Anxiety and depression disorders in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension

'Fear, uncertain, tired…...' psychological distress among pulmonary hypertension patients: a qualitative interview study

BACKGROUND

Patient-centered health care for patients with pulmonary hypertension (PH) is important and requires an understanding of patient experiences. However, there is a lack of approaches to examine what's the effects and how the disease impact patients' psychological well-beings.

METHODS

We conducted qualitative interviews with PH patient representatives to understand patient psychological experiences and inform patient-centered research and care. Participants were chosen from a tertiary hospital located in northwest China. 20 patients with PH who be treated at the hospital (13 participants were women, aged 18-74 years) were strategically selected and individually interviewed. We used qualitative analysis to identify themes relating to existential psychological distress that would clarify the nature of such concerns.

RESULTS

We found that patients experience tremendous psychological distress throughout the treatment process. Four categories that describe patients' psychological experiences emerged: burden of PH treatment, fear and uncertainty about the disease, frustration in social and family role, and lack of recognition of the condition.

CONCLUSIONS

Existential concerns are salient in PH and involve the experience of loss and disruptions to the sense of self and relationships. Healthcare practitioners must work more in collaboration to detect patients' need for support and to develop the patient's own skills to manage daily life. The PH teams should tailor interventions to provide emotional, informational and instrumental support and guidance to patients.

Management of Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a rare pulmonary vascular disease characterized by progressive pulmonary arterial remodeling, increased pulmonary vascular resistance, right ventricular dysfunction, and reduced survival. Effective therapies have been developed that target three pathobiologic pathways in PAH: nitric oxide, endothelin-1, and prostacyclin. Approved therapies for PAH include phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogs, and prostacyclin receptor agonists. Management of PAH in the modern era incorporates multidimensional risk assessment to guide the use of these medications. For patients with PAH and without significant comorbidities, current guidelines recommend two oral medications (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) for low- and intermediate-risk patients, with triple therapy including a parenteral prostacyclin to be considered in those at high or intermediate-high risk. Combination therapy may be poorly tolerated and less effective in patients with PAH and cardiopulmonary comorbidities. Thus, a single-agent approach with individualized decisions to add-on other PAH therapies is recommended in older patients and those with significant comorbid conditions. Management of PAH is best performed in multidisciplinary teams located in experienced centers. Other core pillars of PAH management include supportive and adjunctive treatments including oxygen, diuretics, rehabilitation, and anticoagulation in certain patients. Patients with PAH who progress despite optimal treatment or who are refractory to best medical care should be referred for lung transplantation, if eligible. Despite considerable progress, PAH is often fatal and new therapies that reverse the disease and improve outcomes are desperately needed.

Impact of psychiatric disorders on the hemodynamic and quality of life outcome of balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension: a retrospective study

BACKGROUND

Balloon pulmonary angioplasty (BPA) has beneficial effects on pulmonary hemodynamics, exercise capacity, and quality of life (QOL) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Recently, emerging evidence suggests a relationship between CTEPH and psychiatric disorders (PD). However, data on the clinical efficacy of BPA in CTEPH patients with PD are lacking.

METHODS

We retrospectively analyzed 75 patients with inoperable/residual CTEPH who underwent BPA and right-sided heart catheterization before the initial BPA and within 1 year after the last procedure. QOL was evaluated using the European Quality of Life Five Dimension (EQ-5D) scale in 27 patients before and after BPA sessions. Baseline and post-procedural hemodynamic, functional, and QOL parameters were compared between the patients with and without PD.

