower rates of implantation compared with White patients. There is little understanding of how mental health impacts the decision-making process among Black patients considering ICDs. Our objective was to assess the association between depressive symptoms and ICD implantation among Black patients with heart failure.

METHODS AND RESULTS

This is a secondary analysis of the VIVID (Videos to Address Racial Disparities in ICD Therapy via Innovative Designs) randomized trial, which enrolled self-identified Black individuals with chronic systolic heart failure. Depressive symptoms were assessed by the Patient Health Questionnaire-2 and the Mental Component Summary of the 12-Item Short-Form Health Survey. Decisional conflict was measured by an adapted Decisional Conflict Scale (DCS). ANCOVA was used to assess differences in Decisional Conflict Scale scores. Multivariable logistic regression was used to examine the association between depressive symptoms and ICD implantation. Among 306 participants, 60 (19.6%) reported depressed mood, and 142 (46.4%) reported anhedonia. Participants with the lowest Mental Component Summary of the 12-Item Short-Form Health Survey scores (poorer mental health and higher likelihood of depression) had greater decisional conflict regarding ICD implantation compared with those with the highest Mental Component Summary of the 12-Item Short-Form Health Survey scores (adjusted mean difference in Decisional Conflict Scale score, 3.2 [95% CI, 0.5-5.9]). By 90-day follow-up, 202 (66.0%) participants underwent ICD implantation. There was no association between either the Patient Health Questionnaire-2 score or the Mental Component Summary of the 12-Item Short-Form Health Survey score and ICD implantation.

CONCLUSIONS

Depressed mood and anhedonia were prevalent among ambulatory Black patients with chronic systolic heart failure considering ICD implantation. The presence of depressive symptoms did not impact the likelihood of ICD implantation in this population.

Clinical Variables Associated with Successful Treatment of Depression or Anxiety in Collaborative Care

Collaborative Care, an evidence-based model, has proven effective in treating depression and anxiety in healthcare settings. However, limited attention has been paid to exploring treatment outcome differences by clinical variables and diagnosis within this model. While previous research suggests that early and frequent contacts and swift treatment access lead to positive outcomes for depression and anxiety, these aspects have not been comprehensively examined in Collaborative Care. This study investigates the impact of clinical variables on treatment completion in patients primarily diagnosed with anxiety or depression who received collaborative care treatment as a treatment program. Analysis was completed as an observational study of patients (n =2018) with behavioral health diagnoses spanning from 2016 to 2023. Classification analysis offers insights into optimal practices for implementing Collaborative Care across diverse healthcare populations from pediatric to geriatric. Identifying clinical characteristics associated with successful treatment in Collaborative Care has far-reaching implications for model adoption and enhancing patient outcomes. Across all results, patients who received more clinical support and had shorter enrollment durations showed a strong association with successful treatment completion.

Trajectory of the body mass index of children and adolescents attending a reference mental health center

OBJECTIVES

The primary objective was to describe the standardized body mass index (z-BMI) trajectory of children and adolescents admitted to a psychiatric reference center in Mexico City according to their diagnosis and medication use. The secondary objective was to compare z-BMI between antipsychotic users and non-users.

METHODS

This is a retrospective cohort study. The psychiatric diagnosis, prescribed medications, serial heights, and weights were collected from the medical records.

RESULTS

The median baseline z-BMI of the 129 analyzed cases was 0.88 (interquartile range [IQR]: 0-1.92), and the prevalence of excessive weight (obesity or overweight) was 46.8 %. At the end of follow-up (median 50.3 weeks), the median change in z-BMI was -0.09 (IQR: -0.68 to 0.42). New long-term users of antipsychotics (n=29) had an increase in their z-BMI, in contrast to never-users (median difference 0.73, p=0.01) and to previous users (median difference 0.92, p=0.047). The 59 subjects with excessive weight at admission had a median z-BMI change of -0.39 (IQR: -0.81 to -0.04). Among patients with excessive weight and depression, there was a greater decrease in z-BMI in sertraline users (n=13) compared with fluoxetine users (n=15) (median -0.65 vs. 0.21, p<0.001).

CONCLUSIONS

New long-term users of antipsychotics showed a significant increase in their z-BMI. Patients with depressive disorders and obesity on sertraline therapy tended to show a decrease in their z-BMI.

The effect of single nucleotide polymorphisms on depression in combination with coronary diseases: a systematic review and meta-analysis

Background

Depression and coronary heart disease (CHD) have common risk mechanisms. Common single nucleotide polymorphisms (SNPs) may be associated with the risk of depression combined with coronary heart disease.

Methods

This study was designed according to the PRISMA-P guidelines. We will include case-control studies and cohort studies investigating the relationship between gene SNPs and depression and coronary heart disease comorbidities. The Newcastle-Ottawa Scale (NOS) will be used to assess the risk of bias. When measuring dichotomous outcomes, we will use the odds ratio (OR) and 95% confidence interval (95%CIs) in a case-control study. Five genetic models (allele model, homozygous model, co-dominant model, dominant model, and recessive model) will be evaluated for each included study. Subgroup analysis by ethnicity will be performed. If necessary, post hoc analysis will be made according to different types.

Results

A total of 13 studies were included in this study, and the types of genes included are FKBP5 and SGK1 genes that act on glucocorticoid; miR-146a, IL-4-589, IL-6-174, TNF-α-308, CRP-717 genes that act on inflammatory mechanisms; eNOS genes from endothelial cells; HSP70 genes that act on the autoimmune response; ACE2 and MAS1 genes that act to mediate Ang(1-7) in the RAS system; 5-HTTLPR gene responsible for the transport of serotonin 5-HT and neurotrophic factor BDNF gene. There were three studies on 5-HTTLPR and BDNF genes, respectively, while there was only one study targeting FKBP5, SGK1, miR-146a, IL-4-589, IL-6-174, TNF-alpha-308, CRP-717, eNOS, HSP70, ACE2, and MAS1 genes. We did not perform a meta-analysis for genes reported in a single study, and meta-analysis was performed separately for studies exploring the 5-HTTLPR and BDNF genes. The results showed that for the 5-HTTLPR gene, there was a statistically significant association between 5-HTTLPR gene polymorphisms and depression in combination with coronary diseases (CHD-D) under the co-dominant model (LS vs LL: OR 1.76, 95%CI 1.20-2.59; SS vs LL: OR 2.80, 95%CI 1.45 to 5.41), the dominant model (LS+SS vs LL: OR 2.06, 95%CI 1.44 to 2.96), and the homozygous model (SS vs LL: OR 2.80 95%CI 1.45 to 5.5.41) were statistically significant for CHD-D, demonstrating that polymorphisms in the 5-HTTLPR gene are associated with the development of CHD-D and that the S allele in the 5-HTTLPR gene is likely to be a risk factor for CHD-D. For the BDNF gene, there were no significant differences between one of the co-dominant gene models (AA vs GG: OR 6.63, 95%CI 1.44 to 30.64), the homozygous gene model (AA vs GG: OR 6.63,95% CI 1.44 to 30.64), the dominant gene model (GA+AA vs GG: OR4.29, 95%CI 1.05 to 17.45), recessive gene model (AA vs GG+GA: OR 2.71, 95%CI 1.16 to 6.31), and allele model (A vs G: OR 2.59, 95%CI 1.18 to 5.67) were statistically significant for CHD-D, demonstrating that BDNFrs6265 gene polymorphisms are associated with the CHD-D development and that the A allele in the BDNFrs6265 gene is likely to be a risk factor for CHD-D. We analyzed the allele frequencies of SNPs reported in a single study and found that the SNPs in the microRNA146a gene rs2910164, the SNPs in the ACE2 gene rs2285666 and the SNPs in the SGK1 gene rs1743963 and rs1763509 were risk factors for the development of CHD-D. We performed a subgroup analysis of three studies involving the BDNFrs6265 gene. The results showed that European populations were more at risk of developing CHD-D than Asian populations in both dominant model (GA+AA vs GG: OR 10.47, 95%CI 3.53 to 31.08) and co-dominant model (GA vs GG: OR 6.40, 95%CI 1.98 to 20.73), with statistically significant differences. In contrast, the studies involving the 5-HTTLPR gene were all Asian populations, so subgroup analyses were not performed. We performed sensitivity analyses of studies exploring the 5-HTTLPR and BDNF rs6265 genes. The results showed that the results of the allele model, the dominant model, the recessive model, the homozygous model and the co-dominant model for both 5-HTTLPR and BDNF rs6265 genes were stable. Due to the limited number of studies of the 5-HTTLPR and BDNF genes, it was not possible to determine the symmetry of the funnel plot using Begg's funnel plot and Egger's test. Therefore, we did not assess publication bias.

