Anxiety, Depression, and Adverse Clinical Outcomes in Patients With Atrial Fibrillation Starting Warfarin: Cardiovascular Research Network WAVE Study

Prevalence of demoralization and depressive symptoms in a sample of patients with supraventricular tachyarrhythmias: preliminary results

Introduction

Supraventricular tachyarrhythmias (ST) are the most common cardiac arrhythmias. Little is known about the potential impact of demoralization, which is considered as partially distinct from depression, on the course of ST. A correct assessment of both depressive symptoms and demoralization appears relevant for the treatment of these cardiac diseases, potentially influencing their course.

Methods

The sample consisted of 110 subjects affected by different ST, such as atrial fibrillation (AF), atrial flutter (AFL) and paroxysmal supraventricular tachycardia (PSVT). They all underwent a psychiatric evaluation; the Italian version of 9-item Patient Health Questionnaire (PHQ-9) and the Italian version of Demoralization Scale (DS) were administered. Descriptive statistics, pairwise comparisons, and correlational analysis have been implemented.

Results

26 individuals (23.6%) presented high levels of demoralization. Of these, 20 (76.9%) had a diagnosis of AF and six patients (23.1%) received a diagnosis of other ST. No differences in demoralization levels resulted in regard of sex, cardiac diagnoses and anticoagulant therapies. Amongst people with high levels of demoralization, 13 (50%) received no formal psychiatric diagnosis, and 12 (46.2%) showed moderate/severe depressive symptoms. Demoralization levels and PHQ-9 scores showed a significant positive correlation in the whole sample (r=0.550, p<0.001).

Discussion

The present study found that in a sample of patients suffering from ST, high levels of demoralization were more frequent than clinically relevant depressive symptoms. We propose that demoralization and depression show partially distinguished psychopathological features, potentially associated with different therapeutic trajectories.

Concomitant Use of Selective Serotonin Reuptake Inhibitors With Oral Anticoagulants and Risk of Major Bleeding

Importance

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed antidepressants associated with a small increased risk of major bleeding. However, the risk of bleeding associated with the concomitant use of SSRIs and oral anticoagulants (OACs) has not been well characterized.

Objectives

To assess whether concomitant use of SSRIs with OACs is associated with an increased risk of major bleeding compared with OAC use alone, describe how the risk varies with duration of use, and identify key clinical characteristics modifying this risk.

Design, Setting, and Participants

A population-based, nested case-control study was conducted among patients with atrial fibrillation initiating OACs between January 2, 1998, and March 29, 2021. Patients were from approximately 2000 general practices in the UK contributing to the Clinical Practice Research Datalink. With the use of risk-set sampling, for each case of major bleeding during follow-up, up to 30 controls were selected from risk sets defined by the case and matched on age, sex, cohort entry date, and follow-up duration.

Exposures

Concomitant use of SSRIs and OACs (direct OACs and vitamin K antagonists [VKAs]) compared with OAC use alone.

Main Outcomes and Measures

The main outcome was incidence rate ratios (IRRs) of hospitalization for bleeding or death due to bleeding.

Results

There were 42 190 patients with major bleeding (mean [SD] age, 74.2 [9.3] years; 59.8% men) matched to 1 156 641 controls (mean [SD] age, 74.2 [9.3] years; 59.8% men). Concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding compared with OACs alone (IRR, 1.33; 95% CI, 1.24-1.42). The risk peaked during the initial months of treatment (first 30 days of use: IRR, 1.74; 95% CI, 1.37-2.22) and persisted for up to 6 months. The risk did not vary with age, sex, history of bleeding, chronic kidney disease, and potency of SSRIs. An association was present both with concomitant use of SSRIs and direct OACs compared with direct OAC use alone (IRR, 1.25; 95% CI, 1.12-1.40) and concomitant use of SSRIs and VKAs compared with VKA use alone (IRR, 1.36; 95% CI, 1.25-1.47).

Conclusions and Relevance

This study suggests that among patients with atrial fibrillation, concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding compared with OAC use alone, requiring close monitoring and management of risk factors for bleeding, particularly in the first few months of use.

Generalized anxiety is a predictor of impaired quality of life in patients with atrial fibrillation: Findings from the prospective observational ARENA study

OBJECTIVE

Atrial fibrillation (AF) is associated with impaired health-related quality of life (HRQoL), an increased risk of morbidity, and mortality. Traditional AF-related outcomes (e.g., AF recurrence) primarily demonstrate the physiological benefits of AF management but do not focus on the benefits experienced subjectively by the patient (i.e., patient-reported outcomes), which have been suggested as optimal endpoints in AF intervention studies. The aim of this study is to identify medical and psychological factors associated with impaired HRQoL at 1-year follow-up.