RESULTS

Among the 75 participants, 22 (29.3%) patients were categorized in the PD group. Although PD group had a similar mean pulmonary artery pressure level compared with non-PD group (40 ± 7 vs. 41 ± 9 mmHg, p = 0.477), they tended to have unfavorable QOL status (0.63 ± 0.22 vs. 0.77 ± 0.19, p = 0.102). BPA significantly improved pulmonary hemodynamics, laboratory parameters and exercise tolerance in both groups. BPA also significantly improved EQ-5D scores in the non-PD group (from 0.77 ± 0.19 to 0.88 ± 0.13, p < 0.001), but the scores remained unchanged in the PD group (from 0.63 ± 0.22 to 0.67 ± 0.22, p = 0.770). During the long-term period [1,848 (1,055-2,565) days], both groups experienced similar mortality rates (PD 4.6% vs. non-PD 5.7%, p = 1.000).

CONCLUSIONS

BPA improved hemodynamic and functional parameters irrespective of PD, but its effect on QOL was limited in patients with PD.

Development of a complex exercise rehabilitation intervention for people with pulmonary hypertension: the supervised pulmonary hypertension exercise rehabilitation (SPHERe) trial

BACKGROUND

People with pulmonary hypertension (PH) are not routinely referred for exercise rehabilitation despite the potential for reducing breathlessness and improving quality of life. We describe the development of a supervised pulmonary hypertension exercise rehabilitation (SPHERe) programme for people with PH.

METHODS

Development was completed in three phases: (1) systematic review, (2) stakeholder engagement with consensus from patients and experts and (3) prepilot intervention acceptability testing. We completed systematic reviews to identify international cardiopulmonary rehabilitation guidance and trials of exercise-based interventions for people with PH. Evidence from systematic reviews and stakeholder consensus shaped the SPHERe intervention, including addition of individual behavioural support sessions to promote exercise adherence. The draft SPHERe intervention was ratified through discussions with multidisciplinary professionals and people living with PH. We acceptability tested the centre-based intervention with eight participants in a prepilot development phase which identified a number of condition-specific issues relating to safety and fear avoidance of activity. Comprehensive intervention practitioner training manuals were produced to ensure standardised delivery. Participant workbooks were developed and piloted. Trial recruitment began in January 2020 but was subsequently suspended in March 2020 further to COVID-19 pandemic 'lockdowns'. In response to the pandemic, we undertook further development work to redesign the intervention to be suitable for exclusively home-based online delivery. Recruitment to the revised protocol began in June 2021.

DISCUSSION

The final SPHERe intervention incorporated weekly home-based online group exercise and behavioural support 'coaching' sessions supervised by trained practitioners, with a personalised home exercise plan and the optional loan of a stationary exercise bike. The intervention was fully manualised with clear pathways for assessment and individualised exercise prescription. The clinical and cost-effectiveness of the SPHERe online rehabilitation intervention is currently being tested in a UK multicentre randomised controlled trial.

TRIAL REGISTRATION NUMBER

ISCRTN10608766.

Mental Health and Quality of Life in Pulmonary Embolism: A Literature Review

Pulmonary embolismis an acute disease with chronic complications and, although it is not considered a chronic disease, it requires close follow-up. The scope of the present literature review is to decode the existing data concerning quality of life and the mental health impact of PE during the acute and long-term phases of the disease. The majority of studies reported impaired quality of life in patients with PE when compared to population norms, both in the acute phase and >3 months after PE. Quality of life improves over time, irrespectively of the measurement used. Fear of recurrences, elderly, stroke, obesity, cancer and cardiovascular comorbidities are independently associated with worse QoL at follow-up. Although disease specific instruments exist (e.g., the Pulmonary Embolism Quality of Life questionnaire), further research is required in order to develop questionnaires that may fulfil international guideline requirements. The fear of recurrences and the development of chronic symptoms, such as dyspnea or functional limitations, may further impair the mental health burden of PE patients. Mental health may be implicated by post-traumatic stress disorder, anxiety and depressive symptoms present following the acute event. Anxiety may persist for 2 years following diagnosis and may be exaggerated by persistent dyspnea and functional limitations. Younger patients are at higher risk of anxiety and trauma symptoms while elderly patients and patients with previous cardiopulmonary disease, cancer, obesity or persistent symptoms exhibit more frequently impaired QoL. The optimal strategy for the assessment of mental health in this patient pool is not well defined in the literature. Despite mental burden being common following a PE event, current guidelines have not incorporated the assessment or management of mental health issues. Further studies are warranted to longitudinally assess the psychological burden and elucidate the optimal follow-up approach.