Discussion

SNPs of the microRNA146a gene at rs2910164, the ACE2 gene at the rs2285666 and the SGK1 gene at rs1743963 and rs1763509, and the SNPs at the 5-HTTLPR and BDNF gene loci are associated with the onset of comorbid depression in coronary heart disease. We recommend that future research focus on studying SNPs' impact on comorbid depression in coronary heart disease, specifically targeting the 5-HTTLPR and BDNF gene at rs6265.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021229371.

Associations of cumulative depressive symptoms within 1-year of discharge with subsequent mortality among patients hospitalized for acute heart failure: Findings from The China PEACE Prospective Heart Failure Study

BACKGROUND

To examine the associations between cumulative depressive symptoms and subsequent mortality among patients hospitalized for acute hear failure (AHF).

METHODS

By using data from a prospective cohort study of patients with HF, depressive symptoms were measured by using Patient Health Questionnaire-2 (PHQ-2) at admission, 1-and 12-month after discharge. Cumulative depressive symptoms were interpreted by cumulative PHQ-2 score and cumulative times of depressive symptoms. Outcomes included subsequent 3-year all-cause and cardiovascular mortality.

RESULTS

We included 2347 patients with the median follow-up of 4.4 (interquartile range [IQR]: 4.0-5.0) years. Tertile 3 of cumulative PHQ-2 score had the highest risk of all-cause (hazard ratio [HR]: 1.47, 95 % confidence interval [CI]: 1.21-1.78) and cardiovascular mortality (HR: 1.51, 95 % CI: 1.21-1.89) compared with Tertile 1; patients with≥2 times of depressive symptoms had the highest risk of all-cause (HR: 1.62, 95 % CI: 1.31-2.00) and cardiovascular mortality (HR: 1.60, 95 % CI: 1.25-2.05) compared with patients without any depressive symptom. Cumulative PHQ-2 score provided the highest level of incremental prognostic ability in predicting the risk of all-cause (C-statistics: 0.64, 95 % CI: 0.62-0.66) and cardiovascular mortality (C-statistics: 0.65, 95 % CI: 0.62-0.67) on the basis of Get With The Guidelines-Heart Failure score.

CONCLUSION

Cumulative depressive symptoms were associated with the increased risk of subsequent mortality and provided incremental prognostic ability for the outcomes among patients with HF. Repeated depressive symptom measurements could be helpful to monitor long-term depressive symptoms, identify targeted patients and perform psychological interventions and social support to improve clinical outcomes among patients with AHF.

Impact of mental disorders on unplanned readmissions for congestive heart failure patients: a population-level study

AIMS

Reducing preventable hospitalization for congestive heart failure (CHF) patients is a challenge for health systems worldwide. CHF patients who also have a recent or ongoing mental disorder may have worse health outcomes compared with CHF patients with no mental disorders. This study examined the impact of mental disorders on 28 day unplanned readmissions of CHF patients.

METHODS AND RESULTS

This retrospective cohort study used population-level linked public and private hospitalization and death data of adults aged ≥18 years who had a CHF admission in New South Wales, Australia, between 1 January 2014 and 31 December 2020. Individuals' mental disorder diagnosis and Charlson comorbidity and hospital frailty index scores were derived from admission records. Competing risk and cause-specific risk analyses were conducted to examine the impact of having a mental disorder diagnosis on all-cause hospital readmission. Of the 65 861 adults with index CHF admission discharged alive (mean age: 78.6 ± 12.1; 48% female), 19.2% (12 675) had at least one unplanned readmission within 28 days following discharge. Adults with CHF with a mental disorder diagnosis within 12 months had a higher risk of 28 day all-cause unplanned readmission [hazard ratio (HR): 1.21, 95% confidence interval (CI): 1.15-1.27, P-value < 0.001], particularly those with anxiety disorder (HR: 1.49, 95% CI: 1.35-1.65, P-value < 0.001). CHF patients aged ≥85 years (HR: 1.19, 95% CI: 1.11-1.28), having ≥3 other comorbidities (HR: 1.35, 95% CI: 1.25-1.46), and having an intermediate (HR: 1.34, 95% CI: 1.28-1.40) or high (HR: 1.37, 95% CI: 1.27-1.47) frailty score on admission had a higher risk of unplanned readmission. CHF patients with a mental disorder who have ≥3 other comorbidities and an intermediate frailty score had the highest probability of unplanned readmission (29.84%, 95% CI: 24.68-35.73%) after considering other patient-level factors and competing events.

CONCLUSIONS

CHF patients who had a mental disorder diagnosis in the past 12 months are more likely to be readmitted compared with those without a mental disorder diagnosis. CHF patients with frailty and a mental disorder have the highest probability of readmission. Addressing mental health care services in CHF patient's discharge plan could potentially assist reduce unplanned readmissions.

The heart-mind relationship in women cardiovascular primary prevention: the role of depression, anxiety, distress and Type-D personality in the 10-years cardiovascular risk evaluation

Introduction

Cardiovascular diseases are the leading cause of death among women. Prevention programmes underscore the need to address women-specific risk factors. Additionally, mental well-being is a significant aspect to consider when grappling with cardiovascular disease in women, particularly depression, anxiety, distress, and personality traits. This study aimed to create "at-risk" psychological profiles for women without prior cardiovascular disease history and to evaluate the association between anxiety, depression, distress, and Type-D personality traits with increased cardiovascular risk over 10 years.

Methods

219 women voluntarily participated in the "Monzino Women's Heart Centre" project for primary prevention and early diagnosis of cardiovascular diseases. Psychological profiles were developed utilising cluster analysis.

Results

The primary finding indicating that belonging to the "at-risk" psychological cluster was associated with a surge in the 10-year cardiovascular risk prediction score, despite the number of comorbid risk factors (Psychological "at-risk" cluster: β = .0674; p = .006; Risk factors: β = .0199; p = .242).

Conclusions

This finding suggests that psychological well-being of women should be assessed from the very beginning of cardiovascular prevention programmes.

Enhancement of Preoperative Mental Health Assessment Through Clinical Nurse Specialist Project Leadership

PURPOSE/OBJECTIVES

The aim of the project was to discern whether a collaborative, consultative-rich, clinical nurse specialist-led project could increase completion rates of a patient health questionnaire for depression and a generalized anxiety disorder questionnaire with appropriate referrals in adult patients in the ambulatory and hospital settings of a robust cardiovascular surgery practice before cardiovascular surgery.

DESCRIPTION OF PROJECT

The Define, Measure, Analyze, Improve, Control implementation methodology guided this quality improvement project. The workflow was analyzed in collaboration with stakeholders, and barriers to and facilitators of questionnaire completion were identified. Interpreter services partnerships were enhanced and used for patients with a preferred language other than English. Weekly data analysis assessed ongoing questionnaire completion rates.