METHODS

Using data from the prospective observational multicenter ARENA study in patients with AF, we analyzed associations between medical factors, anxiety, and HRQoL at 1-year follow-up assessed using 5-level EuroQoL-5D.

RESULTS

In 1353 AF patients (mean age 71.4 ± 10.3 years, 33.8% female), none of the medical predictors (e.g., heart disease) or history of cardioversion were associated with HRQoL at the 1-year follow-up. Higher generalized anxiety (β = -0.114, p < .001) but not cardiac anxiety (β = -0.006, p = .809) at baseline predicted decreased HRQoL, independent of confounding variables and patients' medical status. Furthermore, the worsening of patients' generalized anxiety was associated with decreased HRQoL (ß = -0.091, p < .001). In contrast, the improvement of generalized anxiety over time predicted higher HRQoL (ß = 0.097, p < .001). Finally, the worsening of patients' cardiac anxiety over time was associated with decreased HRQoL (ß = -0.081, p < .001).

CONCLUSION

Our results highlight the importance of anxiety as a predictor of future HRQoL in patients with AF. Additional studies to examine the impact of anxiety treatment on HRQoL in this population are needed.

CLINICAL TRIAL REGISTRATION

The investigators registered on ClinicalTrials.gov (NCT02978248) on November 30, 2016 https://clinicaltrials.gov/ct2/show/NCT02978248.

Post-traumatic stress disorder among heart disease patients: a clinical follow-up of individuals with myocardial infarction in the Tromsø Study

BACKGROUND

Myocardial infarction is likely to be experienced as a life-threatening and potentially traumatic event. Approximately one-third of patients with myocardial infarction experience clinically significant symptoms of anxiety/depression. However, it is unclear how many of these patients experience these symptoms because of post-traumatic stress disorder (PTSD). We conducted a clinical screening of individuals with a confirmed myocardial infarction diagnosis. Our goal was to examine the prevalence of PTSD in myocardial infarction patients and study how PTSD symptoms were associated with exposure to potentially traumatic events.

METHOD

This is epidemiological research with a cross-sectional design following up participants from the Tromsø Study with a confirmed diagnosis of myocardial infarction. We sent invitations to participants in the Tromsø Study with clinically significant self-reported anxiety or depression symptoms following myocardial infarction. A cross-sectional sample of N = 79 participants (61 men and 18 women) was collected. During an interview, participants completed the Stressful Life Events Screening Questionnaire and the PTSD checklist PCL-5.

RESULTS

We found nine participants (11.6%) with probable PTSD. This was significantly higher than the postulated population prevalence in Norway (p < 0.015). We found no direct association between myocardial infarction as illness trauma and symptom levels (p = 0.123). However, we found a significant linear trend (p = 0.002), indicating that symptom severity increased proportionately as the number of post-traumatic events increased.

CONCLUSION

PTSD prevalence in myocardial infarction patients was related to lifetime exposure to traumatic events, not the myocardial infarction event alone. More research is required to examine the interaction between myocardial infarction and PTSD. Clinicians should be aware that anxiety or depression symptoms after MI could be secondary symptoms of PTSD.

Major depression disorder may causally associate with the increased atrial fibrillation risk: evidence from two-sample mendelian randomization analyses

BACKGROUND

Observational studies have revealed a link between major depressive disorder (MDD) and a higher chance of developing atrial fibrillation (AF). It is still uncertain whether or not this correlation indicates a causal relationship. This research set out to evaluate the causal impact of MDD on AF.

METHODS

To evaluate the causal relationship between MDD and AF, we employed a two-sample Mendelian randomization (MR) method. A new genome-wide association study (GWAS) with 500,199 participants was used to obtain an overview of the association of genetic variations with MDD. An additional GWAS incorporating 1,030,836 people provided data on the relationship between gene variants and AF. The inverse-variance weighted technique was utilized to assess the effect sizes. Sensitivity analysis included the use of other statistical approaches such as weighted median, Outlier, MR Pleiotropy Residual Sum, weighted mode, simple mode, and MR - Egger.

RESULTS

By employing 47 single nucleotide polymorphisms (SNPs) as markers, MR analyses in random-effect inverse-variance weighted models found that genetically projected MDD was linked to an elevated incidence of AF (odds ratio [OR] = 1.098, 95% CI 1.000-1.206; P = 0.049). No gene pleiotropy was discovered as indicated by MR-Egger (intercept= -0.011, P = 0.169). Sensitivity analysis employing other MR techniques yielded reliable results.