Allgemeine Therapie der pulmonalarteriellen Hypertonie nach den neuen Leitlinien

In den neuen Leitlinien (LL) für pulmonalarterielle Hypertonie (PAH) sind die allgemeinen Maßnahmen ein integraler Bestandteil der Behandlung der Patienten. Auch die systemischen Auswirkungen der pulmonalen Hypertonie und Rechtsherzinsuffizienz sollten angemessen berücksichtigt und behandelt werden. Im folgenden Artikel werden die in den LL genannten Maßnahmen unter Berücksichtigung des bestehenden Empfehlungsgrads und der Evidenzen beschrieben. Leider sind die meisten Allgemeinmaßnahmen, wie die Gabe von Diuretika, Sauerstoff, psychosozialer Support und Impfungen, nicht oder unzureichend in randomisierten, kontrollierten Studien untersucht worden. So haben sie zwar einen hohen I-Empfehlungsgrad, aber einen niedrigen Evidenzgrad C. Nur bei dem spezialisierten körperlichen Training liegen bislang insgesamt 7 randomisierte, kontrollierte Studien und 5 Metaanalysen vor, die eine Verbesserung der Sauerstoffaufnahme, körperlichen Belastbarkeit, der Beschwerden (WHO-Funktionsklasse), Lebensqualität und Hämodynamik nachgewiesen haben (daher neu IA-Empfehlung). Auch weitere Maßnahmen wie die Antikoagulation, Eisensubstitution und andere werden im Folgenden besprochen.

Depression and anxiety among people with hypertension on follow-up in Eastern Ethiopia: A multi-center cross-sectional study

Background

People with hypertension have a high risk of developing mental disorders, such as depression and/or anxiety. However, there is a paucity of data regarding comorbid depression and anxiety symptoms among people with hypertension in study settings.

Objective

The study determined the prevalence and associated factors of depression, and anxiety symptoms among people with hypertension on follow-up at public hospitals, in Eastern Ethiopia.

Materials and methods

A cross-sectional study was carried out among 471 people with hypertension who were randomly chosen from four public hospitals in Harar town and the Dire Dawa Administration. The data were collected by interviewer-administered structured questionnaires. A validated nine-item Patient Health Questionnaire and Generalized Anxiety Disorder scales were used to assess depression and anxiety symptoms, respectively. A logistic regression model was used to identify the association among depression, anxiety, and their predictors. An adjusted odds ratio and a 95% confidence interval were used to report the association. The statistical significance was set at a p-value of < 0.05.

Results

Depression and anxiety symptoms were present in 27.2 and 32.7% of people with hypertension, respectively. Being women (AOR = 1.74, 1.09-2.78), having no formal education (AOR = 2.19, 1.19-4.81), presence of other medical illnesses (AOR = 2.23, 1.39-3.56), having a family history of depression (AOR = 2.01, 1.25-3.19), and poor social support (AOR = 2.80, 1.60-5.22) were statistically associated with depressive symptoms, whereas being women (AOR = 1.54, 1.01-2.35), widowed and divorced (AOR = 2.22, 1.41-3.52), presence of other medical illnesses (AOR = 1.64, 1.06-2.53), and poor social support (AOR = 3.54, 2.09-6.01) were statistically associated with anxiety symptoms.

Conclusion

More than a quarter of people with hypertension reported symptoms of depression and anxiety. Findings demonstrated that being a woman, having an additional medical illness and having poor social support were statistically associated with depressive and anxiety symptoms. Regular screening, early detection, and offering the proper intervention should be on top priorities for healthcare professionals.