OUTCOME

Documented completion rates of questionnaires improved across ambulatory and hospital settings by 15%. Patients with a preferred language other than English had an 80-percentage-point increase in documented questionnaire completion.

CONCLUSION

Clinical nurse specialists are poised to lead projects because of their use of the collaborative and consultative core competencies. A formal electronic health record report was established for monitoring outcomes. Embedding questionnaire administration within the standard workflow of ambulatory and hospital staff makes administering questionnaires preoperatively a sustainable practice in both settings.

Lifestyle Intervention for the Prevention of Cardiovascular Disease

Lifestyle medicine is a cornerstone of cardiovascular disease prevention and early disease intervention. A leading cause of death in developed countries, modifiable risk factors of cardiovascular disease like diet, exercise, substance use, and sleep hygiene have significant impacts on population morbidity and mortality. One should address these amendable risks in all patients, independently, and stress the importance of intervention adherence while avoiding the sacrifice of patient trust. One must also understand a patient's psychological well-being can be compromised by organic chronic disease states, and poor psychological well-being can have a negative impact on patient compliance and overall health.

Psychological Distress Affects Performance during Exercise-Based Cardiac Rehabilitation

BACKGROUND

It is known that psychosocial distress affects the morbidity and mortality of patients with cardiovascular disease of every age. The aim of this study was to produce novel information on how psychological distress can influence cardiovascular performance in patients after cardiac surgery undergoing multidisciplinary cardiac rehabilitation.

METHODS

Patients (n = 57) admitted after cardiac surgery for valvular or coronary disease underwent, within 5 days of admission, the Symptom Checklist-90-Revised (SCL-90-R) self-report questionnaire to measure psychiatric symptoms and the 12-item General Health Questionnaire (GHQ-12) to assess the level of psychological distress. The Positive Symptom Distress Index (PSDI) was measured to indicate the amplitude of symptom distress. Cardiovascular performance was assessed by a 6 min walking test (6MWT) at admission and discharge, and oxygen consumption (VO2 max) was derived.

RESULTS

Within the SCL-90-R score, somatic symptoms (47.4%), depressive and anxiety symptoms (36.8% and 33.3%, respectively), symptoms of phobic anxiety (21.1%), and psychoticism (24.6%) were over-represented. As for the GHQ-12, 75.4% of the sample reported an abnormally negative perception of their health status. An inverse correlation was shown between the variation in 6MWT and SCL depression (p = 0.048), PSDI (p = 0.022), and the GHQ-12 (p = 0.040). Similarly, an inverse correlation was shown between the variation in the VO2 max, GHQ-12 (p = 0.041), and the PSDI (p = 0.023).

CONCLUSIONS

Post-cardiac surgery cardiac rehabilitation was associated with increased symptoms of psychological discomfort, as compared with the general population. The amplitude of psychological distress, depression, and hostility are associated with limited improvement in performance. These data strengthen the need for psychological support during cardiac rehabilitation programs.

Psychological Distress and the Risk of Adverse Cardiovascular Outcomes in Patients With Coronary Heart Disease

BACKGROUND

Psychological distress is a recognized risk factor in patients with coronary heart disease (CHD), but its clinical significance is unclear.

OBJECTIVES

The purpose of this study was to determine if an index of psychological distress is independently associated with adverse outcomes and significantly contributes to risk prediction.

METHODS

Pooled analysis of 2 prospective cohort studies of patients with stable CHD (N = 891). A psychological distress score was constructed using measures of depression, anxiety, anger, perceived stress, and post-traumatic stress disorder, measured at baseline. The study endpoint included cardiovascular death or first or recurrent nonfatal myocardial infarction or hospitalization for heart failure at 5.9 years.

RESULTS

In both cohorts, first and recurrent events occurred more often among those in the highest tertile of distress score than those in the lowest tertile. After combining the 2 cohorts, compared with the lowest tertile, the hazards ratio for having a distress score in the highest tertile was 2.27 (95% CI: 1.69-3.06), and for the middle tertile, it was 1.52 (95% CI: 1.10-2.08). Adjustment for demographics and clinical risk factors only slightly weakened the associations. When the distress score was added to a traditional clinical risk model, C-statistic, net reclassification index, and integrative discrimination index all significantly improved.

CONCLUSIONS

Among patients with CHD, a composite measure of psychological distress was significantly associated with an increased risk of adverse events and significantly improved risk prediction.

The interplay between Sars-Cov-2 infection related cardiovascular diseases and depression. Common mechanisms, shared symptoms

In 2020 the World Health organization announced a pandemic due to the outbreak of the Coronavirus disease 19. Pneumonia was the most common manifestation of the Sars-Cov-2 infection, however, clinical papers describe Sars-Cov-2 associated cardiovascular pathologies, such as ACS, myopericarditis, cardiomyopathies, dysrhythmias, as leading causes of increased morbidity and mortality. The short and long term prognosis of Sars-Cov-2-related cardiovascular diseases was defined not only by the disease severity itself but also by associated conditions and complications, among which mental health issues (stress, depression and anxiety) have a negative impact. The interplay between Sars-Cov-2 infection, cardiovascular disease and depression may be explained by hyperinflammation, unhealthy lifestyle and inter-organ communication, mediated by extracellular vesicles (EV) and non-coding MicroRNA (miRNA). The long Covid syndrome is characterized with orthostatic hypotension, impaired cardiac and cerebral perfusion, postural orthostatic tachycardia syndrome (POTS), syncope, chest pain, dyspnea, palpitation, chronic fatigue syndrome, 'brain fog', memory, cognitive and sleep difficulties, depression and anxiety. From a clinical point of view these symptoms may be considered as common symptoms representing not only a cardiac but also a neurological/psychiatric problem. Consequently assessment of these symptoms are of paramount importance. Due to their complexity, management of these patients requires multidisciplinary care.

Comparative Effectiveness of Psychotherapy vs Antidepressants for Depression in Heart Failure: A Randomized Clinical Trial

Importance

Heart failure (HF) affects more than 6 million adults in the US and more than 64 million adults worldwide, with 50% prevalence of depression. Patients and clinicians lack information on which interventions are more effective for depression in HF.

Objective

To compare the effectiveness of behavioral activation psychotherapy (BA) vs antidepressant medication management (MEDS) on patient-centered outcomes inpatients with HF and depression.

Design, Setting, and Participants

This pragmatic randomized comparative effectiveness trial was conducted from 2018 to 2022, including 1-year follow-up, at a not-for-profit academic health system serving more than 2 million people from diverse demographic, socioeconomic, cultural, and geographic backgrounds. Participant included inpatients and outpatients diagnosed with HF and depression, and data were analyzed as intention-to-treat. Data were analyzed from 2022 to 2023.

Interventions

BA is an evidence-based manualized treatment for depression, promoting engagement in personalized pleasurable activities selected by patients. MEDS involves the use of an evidence-based collaborative care model with care managers providing coordination with patients, psychiatrists, and primary care physicians to only administer medications.

Main Outcomes and Measures

The primary outcome was depressive symptom severity at 6 months, measured using the Patient Health Questionnaire 9-Item (PHQ-9). Secondary outcomes included physical and mental health-related quality of life (HRQOL), measured using the Short-Form 12-Item version 2 (SF-12); heart failure-specific HRQOL, measured using the Kansas City Cardiomyopathy Questionnaire; caregiver burden, measured with the Caregiver Burden Questionnaire for Heart Failure; emergency department visits; readmissions; days hospitalized; and mortality at 3, 6, and 12 months.