CONCLUSION

This MR study established a causal relationship between genetically predicted MDD and an elevated risk of AF.

Concomitant Use of Selective Serotonin Reuptake Inhibitors and Oral Anticoagulants and Risk of Major Bleeding: A Systematic Review and Meta-analysis

BACKGROUND

 Selective serotonin reuptake inhibitors (SSRIs), the most prescribed antidepressants, are associated with a modestly increased risk of major bleeding. However, in patients treated with both SSRIs and oral anticoagulants (OACs), the risk of major bleeding may be substantial.

OBJECTIVE

 To assess the risk of major bleeding associated with concomitant use of SSRIs and OACs, compared with OAC use alone.

METHODS

 We searched MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials (from inception to December 1, 2021) for clinical trials and observational studies assessing the association between concomitant use of SSRIs and OACs and the risk of major bleeding. Given sufficient homogeneity of studies, we conducted a random-effects meta-analysis to estimate a pooled hazard ratio (HR) of major bleeding associated with concomitant use of SSRIs and OACs, compared with OAC use alone.

RESULTS

 The review comprised 14 studies, including 7 cohort and 7 nested case-control studies. Following assessment of clinical and methodological heterogeneity, eight studies with a total of 98,070 patients were eligible for the meta-analysis. The pooled HR of major bleeding associated with concomitant use of SSRIs and OACs was 1.35 (95% confidence interval [CI]: 1.14-1.58). In secondary analyses, the pooled HR for concomitant use of SSRIs and direct OACs was 1.47 (95% CI: 1.03-2.10).

CONCLUSION

 Concomitant use of SSRIs and OACs was associated with an increased risk of major bleeding. Overall, our findings suggest that physicians may need to tailor treatment according to individual patient risk factors for bleeding when prescribing SSRIs to patients using OACs.

Adenosine and Adenosine Receptors: Advances in Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia in the world. Because the key to developing innovative therapies that limit the onset and the progression of AF is to fully understand the underlying molecular mechanisms of AF, the aim of the present narrative review is to report the most recent advances in the potential role of the adenosinergic system in the pathophysiology of AF. After a comprehensive approach describing adenosinergic system signaling and the mechanisms of the initiation and maintenance of AF, we address the interactions of the adenosinergic system's signaling with AF. Indeed, adenosine release can activate four G-coupled membrane receptors, named A₁, A_2A, A_2B and A₃. Activation of the A_2A receptors can promote the occurrence of delayed depolarization, while activation of the A₁ receptors can shorten the action potential's duration and induce the resting membrane's potential hyperpolarization, which promote pulmonary vein firing, stabilize the AF rotors and allow for functional reentry. Moreover, the A_2B receptors have been associated with atrial fibrosis homeostasis. Finally, the adenosinergic system can modulate the autonomous nervous system and is associated with AF risk factors. A question remains regarding adenosine release and the adenosine receptors' activation and whether this would be a cause or consequence of AF.

Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study

BACKGROUND

In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear.

OBJECTIVE

To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation.

DESIGN

Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics.

PARTICIPANTS

Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened.

MAIN MEASURES

A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel.

KEY RESULTS

At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding.

CONCLUSIONS

In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

Cardiovascular disease and subsequent risk of psychiatric disorders: a nationwide sibling-controlled study

Background

The association between cardiovascular disease (CVD) and selected psychiatric disorders has frequently been suggested while the potential role of familial factors and comorbidities in such association has rarely been investigated.

Methods

We identified 869,056 patients newly diagnosed with CVD from 1987 to 2016 in Sweden with no history of psychiatric disorders, and 910,178 full siblings of these patients as well as 10 individually age- and sex-matched unrelated population controls (N = 8,690,560). Adjusting for multiple comorbid conditions, we used flexible parametric models and Cox models to estimate the association of CVD with risk of all subsequent psychiatric disorders, comparing rates of first incident psychiatric disorder among CVD patients with rates among unaffected full siblings and population controls.