Coping styles associated with depression, health anxiety and health-related quality of life in pulmonary hypertension: cross-sectional analysis

OBJECTIVES

Pulmonary hypertension (PH) is a life-shortening disease associated with early mortality and high morbidity. With advancements in medical treatment, people are living longer with the disease, and research is now needed to explore variables that help to enhance patient-reported outcomes. This study investigated the coping strategies of individuals with PH and examined the relationship between coping, depression, health anxiety and health-related quality of life (HRQoL).

DESIGN

A cross-sectional survey design was used.

PARTICIPANTS

Participants (n=121) were recruited from membership of Pulmonary Hypertension Association (PHA) UK.

OUTCOME MEASURES

Participants completed a series of questionnaires assessing depression (Patient Health Questionnaire-9), health anxiety (Short Health Anxiety Inventory), HRQoL (emPHasis-10) and coping (Brief COPE). A principal component analysis was used to identify participants' coping profile. A series of correlational, linear and moderated multiple regression analyses were performed to examine the relationship between coping and health-related outcomes.

RESULTS

Overall, 43% participants met criteria for potential clinical depression. Depression and health anxiety were strongly associated with HRQoL, explaining 37% and 30% of variance respectively (p<0.001). A principal component analysis identified a four-component model of coping. Dimensions were named based on construct items: 'cognitive and affirmation coping' (seven items), 'passive coping' (four items), 'external coping' (seven items) and 'substance use coping' (two items). Cognitive and affirmation and external coping moderated the relationship between depression and HRQoL, with high use of these coping strategies reducing the impact of depression on HRQoL. External coping also moderated the effect of health anxiety on HRQoL.

CONCLUSIONS

The results uniquely highlight the importance of coping styles and psychological distress in predicting HRQoL in PH. Our findings indicate the importance to assess for psychological distress in this population and suggest the need to offer psychological interventions that take into account coping resources and strategies.

Prevalence, Risk Factors and Intervention for Depression and Anxiety in Pulmonary Hypertension: A Systematic Review and Meta-analysis

Background

Current guidelines recommend psychological support for patients with pulmonary hypertension suffering from psychological adversity. However, little is known about the prevalence and risk factors of depression and anxiety in patients with pulmonary hypertension (PH).

Methods

Medline and Embase were searched from inception to 6 May 2021. Meta-analysis of proportions using the generalized linear mixed model was conducted to analyze the pooled prevalence rates of depression and anxiety in PH patients. Risk factors for depression and anxiety in PH patients were evaluated using meta regression.

Results

A total of 24 studies involving 2,161 PH patients were included. The pooled prevalence of depression in PH was 28.0% (95% CI: 20.5–36.8) and pooled prevalence of anxiety was 37.1% (95% CI: 28.7–46.4). There was a significantly higher prevalence of anxiety (p = 0.0013) amongst PH patients in Asia (61.1%) compared to Europe (40.3%) and North America (22.9%). In terms of risk factors, congenital heart disease-related pulmonary arterial hypertension (PAH-CHD) were significantly associated with both depression (OR: 1.68, 95% CI: 1.27–2.23, p = 0.024) and anxiety (OR: 1.63, 95% CI: 1.45–1.83, p = 0.002). On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH, OR: 1.18, 95% CI: 1.10–1.26, p = 0.004) was significantly associated with depression, whereas worse pulmonary vascular resistance (β: 0.30, 95% CI: 0.09–0.52, p = 0.005) and cardiac index (β: −0.96, 95% CI: −1.58 to −0.35, p = 0.002) were significantly correlated with anxiety.

Conclusion

The prevalence of anxiety and depression in PH patients is alarmingly high, with an increased prevalence of anxiety in Asia compared to Europe or North America. Psychological support is warranted for patients with PH, particularly those with underlying congenital heart disease, CTEPH, and severe disease.

Systematic Review Registration

CRD42021251733.