Results

A total of 416 patients (mean [SD] age, 60.71 [15.61] years; 243 [58.41%] male) were enrolled, with 208 patients randomized to BA and 208 patients randomized to MEDS. At baseline, mean (SD) PHQ-9 scores were 14.54 (3.45) in the BA group and 14.31 (3.60) in the MEDS group; both BA and MEDS recipients experienced nearly 50% reduction in depressive symptoms at 3, 6, and 12 months (eg, mean [SD] score at 12 months: BA, 7.62 (5.73); P < .001; MEDS, 7.98 (6.06); P < .001; between-group P = .55). There was no statistically significant difference between BA and MEDS in the primary outcome of PHQ-9 at 6 months (mean [SD] score, 7.53 [5.74] vs 8.09 [6.06]; P = .88). BA recipients, compared with MEDS recipients, experienced small improvement in physical HRQOL at 6 months (mean [SD] SF-12 physical score: 38.82 [11.09] vs 37.12 [10.99]; P = .04), had fewer ED visits (3 months: 38% [95% CI, 14%-55%] reduction; P = .005; 6 months: 30% [95% CI, 14%-40%] reduction; P = .008; 12 months: 27% [95% CI, 15%-38%] reduction; P = .001), and spent fewer days hospitalized (3 months: 17% [95% CI, 8%-25%] reduction; P = .002; 6 months: 19% [95% CI, 13%-25%] reduction; P = .005; 12 months: 36% [95% CI, 32%-40%] reduction; P = .001).

Conclusions and Relevance

In this comparative effectiveness trial of BA and MEDS in patients with HF experiencing depression, both treatments significantly reduced depressive symptoms by nearly 50% with no statistically significant differences between treatments. BA recipients experienced better physical HRQOL, fewer ED visits, and fewer days hospitalized. The study findings suggested that patients with HF could be given the choice between BA or MEDS to ameliorate depression.

Trial Registration

ClinicalTrials.gov Identifier: NCT03688100.

Prevalence of depression in postmyocardial infarction patients in a tertiary care center in Riyadh

BACKGROUND

The coexistence of coronary artery disease (CAD) and depression is a growing concern, as both conditions lead to disability. Although depression is more prevalent in CAD patients than in the general population and has been associated with adverse cardiac outcomes, the underlying mechanisms linking depression and CAD are not yet fully understood. This study aims to assess the prevalence of depression in postmyocardial infarction (MI) patients as baseline data in Saudi Arabia.

MATERIALS AND METHODS

A cross-sectional study was conducted at King Saud Medical City, Riyadh. The study population included male and female patients who had survived MI from January 2022 to June 2022. A sample size of 323 patients was initially planned, but only 249 patients could be included on account of exclusions. The patients underwent screening for depression using Patient Health Questionnaire-2 (PHQ-2), and those who were positive on screening were further assessed using the PHQ-9 according to DSM-5 criteria. Sociodemographic data, comorbidities, and previous cardiac interventions were collected from medical records.

RESULTS

The mean age of the study participants was 57.15 years, and majority (76.6%) were males. The prevalence of previously diagnosed depression was 9.2%, and 5.2% of patients reported using antidepressant medication. According to the PHQ-9 scores, 33.33% had depression, 9% had moderate depression, and 2.4% had severe depression. There were significant associations between the severity of depression and previous CAD (P < 0.05), previous coronary artery bypass graft surgery (P < 0.05), and heart failure (P < 0.05).

CONCLUSION

This study reveals a high prevalence of depression in post-MI patients at King Saud Medical City. The findings highlight the need for comprehensive management of depression in this population to improve outcomes. Further research into the underlying mechanisms linking depression and CAD to develop effective interventions is required.

The Impact of Post-Myocardial Infarction (MI) Depression on Cardiovascular-Related Hospitalizations

Routine depression screening and subsequent treatment in post-myocardial infarction (MI) patients may lead to improved cardiac outcomes. However, screening for depression is not a standard of post-MI care. Though the American Heart Association (AHA) published an advisory recommending routine depression screening in post-MI patients, there is conflicting evidence on the benefit that routine depression screening has on cardiovascular outcomes. The purpose of this study is to compare the occurrence of cardiovascular-related readmissions in post-MI patients diagnosed with depression versus post-MI patients not diagnosed with depression. This retrospective cohort study analyzed the incidence of cardiovascular-related readmissions and mortality in adult post-MI patients diagnosed with depression within 1 year compared to those not diagnosed with depression within a year. Those diagnosed with depression were more likely to experience a subsequent cardiovascular-related hospitalization within 2 years of MI than those not diagnosed with depression (52.6% vs 28.7%; odds ratio [OR], 3.19; 95% CI 2.33-4.38). There was no difference between groups in the incidence of in-hospital mortality.

Association of Frailty and Depressive Symptoms With the Establishment of Exercise Habits in Patients Undergoing Outpatient Cardiac Rehabilitation

Objective

To assess whether patients undergoing outpatient cardiac rehabilitation who have frailty and depressive symptoms at discharge are less likely than those without these condition to establish positive exercise habits.

Design

A retrospective cohort study that involved the assessment of frailty and depressive symptoms at the end of a 3-month course of cardiac rehabilitation. Frailty was defined as the patient noting 3 or more items using the criteria of Fried et al, while depressive symptoms were delineated by Patient Health Questionnaire-9 (PHQ-9) scores of 10 or greater.

Setting

General hospital (1048 beds) with outpatient cardiac rehabilitation in a suburb location in Japan.

Participants

344 individuals underwent outpatient cardiac rehabilitation during the January 1, 2019-June 1, 2022, study period. Of these, 48 individuals were excluded because they did not complete the course and 54 were excluded because they lacked outcome data. Finaly, 242 individuals (mean age: 68.2±11.1 years) were analyzed.

Interventions

Not applicable.

Main Outcome Variable

The establishment of an exercise habit defined as exercising at least 2 days per week and 30 minutes per day.

Results

Participants were divided into 4 groups depending upon the presence or absence of frailty and depressive symptoms: non-frail with no reported depressive symptoms (173 subjects), frailty-only (21 subjects), depressive symptoms-only (38 subjects), and frailty and depressive symptoms (10 subjects). Compared with patients who were not depressed and not frail, those with frailty only (odds ratio [OR]: 0.43, 95% confidence interval: 0.21-0.88, P=.02) and those with frailty and depressive symptoms (OR: 0.21, 95% confidence interval: 0.05-0.82, P=.025) had significantly lower ORs for establishing exercise habits. After multivariate adjustment, the OR of establishing an exercise habit was significantly lower in those with only frailty (OR: 0.35, 95% confidence interval: 0.14-0.85, P=.005).

Conclusions

This study, while limited by the small number of subjects with both frailty and depressive symptoms, indicates that interventions to prevent frailty during hospitalization and cardiac rehabilitation may be essential for cardiovascular disease patients with frailty whether or not associated with depressive symptoms.

New onset postoperative depression after major surgery: an analysis from a national claims database

Background

Postoperative depression is not well characterised. We investigated the incidence of postoperative depression with the hypothesis that after controlling for confounders, new onset depression would vary significantly by surgical type.

Methods

We conducted a retrospective cohort study using the Optum Clinformatics Datamart. The primary outcome was new onset postoperative depression, defined by a new diagnosis of depression or new prescription for an antidepressant in the year after surgery using International Classification of Diseases (ICD) 9/10 codes and drug names. Adjustment for preoperative comorbidities and predictors of depression was with multivariable Cox regression and propensity score matching. Sensitivity analyses defining new onset depression as both a new diagnosis of depression and a new prescription for an antidepressant, or either outcome separately, were conducted.