Results

The median age at diagnosis was 60 years for patients with CVD and 59.2% were male. During up to 30 years of follow-up, the crude incidence rates of psychiatric disorder were 7.1, 4.6, and 4.0 per 1000 person-years for patients with CVD, their siblings and population controls. In the sibling comparison, we observed an increased risk of psychiatric disorder during the first year after CVD diagnosis (hazard ratio [HR], 2.74; 95% confidence interval [CI], 2.62-2.87) and thereafter (1.45; 95% CI, 1.42-1.48). Increased risks were observed for all types of psychiatric disorders and among all diagnoses of CVD. We observed similar associations in the population comparison. CVD patients who developed a comorbid psychiatric disorder during the first year after diagnosis were at elevated risk of subsequent CVD death compared to patients without such comorbidity (HR, 1.55; 95% CI, 1.44-1.67).

Conclusions

Patients diagnosed with CVD are at an elevated risk for subsequent psychiatric disorders independent of shared familial factors and comorbid conditions. Comorbid psychiatric disorders in patients with CVD are associated with higher risk of cardiovascular mortality suggesting that surveillance and treatment of psychiatric comorbidities should be considered as an integral part of clinical management of newly diagnosed CVD patients.

Funding

This work was supported by the EU Horizon 2020 Research and Innovation Action Grant (CoMorMent, grant no. 847776 to UV, PFS, and FF), Grant of Excellence, Icelandic Research Fund (grant no. 163362-051 to UV), ERC Consolidator Grant (StressGene, grant no. 726413 to UV), Swedish Research Council (grant no. D0886501 to PFS), and US NIMH R01 MH123724 (to PFS).

Analysis of Early Warning Diagnostic Indexes and Influencing Factors of Anxiety and Depression in Patients with Arrhythmia

Objective

Arrhythmia patients complicated with psychological problems are very common in clinics. The imbalance of autonomic nervous regulation of the heart caused by anxiety and depression will further promote the occurrence and development of arrhythmia. For nonorganic heart disease, β receptor blockers combined with antianxiety drugs have a good effect. Therefore, it is necessary to analyze the influencing factors of anxiety and depression in patients with arrhythmias.

Methods

We included 150 patients with arrhythmia and divided them into observation groups (80 patients with anxiety and depression) and control groups (70 patients without anxiety and depression). All patients were monitored by Holter, and the detection of arrhythmia was compared between the two groups. We took the general situation and quality of life of the investigated patients as independent variables and the anxiety and depression status of the patients as dependent variables.

Results

The detection rates of atrioventricular premature beats, ventricular premature beats, atrial fibrillation, short bursts of atrial tachycardia, and atrioventricular block in the observation group were all higher than those in the control group by dynamic electrocardiogram. Multivariate logistic stepwise regression analysis showed that age, years of education, obsessive-compulsive score, somatization score and alcohol consumption were the main influencing factors for anxiety and depression.

Conclusions

The detection rate of arrhythmia in patients with anxiety/depression status was higher than in those without abnormal psychophylaxis. We should need to pay close attention to the risk factors of age, education years, obsessive-compulsive score, somatization score, and alcohol consumption, so as to prevent and timely detect anxiety and depression symptoms in patients with arrhythmias.

Comparing Patient and Provider Experiences with Atrial Fibrillation to Highlight Gaps and Opportunities for Improving Care

BACKGROUND

Atrial fibrillation (AF), the most common abnormal heart rhythm, places a considerable burden on patients, providers, and the US healthcare system.

OBJECTIVE

The purpose of this qualitative study was to compare patients' and providers' interpretations and responses to AF symptoms and to identify where treatment can be improved to better address patient needs and well-being.

DESIGN

Qualitative design using focus groups with patients (3 groups) and providers (3 groups).

PARTICIPANTS

Patients with physician-confirmed AF (n=29) and cardiologists, primary care physicians, and cardiac nurses (n=24).

APPROACH

Focus groups elicited patient and provider perspectives regarding the symptom experience of AF, treatment goals, and gaps in care. Patient and provider transcripts were analyzed separately, using a thematic content analysis approach, and then compared.

KEY RESULTS

While patients and providers described similar AF symptoms, patients' illness experiences included a wider range of symptoms that elicited anxiety and impacted quality of life (QOL) across many biopsychosocial domains. Patients and providers prioritized different treatment goals. Providers tended to focus on controlling symptoms congruent with objective findings, minimizing stroke risk, and restoring sinus rhythm. Patients focused on improving QOL by reducing medication use or procedures. Both patients and providers struggled with patients' cardiac-related anxiety. Patients expressed an unmet need for education and support.

CONCLUSION

Patients with AF experience a range of symptoms and QOL issues. While guidelines recommend shared-decision making, discordance between patient and provider perspectives on the importance, priority, and impact of patients' perceived AF symptoms and consequent cardiac anxiety may result in differing treatment priorities. Starting from a perspective that contextualizes AF in the broader context of patients' lives, prioritizes QOL, and addresses symptom-specific anxiety as a prime concern may better address patients' unmet needs.