Metacognitions in Patients With Frequent Mental Disorders After Diagnosis of Pulmonary Arterial Hypertension

BACKGROUND

The prevalence of mental disorders, particularly adjustment disorder (AD), major depressive disorder (MDD) and panic disorder (PD) is increased in patients with pulmonary arterial hypertension (PAH). However, it is unclear which pathogenic mechanisms determine their development and could therefore be targeted in prevention or therapeutic interventions. Here, we assessed metacognitions in a sample of PAH patients with and without MDD and PD. Moreover, we reconstructed the course of mental illnesses following the PAH diagnosis.

METHODS

Two hundred seventeen PAH patients were included in this cross-sectional study. The prevalence of AD was assessed retrospectively using DSM-V criteria. Current mental disorders were assessed using the structured clinical interview for DSM-V. Additionally, metacognitive beliefs and processes were assessed using established questionnaires (MCQ-30, AnTI).

RESULTS

Patients with an AD consecutive to the PAH diagnosis more frequently developed MDD (37.5 vs. 13.9%, p < 0.001) and PD (26.3 vs. 8.8%, p = 0.001) later on compared to PAH patients without a former AD. Moreover, patients with current MDD/PD displayed more dysfunctional metacognitions than those without current MDD/PD (p < 0.001). Patients with current MDD/PD in the context of former AD had more dysfunctional metacognitive worries and beliefs compared to patients with current MDD/PD without former AD (p = 0.009).

CONCLUSION

Our results suggest that in the context of PAH, dysfunctional metacognitions are associated with MDD and PD. Therefore, a metacognitive approach to treat and prevent those mental illnesses seems promising and should be investigated in future studies.

Prevalence of Mental Disorders in Patients With Chronic Thromboembolic Pulmonary Hypertension

OBJECTIVE

Pulmonary hypertension (PH) is a chronic and progressive pulmonary vascular disease resulting in symptoms such as shortness of breath and fatigue and leading to death from right heart failure if not adequately treated. Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of PH characterized by obstruction or occlusion of pulmonary arteries by post-embolic fibrotic material. To date, few studies examined symptoms of depression and anxiety in patients with CTEPH, showing depression levels as high as 37.5%. However, none of the former studies used structured expert interviews.

METHODS

Mental disorders were diagnosed using the Structured Clinical Interview for DSM-5 (SCID). The prevalence of mental disorders in patients with CTEPH were compared to the prevalence in patients with pulmonary arterial hypertension (PAH) and the general German population. Quality of life (QoL) was measured with World Health Organization (WHO) Quality of Life questionnaire (short form). Factors associated with QoL were analyzed with linear regression and the diagnostic value of the Hospital Anxiety and Depression Scale (HADS) was evaluated using receiver operating characteristics (ROC) curve analysis.

RESULTS

Hundred and seven patients with CTEPH were included. Almost one-third of the patients (31.8%) had current psychological disorders. Panic disorder (8.4%), specific phobia (8.4%), and major depressive disorder (6.5%) were the most prevalent mental illnesses. The prevalence of panic disorders was higher in CTEPH compared to the German population while major depressive disorder was fewer in CTEPH compared to PAH. The presence of mental disorders had a major impact on QoL. Hospital Anxiety and Depression Scale discriminated depression and panic disorder reliably.

CONCLUSION

Mental disorders are common in patients with CTEPH and associated with an impaired QoL. The HADS may be a useful screening tool for panic and depression disorders in patients with CTEPH. Further research on therapeutic strategies targeting mental disorders in patients with CTEPH is needed.

Self-help cognitive behavioural therapy for anxiety in pulmonary hypertension: pilot randomised controlled trial

Objective

People with pulmonary hypertension (PH) are at an increased risk of experiencing anxiety disorders. This study developed and tested the acceptability, feasibility and preliminary effectiveness of a cognitive behavioural self-help intervention for anxiety in adults with PH using a pilot randomised control trial design.

Methods

Individuals with PH recruited from pulmonary hypertension associations were randomised to either receive a newly developed self-help intervention (n=37) or a wait-list condition (n=40). Acceptability was explored using mixed-methods questionnaires. A 2×3 repeated-measures analysis of variance was used to explore anxiety (GAD-7), depression (PHQ-9), health-related quality of life (emPHAsis-10), dyspnoea (D-12), self-mastery (Self-Mastery Scale) and mood-related cognitions and behaviours (CBP-Q) at baseline, post-intervention and 1-month follow up. A mediation analysis was performed to examine potential mechanisms of change.