Results

Data from 132 390 cardiac surgery, 12 538 thoracotomy, 32 630 video-assisted thoracoscopic surgery (VATS), 96 750 hip fracture surgery, 157 484 hip replacement, and 347 878 laparoscopic cholecystectomy patients from January 2004 to June 2021 were analysed. The incidence of new onset postoperative depression was 18.8% for hip fracture surgery, 16.1% for thoracotomy, 12.6% for cardiac surgery, 12.4% for VATS, 8.6% for laparoscopic cholecystectomy, and 6.8% for hip replacement. After multivariable adjustment, hip fracture surgery patients were most likely to develop new onset postoperative depression (hazard ratio [95% confidence interval]) 1.56 [1.45-1.68]), followed by thoracotomy (1.12 [1.03-1.22]), cardiac surgery (1.09 [1.04-1.12]), VATS (0.95 [0.90-1.00]), and hip replacement (0.55 [0.52-0.57]) compared with patients undergoing laparoscopic cholecystectomy (hazard ratio=1). Results from propensity score matched analyses and sensitivity analyses were similar.

Conclusions

The risk of postoperative depression differs by surgical type after controlling for preoperative characteristics.

Crosstalk between Endothelial Cells and Tumor Cells: A New Era in Prostate Cancer Progression

Prostate cancer stands as one of the most prevalent malignancies afflicting men worldwide. The tumor microenvironment plays a pivotal role in tumor progression, comprising various cell types including endothelial cells, tumor-associated fibroblasts, and macrophages. Recent accumulating evidence underscores the indispensable contribution of endothelial cells to prostate cancer development. Both endothelial cells and tumor cells release a multitude of factors that instigate angiogenesis, metastasis, and even drug resistance in prostate cancer. These factors serve as regulators within the tumor microenvironment and represent potential therapeutic targets for managing prostate cancer. In this review, we provide an overview of the crucial functions of endothelial cells in angiogenesis, metastasis, and drug resistance, and their prospective therapeutic applications in combating this disease.

Instruments to assess post-intensive care syndrome assessment: a scoping review and modified Delphi method study

BACKGROUND

The assessment of post-intensive care syndrome (PICS) is challenging due to the numerous types of instruments. We herein attempted to identify and propose recommendations for instruments to assess PICS in intensive care unit (ICU) survivors.

METHODS

We conducted a scoping review to identify PICS follow-up studies at and after hospital discharge between 2014 and 2022. Assessment instruments used more than two times were included in the modified Delphi consensus process. A modified Delphi meeting was conducted three times by the PICS committee of the Japanese Society of Intensive Care Medicine, and each score was rated as not important (score: 1-3), important, but not critical (4-6), and critical (7-9). We included instruments with ≥ 70% of respondents rating critical and ≤ 15% of respondents rating not important.

RESULTS

In total, 6972 records were identified in this scoping review, and 754 studies were included in the analysis. After data extraction, 107 PICS assessment instruments were identified. The modified Delphi meeting reached 20 PICS assessment instrument recommendations: (1) in the physical domain: the 6-min walk test, MRC score, and grip strength, (2) in cognition: MoCA, MMSE, and SMQ, (3) in mental health: HADS, IES-R, and PHQ-9, (4) in the activities of daily living: the Barthel Index, IADL, and FIM, (5) in quality of life: SF-36, SF-12, EQ-5D-5L, 3L, and VAS (6), in sleep and pain: PSQI and Brief Pain Inventory, respectively, and (7) in the PICS-family domain: SF-36, HADS, and IES-R.

CONCLUSION

Based on a scoping review and the modified Delphi method, 20 PICS assessment instruments are recommended to assess physical, cognitive, mental health, activities of daily living, quality of life, sleep, and pain in ICU survivors and their families.

Low body mass index and disease duration as factors associated with depressive symptoms of Chinese inpatients with chronic heart failure

Depression is common in patients with chronic heart failure (CHF), and is associated with an increased risk of adverse health outcomes. There is a paucity of data on this subject from the developing countries. The aim was to examine the prevalence and related factors of depressive symptoms among Chinese inpatients with CHF. A cross-sectional study was conducted. PHQ-9 questionnaire was used to assess depressive symptoms. The overall prevalence of depressive symptoms was 7.5%. Low BMI (OR = 4.837, CI = 1.278-18.301, p = 0.02), disease duration 3-5 years (OR = 5.033, CI = 1.248-20.292, p = 0.023) and 5-10 years (OR = 5.848, CI = 1.440-23.744, p = 0.013) were risk factors for depressive symptoms, while being married (OR = 0.304, CI = 0.123-0.753, p = 0.010) was protective factor. We should pay more attention to patients without a spouse, with low BMI and whose disease duration is between 3 and 10 years in Chinese inpatients with CHF.

Healthy sleep patterns and common mental disorders among individuals with cardiovascular disease: A prospective cohort study

BACKGROUND

Sleep behaviors are potentially modifiable risk factors for common mental disorders and cardiovascular disease (CVD). However, the associations between combined sleep behaviors and common mental disorders among individuals with CVD remain unclear.

METHODS

A total of 18,776 participants with a history of CVD from UK Biobank, who were free of depression or anxiety from 2006 to 2010 were included. A composite healthy sleep score was constructed based on five sleep behaviors (chronotype, sleep duration, insomnia, snoring, and excessive daytime sleepiness). Cox proportional hazard regression models were performed to calculate hazard ratios (HRs) and 95 % confidence intervals (CIs) for incident depression and anxiety.

RESULTS

During a median follow-up of 11.8 years, 965 depression and 812 anxiety cases were recorded. The adjusted HRs for participants with a healthy sleep pattern compared with a poor sleep pattern were 0.45 (95 % CI: 0.35-0.57) for depression and 0.77 (95 % CI: 0.58-1.03) for anxiety. There was a linear dose-response association of healthy sleep score with incident depression and anxiety (HR = 0.82, 95 % CI: 0.77-0.87; HR = 0.92, 95 % CI: 0.86-0.99 per 1-score increase, respectively). Likewise, these associations were observed among individuals with coronary heart disease, stroke, heart failure and atrial fibrillation.

CONCLUSIONS

A healthy sleep pattern is significantly associated with a lower risk of depression among individuals with CVD, highlighting the importance of monitoring and improving sleep health in the prevention of common mental disorders among individuals with CVD.

Screening for Emotional Distress in Patients with Cardiovascular Disease

PURPOSE OF REVIEW

In this article, we discuss the relationship between emotional distress and common cardiovascular disease condition, including coronary artery disease, atrial fibrillation, congestive heart failure, mechanical circulatory support, and heart transplant. We review screening measures that have been studied and used in clinical practice for each condition, as well as priorities for future research.

RECENT FINDINGS

Studies consistently demonstrate failing to identify and treat emotional distress in patients with cardiovascular disease is associated with adverse outcomes. However, routine emotional distress screening is not formally recommended for all cardiovascular disease conditions and is limited to depression screening in select patient populations. Future research should focus on evaluating the validity and reliability of standardized screening measures across the scope of emotional distress in patients with or at risk for cardiovascular disease. Other areas of future research include implementation of evidence-based pharmaceutical treatments and integrated behavioral health approaches and interventions.

Barriers and facilitators to mental health promotion for Mexican immigrants in the U.S. through the Ventanillas de Salud program

Introduction

Mental health promotion and screenings are recommended as part of standard preventive care. Mexican immigrants in the U.S. are at high risk for mental health illness especially after the COVID-19 pandemic, however access to mental health prevention for this population has been limited, which results in important implementation and equity gaps. The Ventanilla de Salud (VDS) program provides preventive services through Mexican consulates in the U.S.

Objective

The objective of this study was to assess capability, opportunity, and motivation for promotores to implement mental health programming through the VDS, leveraging early experiences of ongoing mental health prevention efforts.

Methods

This was a qualitative study using the Capability, Opportunity, and Motivation for Behavior Change model (COM-B). We conducted 9 focus groups with 40 VDS promotores and 6 semi-structured interviews with program stakeholders. Data were analyzed using inductive and deductive coding.