Mental health conditions and bleeding events in patients with incident atrial fibrillation: A Finnish nationwide cohort study

OBJECTIVE

We assessed the hypothesis that mental health conditions (MHCs) are associated with higher risk of bleeding in patients with atrial fibrillation (AF).

METHODS

The registry-based FinACAF study covers all patients with AF diagnosed during 2007-2018 in Finland. MHCs of interest were depression, bipolar disorder, anxiety disorder, schizophrenia, and any MHC. The outcomes were first-ever gastrointestinal, intracranial, and any bleeding event.

RESULTS

We identified 205,019 patients (50.9% female; mean age 72.3 [standard deviation 13.4] years) with incident AF without prior bleeding, and the prevalence of any MHC was 6.1%. Any MHC, depression, and anxiety disorder were associated with the risk of any bleeding (adjusted hazard ratios (HRs) 1.19 [1.12-1.27], 1.21 [1.13-1.30], and 1.21 [1.08-1.35], respectively). Additionally, any MHC and depression were associated with the risk of gastrointestinal and intracranial bleeding and anxiety disorder with gastrointestinal bleeding. Bipolar disorder and schizophrenia were not associated with risk of bleeding. Use of oral anticoagulants was associated with the risk of any bleeding (adjusted HR 1.24 [95% CI 1.21-1.28)]), and this association was similar in patients with and without MHCs. Serotonin reuptake inhibitors were not associated with bleeding risk.

CONCLUSIONS

MHCs are associated with a higher risk of bleeding in patients with AF.

Assessment of mental health trajectories before and after myocardial infarction, atrial fibrillation or stroke: analysis of a cohort study in Tromsø, Norway (Tromsø Study, 1994-2016)

OBJECTIVES

The increased survival rate of cardiovascular disease (CVD) implies a higher proportion of individuals who live with CVD. Using data from the Tromsø Study, we aimed to investigate mental health symptom trajectories before and after myocardial infarction, atrial fibrillation or stroke in a general population and to explore factors that contribute to the association.

DESIGN

Cohort study.

SETTING

Sample drawn from inhabitants of the municipality of Tromsø, Norway, who participated in the Tromsø Study (1994-2016).

PARTICIPANTS

A total of 18 719 participants (52.3% women) were included, and of these 2098 (32.9% women) were diagnosed with myocardial infarction, 1896 (41.9% women) with atrial fibrillation and 1263 (42.9% women) with stroke.

PRIMARY OUTCOME MEASURES

Mental health symptoms were assessed using the Hopkins Symptom Checklist-10 and the Conor Mental Health Index.

RESULTS

The participants who were diagnosed with either myocardial infarction or stroke had a significant monotonous increase in mental health symptoms before myocardial infarction (p=0.029) and stroke (p=0.029) that intensified at the time of diagnosis. After the event, the study found a higher prevalence of mental health symptoms with a decline in symptom levels over time for myocardial infarction (p<0.001) and stroke (p=0.004), but not for atrial fibrillation (before: p=0.180, after: p=0.410). The risk of elevated mental health symptoms with myocardial infarction, atrial fibrillation and stroke was associated with sex (p<0.001), age (p<0.01), physical activity (p<0.001), diabetes (p<0.05) and other comorbidities (p<0.001).

CONCLUSION

The study indicates that mental health problems among individuals with myocardial infarction, atrial fibrillation and stroke may have started to develop several years before the cardiovascular event and suggests that successful CVD rehabilitation may need to consider previous life factors. Future research is recommended to examine whether health promotion measures in a general population also create mental health resilience after a CVD event.

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08-1.45, I² 0%) and major bleeding (RR 1.17, 95%CI 1.08-1.27, I² 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients.