Results

Dropout was low at 15.6%. All participants would recommend the intervention to another person with PH and felt it had helped with their anxiety. Participants in the intervention group reported a reduction in anxiety, depression and cognitive and behavioural processes linked with mood disorders, compared to the control group. Change in unhelpful cognitions and behaviours mediated the relationship between intervention condition and change in anxiety and depression.

Discussion

The intervention was found to be acceptable, feasible and safe. Anxiety at baseline was higher than previously observed, which could be associated with the additional burden caused by COVID-19 as the intervention was trialled during the pandemic. Findings add to the growing evidence supporting the use of psychological therapies, including cognitive behavioural therapy, in this clinical group.

Relationship between Family Function, Anxiety, and Quality of Life for Older Adults with Hypertension in Low-Income Communities

BACKGROUND

Effective functional family was beneficial for older adults' health, which may affect the quality of life (QoL) in hypertension patients. This study aimed to clarify the association between family function, anxiety, and QoL for older adults with hypertension in low-income communities.

METHODS

A questionnaire survey was conducted on 363 older adults with hypertension in low-income communities in Wuhan from September 2019 to November 2019. The relationships among the variables were examined by Pearson's correlation analysis. Predictor effects were tested using hierarchical multiple regressions, controlling for demographic characteristics. The structural equation model (SEM) was used to test the mediation effects of anxiety on the pathway from family function to QoL.

RESULTS

Family function was negatively correlated with the self-rating anxiety scale (SAS) score and positively correlated with the mental component score (MCS), but had no influence on the physical component score (PCS). Both PCS and MCS were negatively correlated with SAS. Anxiety was the negative predictor of MCS and PCS. Family function was the positive predictor of MCS, but had no influence on PCS. The path model indicated that anxiety significantly mediated the link between family function and QoL (R 2 = 32.8%), but only partially.

CONCLUSION

A significant correlation between anxiety, family function, and QoL was found. Anxiety had a partial mediating effect on the relationship between family function and QoL. Further research should focus on increasing the level of family function and reducing the perceived anxiety of older adults with hypertension to improve their QoL level.

Fear of COVID-19, Anxiety and Depression in Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension during the Pandemic

The COVID-19 pandemic has affected the physical and mental health of people around the world. This may be particularly true for patients with life-threatening diseases. We analyzed the level of fear of COVID-19 (FCV-19S), the prevalence of anxiety (HADS-A) and depression (HADS-D) in pulmonary arterial and chronic thromboembolic pulmonary hypertension (PAH and CTEPH) patients during the COVID-19 pandemic. In this multicenter prospective study, 223 patients (63% females, 66% PAH) with age range 18-90 years were included. The fear of COVID-19 was high, at a mean level of 18.9 ± 7.4 points. Anxiety (HADS-A ≥ 8 points) was diagnosed in 32% of all patients, depression (HADS-D ≥ 8 points) in 21%, and anxiety or depression in 38%. FCV-19S was higher in woman and in elderly people (p = 0.02; p = 0.02, respectively). In the multivariate analysis, FCV-19S higher than the median increased the odds ratio of anxiety, but not of depression (R 6.4 (95%CI 2.0-20.0), p = 0.002; OR 1.9 (0.9-3.9), p = 0.06, respectively). History of COVID-19 increased risk of both HADS-A and HADS-D. Patients with PAH and CTEPH, especially woman over 65 years and those who had been infected with COVID-19, may need additional psychological support due to fear of COVID-19, anxiety or depression.

Mediating effect of social support on the relationship between illness concealment and depression symptoms in patients with pulmonary arterial hypertension

BACKGROUND

Depression symptoms are common in patients with pulmonary arterial hypertension (PAH). Social support may mediate the effect of illness concealment on depression symptoms.