Results

We found high levels of interest from the leadership, partners, and promotores to provide mental health services through the VDS. Early implementation of a mental health strategy that included training sessions for promotores and mental health promotion, screenings and referrals for VDS users was ongoing. We identified facilitators and barriers that could affect capability, opportunity, and motivation to provide mental health services. Facilitators included promotores' extensive knowledge about the importance of mental health, promotores service mindset and commitment to provide services to VDS users, and general support from the VDS network and partners. Barriers included promotores' turnover, need for additional economic compensation, burnout, competing priorities, and lack of mental health professionals to provide clinical services or supervision. Additional investments are recommended to support promotores' well-being.

Conclusion

The main lesson learned from this study was that investing in VDS promotores' training, resources, and well-being is key to their capability, opportunity and motivation to provide mental health services for Mexican immigrants in the US. Results from this study can be applied to improve the ongoing VDS mental health strategy and increase its impact on the mental health of Mexican immigrants.

The impact of gratitude interventions on patients with cardiovascular disease: a systematic review

Positive psychological factors play a pivotal role in improving cardiovascular outcomes. Gratitude interventions are among the most effective positive psychological interventions, with potential clinical applications in cardiology practice. To better understand the potential clinical effects of gratitude interventions in cardiovascular disease, four databases (Web of Science, Scopus, PubMed, and PsycArticles) were searched from 2005 to 2023 for relevant studies. Randomized controlled trials of gratitude interventions as the intervention and that reported physiological or psychosocial outcomes were eligible for inclusion. In total, 19 studies were identified, reporting results from 2951 participants from 19 to 71 years old from both healthy populations and those with clinical diagnoses. The studies showed that gratitude not only promotes mental health and adherence to healthy behaviors but also improves cardiovascular outcomes. Gratitude may have a positive impact on biomarkers of cardiovascular disease risk, especially asymptomatic heart failure, cardiovascular function, and autonomic nervous system activity.

Depression screening in patients with vascular disease

OBJECTIVES

Major depression is associated with increased morbidity and mortality in vascular surgery patients. The US Preventive Services Task Force and American Heart Association recommend routine depression screening for adults, especially those with cardiovascular disease. Since routine depression screening has not been implemented in most vascular surgery clinics across the nation, we sought to determine the feasibility of depression screening and understand the prevalence and predictors of depression in patients presenting to a single institution's vascular surgery clinic over a 4 month period.

METHODS

From June to September 2020, vascular surgery clinic patients were administered a 26-item survey that included validated scales for depression (PHQ-9), pain, frailty, alcohol dependence, and nicotine dependence. Although not validated, the Rosenberg Self-Esteem Scale was also administered. Patient charts were reviewed for demographic information and medical history. 9-digit patient zip codes were used to determine Area Deprivation Index, a measure of socioeconomic status. Univariate and multivariate analyses were performed to understand the factors associated with increased depression prevalence in the study population.

RESULTS

A total of 140 (36.4%) of 385 patients met study inclusion criteria. 35.7% of them screened positive for mild to severe depression (PHQ-9 scores ≥5). On univariate analysis, major depression was significantly associated with lower socioeconomic status (p = 0.007), higher frailty (p < 0.001), lower self-esteem (p < 0.001), higher daily pain (p < 0.001), health problems that interfere with social activities (p < 0.001), fatigue (p < 0.001), unmarried status (p = 0.031), and lack of primary care provider (p = 0.048). Multivariate analyses significantly predicted higher frailty (B= 0.487, p = 0.007) and lower self-esteem (B= -0.413, p < 0.001) in patients with depression. Depression was not associated with gender, age, employment status, smoking status, alcohol use, or type of vascular disease.

COCLUSIONS

More than one-third of vascular surgery clinic patients have comorbid depression. Higher frailty and lower self-esteem are significant risk factors for depression. Prevention and early identification of frailty may improve outcomes. Depression screening in vascular surgery clinics is feasible and could be useful in determining which patients may benefit from more frequent follow-up and monitoring for associated comorbidities. Vascular surgeons may play an important role in screening for depression and referring patients for psychotherapy and/or pharmacotherapy.

Relationship between occlusal force and psychological frailty in Japanese community-dwelling older adults: The Septuagenarians, Octogenarians, Nonagenarians Investigation with Centenarians study

BACKGROUND

Frailty increases the risk of negative health-related events, such as falls, disability, hospitalizations, and death. Although the association between oral health and physical frailty is well established, the relationship between oral health and psychological frailty has not yet been investigated. Therefore, we conducted a cross-sectional study to examine the association between maximal occlusal force and psychological frailty in Japanese community-dwelling older adults.

METHODS

Psychological frailty was defined as a World Health Organization-5 scale (WHO-5) score of <13, cognitive and functional status was defined as a Japanese version of the Montreal Cognitive Assessment (MoCA-J) score of <23, and psychological robustness was defined as a WHO-5 score of ≥13 and a MoCA-J score of ≥23. We used a cross-sectional study design to measure maximal occlusal force in 1810 participants, and examined the following factors relevant to psychological frailty: educational level, financial status, living situation, history of chronic diseases, handgrip strength, and instrumental activities of daily living. We used propensity score matching to match the psychological frailty and psychological robustness groups according to demographic and confounding factors. This process, resulted in 344 participants, of whom 172 were in the psychological frailty group and 172 were in the psychological robustness group. In the matched cohort, differences between groups with and without psychological frailty were compared using generalized estimating equations for maximal occlusal force after adjusting for the number of teeth.

RESULTS

After controlling for potential confounding factors of frailty, the psychological frailty group showed lower maximal occlusal force compared with the psychological robustness group (unstandardized regression coefficients = -72.7, 95% confidence interval: -126.3 to -19.1).

CONCLUSIONS

Maximal occlusal force was associated with a reduced prevalence of psychological frailty among Japanese community-dwelling older adults participating in our study.

The prognostic study of mental stress-induced myocardial ischemia in coronary revascularization patients with depression/anxiety: rationale and design

BACKGROUND

Mental stress-induced myocardial ischemia (MSIMI) frequently occurs in patients with coronary artery disease (CAD), and is even more common in patients with co-occurring CAD and depression/anxiety. MSIMI appears to be a poor prognostic factor for CAD, but existing data on depression/anxiety patients are limited.

METHODS

This cohort study will consecutively screen 2,647 CAD patients between 2023 and 2025. Included subjects will need to have received coronary revascularization and also have depression and/or anxiety at baseline. This study will enroll 360 subjects who meet the criteria. Two mental stress tests will be carried out in each patient at 1 month and 1 year timelines after coronary revascularization, using Stroop color word tests. MSIMI will be assessed by ^99 m-Tc-sestamibi myocardial perfusion imaging. The endothelial function will be assessed by EndoPAT. Furthermore, we will dynamically monitor patients' health and mental conditions every 3 months. The mean follow-up time will be 1 year. The primary endpoint is the major adverse cardiac events, a composite of all-cause death, cardiac death, myocardial infarction, stroke, or unplanned revascularization. Secondary endpoints will include overall health and mental conditions. The reproducibility of mental stress combined with myocardial perfusion for detecting MSIMI and comparisons between coronary stenosis and ischemic segments will also be included.

CONCLUSIONS

This cohort study will provide information on MSIMI outcomes in CAD patients who also have comorbid depression/anxiety after revascularization. In addition, understanding the long-term dynamics of MSIMI and the match between coronary stenosis and ischemia will provide insight into MSIMI mechanisms.

TRAIL REGISTRATION

ChiCTR2200055792, 2022.1.20, www.medresman.org.cn.