Depression as a Driving Force for Low Time in Therapeutic Range and Dementia in Patients With and Without Atrial Fibrillation

Both time in therapeutic range (TTR) for anticoagulation and depression are associated with dementia risk. The purposes of this study were to examine the impact of depression on TTR and to describe the partitioned contribution of depression and TTR on long-term dementia risk. We studied 14,953 patients anticoagulated with warfarin (target INR 2-3) for atrial fibrillation (AF), venous thromboembolism (VTE), or a mechanical heart valve from 2003 to 2015. We excluded patients with a diagnosis of dementia before or within 6 months of warfarin initiation. We examined the association of depression with TTR using finite mixture modeling and logistic regression and utilized multivariable Cox hazard regression to determine the association of TTR and depression with incident dementia at 3 and 13 years. Forty % (n = 6055) of patients were diagnosed with depression before or while on warfarin. Patients with depression had significantly lower TTR and were 1.37 times more likely to have TTR <50% than non-depressed patients (p <0.0001). During follow-up, 4.2% of patients received the diagnosis of dementia within 3 years as compared to 12% during all-time follow up. The 3-year risk of dementia was highest for patients with a ≤50% TTR regardless of depression status. The 3-year dementia risk was associated with TTR (p <0.0001) but not depression. However, for all-time dementia both TTR (p <0.0001) and depression (p <0.0001) as well as their interaction (p = 0.049) were associated with dementia. Depression increased the risk of long-term dementia by 1.69 fold (95% CI: 1.33, 2.15) for patients with the lowest TTR. Depression is prevalent in patients managed with warfarin and is associated with significant decreases in TTR. In conclusion, decreased TTR appears to increase 3-year dementia risk and both low TTR and depression interact to increase risk for all-time dementia in patients taking warfarin.

Returning Cardiac Rhythm Data to Patients: Opportunities and Challenges

Spurred by federal legislation, professional organizations, and patients themselves, patient access to data from electronic cardiac devices is increasingly transparent. Patients can collect data through consumer devices and access data traditionally shared only with health care providers. These data may improve screening, self-management, and shared decision-making for cardiac arrhythmias, but challenges remain, including patient comprehension, communication with providers, and sustained engagement. Ways to address these challenges include leveraging visualizations that support comprehension, involving patients in designing and developing patient-facing digital tools, and establishing clear practices and goals for data exchange with health care providers.

Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation

Background

Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients.

Methods

SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA₂DS₂ -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding.

Results

At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01–2.84), depression (OR 1.94, 95% CI: 1.28–2.95) and frailty (OR 2.55, 95% CI: 1.55–4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09–2.93) and frailty (OR 2.83, 95% CI 1.55–5.17) were significantly associated with clinically relevant bleeding.

Conclusions

 Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients.

Evaluation of Warfarin Use in Patients With Mental Health Conditions in a Rural Community Health Center System

Background: Mental health conditions (MHCs) may affect a patient's ability to comply with requirements necessary for safe warfarin use. Objective: To describe warfarin control, defined as time in therapeutic range (TTR), for patients with and without MHCs receiving care through a pharmacist-driven anticoagulation service within a rural community health center system. Methods: Retrospective cohort study of patients on warfarin between January 1, 2014, and December 31, 2017. The primary study endpoint was TTR. Secondary endpoints were the number of international normalized ratios (INRs) per 30 days, percentage of INRs within, above, and below target range, and warfarin-related adverse events. Results: A total of 79 patients were included-37 with and 42 without MHCs. Patients were mostly male (n = 47; 59.5%) and prescribed warfarin for atrial fibrillation (n = 45; 57.0%). There were no differences in overall TTR between those with (59.6%; interquartile range = 41.8-73.4) versus without (63.4%; interquartile range = 46.7-73.6) MHCs (P = .542). Secondary outcomes showed no differences in the frequency or percentage of INRs in, above, or below target range (all P > .05). However, there were about twice as many hemorrhagic complications in the group with MHCs (27% vs 11.9%; P = .149). Conclusion: Patients with MHCs experienced no difference in overall TTR as compared to patients without MHCs. However, there was a non-statistically significant reduction in TTR, which would be consistent with limited existing data and demonstrates possible reproducibility to a rural, underserved patient population. Future research is needed to validate these outcomes.

Incident atrial fibrillation and risk of psychoactive drug redemptions and psychiatric hospital contacts: a Danish Nationwide Register-based Follow-up Study

AIMS

To investigate whether incident atrial fibrillation or flutter (AF) diagnosis increases the risk of psychiatric outcomes compared with the general population.