OBJECTIVE

To examine the relationships between illness concealment, dimensions of social support, and depression symptoms and the mediating effect of the dimensions of social support on depression symptoms in PAH patients.

METHODS

A cross-sectional design and convenience sampling were applied. Data were collected with three questionnaires and analyzed with hierarchical regression and the PROCESS macro.

RESULTS

Ninety-seven participants were enrolled (mean age 50 ± 14 years). In total, 8% had a Patient Health Questionnaire (PHQ)-9 score ≥15. Hierarchical regression analysis showed that education level (β = 0.28, p < 0.05), illness concealment (β = 0.21, p < 0.05), and emotional support (β = 0.29, p < 0.01) were determinants of depression symptoms. Emotional support mediated the relationship between illness concealment and depression symptoms.

CONCLUSIONS

Emotional support can help patients reduce the effect of illness concealment on depression symptoms.

Establishing expert consensus for the optimal approach to holistic risk-management in pulmonary arterial hypertension: a Delphi process and narrative review

Background: Pulmonary arterial hypertension (PAH) is associated with significant morbidity and reduced life expectancy. Various medical therapies, together with non-medical therapies such as exercise training, have been shown to improve outcomes for patients. We performed a Delphi consensus process to establish optimal approaches to optimizing patient care.Methods: A steering group of PAH experts formulated 38 statements grouped into 6 themes: burden of PAH, risk-stratification, the role of clinical phenotyping in the management of PAH, assessing clinical response to treatment, maximizing the medical treatment pathway and the role of other management options. An online survey was sent to PAH health-care professionals throughout the UK to assess consensus with these statements. Consensus was defined as high if ≥70% and very high if ≥90% of the respondents agreed with a statement. A narrative review for each theme was then performedResults: Consensus was very high in 27 (71%) statements, high in 7 (18%) statements and was not achieved in 4 (11%) statements.Conclusions: Based on the consensus scores, the steering group derived 13 recommendations which, if implemented, should result in improved holistic care of patients with PAH.

Depression, anxiety and psychological distress in patients with pulmonary hypertension: a mixed-methods study

Introduction

Pulmonary hypertension (PH) is a chronic and progressive disease. While prognoses have improved, PH patients still experience side effects and activity restrictions. Accordingly, the key questions asked by this study are ‘How many PH patients have depression/anxiety symptoms?’ and ‘Is there a difference in the symptoms and distress factors between pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) patients, and how are they experiencing distress?’

Methods

A mixed-methods study was conducted to collect and analyse quantitative and qualitative data. We administered questionnaires (Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder-7) and then conducted interviews with participants who reported moderate to severe depressive symptoms (PHQ-9 ≥10).

Results

Seventy-four participants were enrolled in the study, 25 with idiopathic PAH and 49 with CTEPH. Their average age was 55.2 years (PAH 42.7 years, CTEPH 61.5 years). Overall, 44.6% of participants had mild or more severe depressive symptoms (PHQ-9 ≥5) and 17.6% had moderate or more severe depressive symptoms (PHQ-9 ≥10). PAH patients had particularly high depressive symptoms (PHQ-9 ≥5: PAH 64.0%, CTEPH 34.7%; PHQ-9 ≥10: PAH 24%, CTEPH 14.3%). We extracted four common themes from the qualitative interview data on participants’ experience of psychological distress: ‘Loss of myself,’ ‘Isolation from my surroundings,’ ‘Hassle associated with oxygen therapy,’ and ‘Fear of illness progression/deterioration.’ One theme— ‘Suffering from side effects’—was extracted only for PAH patients, while another—‘Rumination on illness due to breathlessness’—was extracted only for CTEPH patients.

Discussion and conclusion

The study found that PH patients are prone to depression. The identification of factors and themes that influence the psychological distress of PH patients is important information that can be used to improve the support for the physical and mental health of these patients. Interventions for these distress may contribute to improving the mental status of PH patients.