Unmet Needs for Cardiac Rehabilitation in Africa: A Perennial Gap in the Management of Individuals with Cardiac Diseases

Cardiac rehabilitation (CR) is a standard model of care, and an established component of comprehensive care that has been proven to reduce mortality and morbidity in patients with cardiac diseases. International clinical practice guidelines routinely recommend that cardiac patients participate in CR programs for comprehensive secondary prevention. However, there is scant guidance on how to deliver these programs in low-resourced settings. This dearth of clinical practice guidelines may be an indication of low emphasis placed on CR as a component of cardiac health services in low-income countries, especially in Africa. Indeed, CR programs are almost non-existent in Africa despite the unmet need for CR in patients with ischemic heart disease in Africa reported to be about one million. This figure represents the highest unmet need of any World Health Organization region, and is colossal given the projected accelerated increases in incidence of cardiovascular diseases (CVD) in the region. This narrative review explored the availability of CR programs, potential barriers to CR and strategies that can mitigate such barriers in Africa.

Cardiology and lifestyle medicine

Poor lifestyle habits, such as physical inactivity and poor diets, are highly prevalent within society and even more so among patients with chronic disease. The need to stem poor lifestyle habits has led to the development of a new field of Lifestyle Medicine, whose mission is to prevent, treat, and even reverse chronic diseases through lifestyle interventions. Three fields within Cardiology relate to this mission: Cardiac Rehabilitation, Preventive Cardiology, and Behavioral Cardiology. Each of these three fields have contributed substantially to the reduction of cardiovascular disease (CVD) morbidity and mortality. The historic contributions of these three cardiac fields are reviewed as well as the challenges each of these fields has faced in optimizing the application of lifestyle medicine practices. A shared agenda between Cardiology and the American College of Lifestyle Medicine could further the utilization of behavioral interventions. This review suggests seven steps that could be shared by these organizations and other medical societies. First, there is a need to develop and promulgate the assessment of lifestyle factors as "vital signs" during patient visits. Second, developing a strong partnership between the fields of Cardiology and Physiatry could improve important aspects of cardiac care, including a potential redesign of cardiac stress testing. Third, behavioral evaluations should be optimized at patients' entrée points into medical care since these may be considered "windows of opportunity". Fourth, there is a need to broaden cardiac rehabilitation into inexpensive programs and make this program eligible for patients with risk factors but no known CVD. Fifth, lifestyle medicine education should be integrated into the core competencies for relevant specialties. Sixth, there is a need for inter-societal advocacy to promote lifestyle medicine practices. Seventh, the well-being effects of healthy lifestyle behaviors, such as their impact on one's sense of vitality, should be emphasized.

Psychosocial services provided by licensed cardiac rehabilitation programs

Background

Professional health organizations recommend that outpatient cardiac rehabilitation programs include activities to optimize the physical, mental, and social well-being of patients. The study objectives were to describe among cardiac rehabilitation programs (1) mental health assessments performed; (2) psychosocial services offered; and (3) leadership's perception of barriers to psychosocial services offerings.

Methods

A cross-sectional survey of North Carolina licensed outpatient cardiac rehabilitation programs on their 2018 services was conducted. Descriptive statistics were used to summarize survey responses. Thematic analysis of free text questions related to barriers to programmatic establishment or expansion of psychosocial services was performed by two team members until consensus was reached.

Results

Sixty-eight programs (89%) responded to the survey. Forty-eight programs (70%) indicated offering psychosocial services; however, a majority (73%) of programs reported not directly billing for those services. At program enrollment, mental health was assessed in 94% of programs of which 92% repeated the assessment at discharge. Depression was assessed with the 9-item Patient Health Questionnaire by a majority (75%) of programs. Psychosocial services included individual counseling (59%), counseling referrals (49%), and educational classes (29%). Directors reported lack of internal resources (92%) and patient beliefs (45%) as the top barriers to including or expanding psychosocial services at their facilities.

Conclusions

Cardiac rehabilitation programs routinely assess mental health but lack the resources to establish or expand psychosocial services. Interventions aimed at improving patient education and reducing stigma of mental health are important public health opportunities.

The mediation effects of metabolic and immune-inflammation factors on the depression-premature coronary heart disease association

BACKGROUND

Accumulated evidence confirmed depression was positively associated with CHD. But evidence of the association between depression and premature CHD is still unknown.

OBJECTIVES

To explore the association between depression and premature CHD, and to investigate whether and to what extent the association is mediated by metabolic factors and systemic immune-inflammation index (SII).

METHODS

In this large population-based cohort study based on the UK Biobank, 176,428 CHD-free (mean age: 52.70) adults were followed up for 15 years to detect incident premature CHD. Depression and premature CHD (mean age: female, 54.53; male, 48.13) were ascertained from self-report data and linked hospital-based clinical diagnosis. Metabolic factors included central obesity, hypertension, dyslipidemia, hypertriglyceridemia, hyperglycemia, and hyperuricemia. Systemic inflammation was evaluated by calculating SII, which equals platelet count (/L) × neutrophil count (/L) / lymphocyte count (/L). Data were analyzed using Cox proportional hazards models and generalized structural equation model (GSEM).

RESULTS

During follow-up (median: 8.0 years, interquartile range: 4.0 to 14.0 years), 2990 participants developed premature CHD (1.7 %). The adjusted hazard ratio (HR) and 95 % confidence interval (CI) of premature CHD related to depression were 1.72 (1.44-2.05). The association between depression and premature CHD was 32.9 % mediated by comprehensive metabolic factors (β = 0.24, 95 % CI: 0.17-0.32) and 2.7 % by SII (β = 0.02, 95 % CI = 0.01-0.04), respectively. Concerning metabolic factors, the strongest indirect association was for central obesity, accounting for 11.0 % of the association between depression and premature CHD (β = 0.08, 95 % CI: 0.05-0.11).

CONCLUSIONS

Depression was associated with an increased risk of premature CHD. Our study provided evidence that metabolic and inflammatory factors might play a mediating role in the association between depression and premature CHD, especially central obesity.

Applying Machine Learning to Construct a Model of Risk of Depression in Patients Following Cardiac Surgery with the Use of the SF-12 Survey

BACKGROUND

Depression is a common problem in patients with cardiovascular diseases. Identifying a risk factor model of depression has been postulated. A model of the risk of depression would provide a better understanding of this disorder in this population. We sought to construct a model of the risk factors of depression in patients following cardiac surgery, with the use of machine learning.

METHODS AND MEASURES

Two hundred and seventeen patients (65.4% men; mean age 65.14 years) were asked to complete the short form health survey-12 (SF-12v.2), three months after hospital discharge. Those at risk of depression were identified based on the SF-12 mental component summary (MCS). Centroid class principal component analysis (CCPCA) and the classification and regression tree (CART) were used to design a model.

RESULTS

A risk of depression was identified in 29.03% of patients. The following variables explained 82.53% of the variance in depression risk: vitality, limitation of activities due to emotional problems (role-emotional, RE), New York Heart Association (NYHA) class, and heart failure. Additionally, CART revealed that decreased vitality increased the risk of depression to 45.44% and an RE score > 68.75 increased it to 63.11%. In the group with an RE score < 68.75, the NYHA class increased the risk to 41.85%, and heart failure further increased it to 44.75%.

CONCLUSION

Assessing fatigue and vitality can help health professionals with identifying patients at risk of depression. In addition, assessing functional status and dimensions of fatigue, as well as the impact of emotional state on daily functioning, can help determine effective intervention options.