METHODS AND RESULTS

First-time AF patients and population controls naive to psychiatric disease or filled prescriptions for psychotropic drugs were identified in Danish nationwide registries during 2005-14. AF patients were matched 1:2 with exposure density matching. Patients and controls were compared for 1-year cumulative incidences of depression, anxiety, and stress disorders, and for filled drug prescriptions for antidepressant, anxiolytic, selected antipsychotics, and hypnotics. Lastly, we examined 1-year cumulative incidences of a composite endpoint of the above-mentioned diagnoses or drug redemptions. We included 146 377 AF patients and 292 754 matched controls, 55% men and median age 74 (25-75% 65-82) years. AF patients had significantly higher cumulative incidences of composite endpoints. Furthermore, filled prescriptions for anxiolytics and hypnotics were significantly higher for AF patients compared with healthy population controls. The cumulative incidence of the composite endpoint was significantly higher in AF patients relative to controls 11.1% vs. 8.3%. For the composite endpoint, a significantly higher risk was apparent both in unadjusted (HR: 2.76, 95% CI: 2.67-2.85) and adjusted (HR: 2.51, 95% CI: 2.43-2.60) models for AF patients vs. controls in the first 3 months after study inclusion.

CONCLUSION

First-time AF patients were significantly more likely to have psychiatric outpatient or hospital contacts and to fill prescriptions for psychotropic drugs compared with healthy population controls. The risk was significantly elevated only during the first 3 months after AF diagnosis.

Psychological disturbances and their association with sleep disturbances in patients admitted for cardiovascular diseases

BACKGROUND

Depression and anxiety are common mental health problems that are strongly associated with sleep disturbances, according to community-based researches. However, this association has not been investigated among patients admitted for cardiovascular diseases (CVDs). We examined the prevalence of depression and anxiety in inpatients with various CVDs and their association with sleep disturbances.

MATERIALS AND METHODS

This cross-sectional study included 1294 patients hospitalized for CVDs in a Japanese university hospital were evaluated for their mental status using the Hospital Anxiety and Depression Scale (HADS), for sleep-disordered breathing (SDB) using pulse oximetry, and for sleep quality using the Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Patient characteristics were as below: mean age, 63.9±14.7 years; 25.7% female. Overall, 18.9% had depression (HADS-depression≥8) and 17.1% had anxiety (HADS-anxiety≥8). The presence of depression was associated with female sex, older age, higher plasma brain natriuretic peptide level, lower estimated glomerular filtration rate, and the prevalence of heart failure. Overall, 46.5% patients were categorized as having a poor sleep quality (PSQI>5), and 28.5% patients had SDB (3% oxygen desaturation index>15). Although depression and anxiety were not associated with SDB, they were independently associated with poor sleep quality (OR = 3.09, 95% CI 2.19-4.36; OR = 3.93, 95% CI 2.71-5.69, respectively).

CONCLUSIONS

Depression and anxiety were not uncommon in patients with CVDs. Poor sleep quality could be an important risk factor linked to psychological disturbances.

Assessment of Frailty and Occurrence of Anxiety and Depression in Elderly Patients with Atrial Fibrillation

Purpose

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its incidence increases with age. The elderly population is commonly affected by frailty syndrome (FS). FS syndrome along with anxiety and depressive symptoms are prevalent among elderly patients with AF. It is unclear whether depression contributes to AF or vice versa. The purpose of this study was to assess correlations between FS and the occurrence of anxiety and depression symptoms in a group of elderly patients with AF.

Patients and Methods

This cross-sectional study included 100 elderly patients (69 females, 31 males, mean age: 70.27 years) with AF. Standardized research instruments were used including the Tilburg Frailty Indicator (TFI) to assess FS, and two questionnaires to assess depression including the Geriatric Depression Scale (GDS), and the Hospital Anxiety Depression Scale (HADS).

Results

Mild FS was found in 38% and moderate FS in 29% of patients. Based on GDS scores, depression symptoms were found in 51% of patients’ sample. Based on HADS scores, 20% of patients were found to have anxiety symptoms, and 28% revealed depression symptoms. Single-factor analysis demonstrated a significant positive correlation between HADS anxiety symptoms (r=0.492), HADS depression symptoms (r=0.696), and GDS score (r=0.673) on the one hand, and overall TFI frailty score on the other. Multiple-factor analysis identified overall GDS score, education, and lack of bleeding as significant independent predictors of TFI scores (p<0.05).

Conclusion

FS is common in the population of elderly patients with AF. We found evidence for the association between symptoms of anxiety and depression and the incidence of FS in this group of patients. Due to the risk of consequences which may in part be irreversible, screening for FS is recommended.

Relationship between psychological factors and atrial fibrillation: A meta-analysis and systematic review

BACKGROUND

Although several studies have investigated the role of psychological factors in atrial fibrillation (AF), the results are still under debate. Therefore, we performed a meta-analysis to examine the relationship between psychological factors and the risk of incident AF.

METHODS

We systematically searched the PubMed and EMBASE databases from inception to December 2019 to identify eligible studies. The hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled by using a random-effects model.