Exercise as a therapeutic modality for the prevention and treatment of depression

While maintaining an active lifestyle and engaging in regular exercise are known to promote cardiovascular (CV) health, increasing evidence has emerged to indicate that these lifestyle behaviors also can promote psychological health and well-being. This has led to research to determine if exercise can serve as a potential therapeutic modality for major depressive disorder (MDD), which is a leading cause of mental-health impairment and overall disability worldwide. The strongest evidence to support this use comes from an increasing number of randomized clinical trials (RCTs) that have compared exercise to usual care, placebo controls, or established therapies in healthy adults and in various clinical populations. The relatively large number of RCTs has led to numerous reviews and meta-analyses, which generally have been concordant in indicating that exercise ameliorates depressive symptoms, improves self-esteem, and enhances various aspects of quality of life. Together, these data indicate that exercise should be considered as a therapeutic modality for improving CV health and psychological well-being. The emerging evidence also has led to a new proposed subspecialty of "lifestyle psychiatry", which promotes the use of exercise as an adjunctive treatment for patients with MDD. Indeed, some medical organizations have now endorsed lifestyle-based approaches as foundational aspects of depression management, with adoption of exercise as a treatment option for MDD. This review summarizes research in the area and provides practical suggestions for the use of exercise in clinical practice.

Importance of Depressive Symptoms in Patients With Coronary Heart Disease - Review Article

Patients with myocardial infarction (MI) have both major depression as well as depressive symptoms. Therefore, due to the high prevalence of depression in post-MI patients, an assessment of its prognostic importance was put on the agenda. Patients after ACS frequently report fatigue, sleep problems, and sadness. Evaluation of these symptoms is very important because it should be clarified whether these symptoms are related only to the main disease or they indicate the presence of concomitant depression. Given a high predictive value of somatic-affective symptoms, it is recommended to assess them in post-MI patients. Further treatment of somatic and cognitive-affective symptoms of depression will improve the quality of life of patients with acute coronary events.

Co-prevalence and incidence of myocardial infarction and/or stroke in patients with depression and/or anxiety: A systematic review and meta-analysis

OBJECTIVE

Co-prevalence and incidence of depression and/or anxiety with stroke and myocardial infarction are currently unclear. This paper explores the relationships, as these are important comorbidities affecting patient outcomes.

METHODS

A systematic search across five databases (PubMed, Scopus, PsycINFO, Embase, Cochrane) was conducted for observational studies reporting co-prevalence of depression or anxiety with stroke or myocardial infarction. We used random-effects models in all meta-analyses and evaluated heterogeneity using I².

RESULTS

This analysis included 48 studies with a total of 57,342 patients. In patients with depression, the pooled prevalence of stroke was 5.9% (95% CI = 5.53-6.37). In patients with myocardial infarction, the pooled prevalence of anxiety and depression was 9.1% (95% CI = 7.07-11.40, I² = 85.6%) and 25.9% (95% CI = 18.46-34.12, I² = 99.1%), respectively, and the pooled cumulative incidence of depression at one year was 20.5% (95% CI = 18.36-22.79). The pooled prevalence of anxiety and depression in patients with stroke was 13.5% (95% CI = 7.67-22.66, I² = 96.9%) and 23.0% (95% CI = 17.93-28.99, I² = 96.7%), respectively. The pooled cumulative incidences of depression at two weeks, three months, six months, and one year, were 29.1% (95% CI = 26.60-31.81), 17.0% (95% CI = 10.74-25.92, I² = 98.0%), 7.4% (95% CI = 6.52-8.49), and 9.1% (95% CI = 3.71-20.79, I² = 99.8%), respectively.

CONCLUSIONS

This meta-analysis outlines the co-morbid burden between depression/anxiety and stroke/myocardial infarction. Future research should be done to evaluate the effectiveness of screening anxiety/depression in myocardial infarction/stroke.

Self-care in coronary heart disease patient and caregiver dyads (HEARTS-IN-DYADS)-Protocol of a multicenter longitudinal study

Self-care performed by patients and the caregiver contribution to this self-care are essential for improving cardiovascular outcomes; however, so far, no studies have sufficiently investigated this field in Italy. This paper describes a research protocol of a multi-center longitudinal study designed to investigate the self-care of patients affected by coronary heart disease (CHD), the caregiver's contribution to this self-care, the predictors of patient and caregiver self-care, the mediating role of self-efficacy, and the self-care outcomes. Data collection will be performed across seven Italian inpatient settings at baseline and 3 and 6 months from enrollment. Multilevel modeling and actor partner interdependence models will be implemented on a sample of 330 patient-caregiver dyads to adjust for the interdependence of measurements. The study received approval from an ethics committee in Italy and was financed in January 2021 by a grant from the Solidal Foundation in Alessandria. This research will advance the knowledge about the self-care process in CHD. The results will guide research and clinical practice by identifying variables sensitive to educational interventions.

PTSD and depression severity are associated with cardiovascular disease symptoms in trauma-exposed women

Background: Posttraumatic stress disorder (PTSD) and depression are associated with increased risk for cardiovascular disease (CVD), which is the leading cause of death and disability worldwide. Epidemiological studies have revealed these illnesses to be highly comorbid, particularly among women. In the current study, we explored associations between indices of cardiovascular health, PTSD, and depression among a sample of trauma-exposed individuals assigned female at birth.Methods: Participants were N = 49 individuals without CVD who reported lifetime Criterion A trauma exposure. Blood pressure (BP), heart rate (HR), and high-frequency heart rate variability (HF-HRV) were collected during a 5-minute resting period. Symptoms of CVD (e.g. extremity pain and swelling, shortness of breath), PTSD, and depression were assessed, along with an exploratory measure of anhedonia.Results: Trauma exposure was positively correlated with systolic BP (r = .32, p = .029) and diastolic BP (r = .30, p = .040). The number of reported CVD symptoms was positively correlated with symptoms of PTSD (r = .41, p = .004), depression (r = .40, p = .005) and anhedonia (r = .38, p = .007). CVD symptoms were also significantly associated with PTSD (β = .41, t = 2.43, p = .023), depression (β = .40, t = 2.76, p = .009), and anhedonia (β = .38, t = 2.51, p = .017) after controlling for age and trauma exposure. These associations were not moderated by HF-HRV in our sample.Conclusions: Our results support the association between PTSD and depressive symptoms and worse cardiovascular functioning among an often-overlooked population that is particularly vulnerable to these illnesses. Future studies should investigate residual impacts of PTSD and depression treatment on CVD risk among trauma-exposed individuals, particularly women.

The association of depression with mortality and major adverse limb event outcomes in patients with peripheral artery disease: A systematic review and meta-analysis

BACKGROUND

Peripheral artery disease (PAD) is highly prevalent and associated with poor outcomes. Depression is a risk factor for adverse outcomes in patients with coronary artery disease. Despite evidence showing that depression is common in patients with PAD, less is known about its association with adverse prognostic outcomes. To address this, we conducted a systematic review and meta-analysis to summarize the association between depression and outcomes in patients with PAD.

METHODS

We performed a systematic search of eight databases to January 2022 including studies that reported a risk estimate for the association of depression or depressive symptoms with all-cause mortality or major adverse limb events (MALE) in patients with PAD and pooled results in a meta-analysis. Risk of bias was assessed using ROBINS-I.

RESULTS

Of the 7048 articles screened, 5 observational studies with 119,123 patients were included. A total of 16.2 % had depression or depressive symptoms. Depression was associated with a statistically significant increased risk of all-cause mortality (HR 1.24, confidence interval 1.07-1.25, p = .005). The association between depression and MALE was not significant but trended toward a positive association.

LIMITATIONS

Due to lack of data, results were limited by a single study with a large sample size, overrepresentation of men, and lack of information of depression severity or treatment status.

CONCLUSION

Depression or depressive symptoms are associated with a 24 % increased risk of all-cause mortality in patients with PAD. Future work should explore the mechanisms and directionality of this association and identify depression as an important comorbidity to address for patients with PAD.

REGISTRATION

PROSPERO CRD 42021223694.