RESULTS

A total of 11 cohort studies were included in this meta-analysis. There were 5, 2, 4, and 5 studies examining the association of anxiety, anger, depression, and psychological stress with AF, respectively. In the pooled analysis by a random-effects model, anxiety (HR = 1.10, 95%CI 0.97-1.24; P = .14), anger (HR = 1.08, 95%CI 0.95-1.23; P = .21), depression (HR = 1.15, 95%CI 0.98-1.35; P = .08), and work stress (HR = 1.14, 95%CI 0.98-1.34; P = .09) were not associated with the risk of AF. These results were not changed when we re-performed the analysis using a fixed-effects model.

CONCLUSIONS

Based on current evidence, no associations were observed for anger, anxiety, and work stress with the risk of AF.

The relevance of depressive symptoms for the outcome of patients receiving vitamin K antagonists: results from the thrombEVAL cohort study

AIMS

Although depressive symptoms are highly prevalent in patients receiving oral anticoagulation (OAC), the relevance of depression for the outcome of anticoagulated individuals is unknown.

METHODS AND RESULTS

We analysed data from the multicentre cohort study thrombEVAL (NCT01809015) investigating the efficacy of OAC with vitamin K antagonists. There was an independent study monitoring, and an independent review panel assessed the endpoints. Out of n = 1558 participants, information about depressive symptoms, as measured by the two-item screener of the patient health questionnaire (PHQ-2), was available in n = 1405 individuals. The mean follow-up period was 28.04 months, with a standard deviation of 11.52 months. In multivariable Cox regression analysis, baseline PHQ-2 sum score was a strong and robust predictor of clinically relevant bleeding [hazard ratio (HR) 1.13, 95% confidence interval 1.03-1.24; P = 0.011] and all-cause mortality (HR 1.18, 1.08-1.28; P = 0.001) independent of age, sex, high school graduation, partnership, clinical profile, intake of serotonin reuptake inhibitors, and quality of OAC therapy. Individuals with clinically significant depressive symptoms (PHQ-2 ≥ 3) had a 57% increased risk for clinically relevant bleeding (fully adjusted HR 1.57, 1.08-2.28) and 54% greater risk for death (fully adjusted HR 1.54, 1.09-2.17). There was no association of depressive symptoms with thromboembolic events. For hospitalization, individuals with depressive symptoms (PHQ-2 ≥ 3) did not experience an elevated risk in the fully adjusted model (HR 1.08, 0.86-1.35; P = 0.52).

CONCLUSION

Assessment of depression by the PHQ-2 provided independent long-term prognostic information beyond common biomedical risk factors. These findings highlight the need for targeting depressive symptoms in the management of patients receiving OAC therapy.

Physical, cognitive, and psychosocial conditions in relation to anticoagulation satisfaction among elderly adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

Successful anticoagulation is critical for stroke prevention in adults with atrial fibrillation (AF). Anticoagulation satisfaction is a key indicator of treatment success. While physical, cognitive, and psychosocial limitations are common in elderly AF patients, their associations with anticoagulation satisfaction are unknown.

OBJECTIVE

Examine whether anticoagulation satisfaction differs among AF patients with and without physical, cognitive, and psychosocial conditions.

METHODS

The study comprised AF patients greater than or equal to 65 years old who were prescribed an oral anticoagulant (warfarin 57%; direct oral anticoagulant [DOAC] 43%). Frailty, cognitive function, social support, depressive symptoms, vision, hearing, and anxiety were assessed using validated measures. Anticoagulation satisfaction was measured using the anticlot treatment scale.

RESULTS

Participants (n = 1037, 50% female) were on average 76 years old. The following conditions were prevalent: frailty (14%), cognitive impairment (42%), social isolation (13%), vision impairment (35%), hearing impairment (36%), depression (29%), and anxiety (24%). Average anticlot treatment burden scale was 55 out of 60 (lower burden scales indicating higher perceived burden). Patients with high perceived burden were older, more likely to be female, and receive warfarin. After adjusting for confounders, visual impairment (adjusted odds ratio [95% confidence interval]: 1.7 [1.2-2.4]), depressive symptoms (2.4 [1.6-3.7]), and anxiety (1.8 [1.2-2.7]) were significantly associated with high perceived burden. Different conditions were associated with high perceived burden in warfarin vs DOAC users.

CONCLUSION

Physical, cognitive, and psychosocial limitations are prevalent and associated with high perceived anticoagulation burden among elderly AF adults. These conditions merit consideration in anticoagulation prescribing.