Integrated Review of Psychosocial and Behavioral Health Assessments and Interventions in Pulmonary Hypertension

BACKGROUND

The medical management of patients with pulmonary hypertension (PH) has advanced, with few evidence-based recommendations about psychosocial and behavioral health interventions. There is also a lack of comprehensive understanding of PH psychosocial and behavioral health needs. Some psychosocial and behavioral health interventions have been tested; however, there is a gap in the systematic evaluation of nonpharmacological complementary approaches to augment PH management when addressing psychosocial and behavioral health needs.

OBJECTIVES

The objectives are to explore psychosocial and behavioral health needs and describe psychosocial and behavioral health interventions for patients with PH.

METHODS

We conducted an integrative systematic review of publications between January 1, 2010, and January 31, 2020, obtained from electronic databases: EMBASE, PubMed, Cumulative Index of Nursing and Allied Health Literature, Cochrane, PsycINFO, and Web of Science. The literature searches focused on empirical literature reporting psychosocial needs and psychosocial and behavioral health interventions for adult PH patients. We included peer-reviewed studies published in English. Search terms used in the study were: "hypertension," "pulmonary hypertension," "psychosocial," "depression," "anxiety," "quality of life," "behavioral health," "self-management," "psychosocial intervention," and "psychological distress." Excluded were opinion and discussion publications, reviews, non-PH populations, and pediatric articles. We used the constant comparison method to guide the synthesis of reports applying the Joanna Briggs quality assessment guidelines.

RESULTS

A total of 44 articles meeting the criteria were included for final consideration. We conducted an integrative systematic review of 27 quantitative studies, narrative synthesis of 10 qualitative studies, and 7 psychosocial and behavioral health intervention studies. PH patients reported psychosocial needs, such as financial, social connections, sexual health, and palliative care needs, as well as levels of psychological distress symptoms. The results from both quantitative and qualitative studies revealed similar overarching psychosocial and behavioral health conceptual categories. Patients described their ongoing needs in PH management by relying on their psychosocial and behavioral health capabilities to adjust to changes at each stage of disease progression. Patients had high levels of psychosocial and behavioral health needs requiring interventions beyond medical treatment.

DISCUSSION

Pilot studies testing psychosocial and behavioral health interventions reported improvement in levels of anxiety and depression and health-related quality of life. Larger scale studies are needed to advance this knowledge. Psychosocial and behavioral health interventions with cognitive-guided foci have the potential of meeting these unmet needs.

Anxiety and Depression in Patients With Pulmonary Arterial Hypertension in Northwest China: A Cross-Sectional Study

OBJECTIVE

Pulmonary arterial hypertension (PAH) is a rare life-threatening and incurable disease. Although symptoms of depression and anxiety have been widely reported, these traits and associated factors have not been systematically assessed in Northwest China.

METHODS

A cross-sectional study was conducted between March 2020 and February 2021. 106 PAH patients in Northwest China were evaluated by Self-rating Anxiety Scale (SAS) and the Self Rating Depression Scale (SDS) questionnaire.

RESULTS

Overall, the included patients had particularly high depressive symptoms (70.09%), while anxiety among them was 17.55%. Multivariate linear regression revealed that patients with lower age (p = 0.04), female (p < 0.01), smoking (p < 0.01), WHO functional class III/IV (p < 0.01), higher mean pulmonary hypertension (p < 0.01), lower left ventricular ejection fraction (p < 0.01), and lower 6-min walking distance (p < 0.01) had higher anxiety scores. Patients who lived in rural areas (p = 0.01), smoking (p < 0.01), WHO functional class III/IV (p < 0.01), higher mean pulmonary hypertension (p = 0.04), lower 6-min walking distance (p < 0.01), and college degree or above had higher depression scores (p = 0.02).

CONCLUSIONS

Mental health problems such as depression are common among patients with PAH in Northwest China. Patients' characteristics such as smoking status, WHO functional class, and 6-min walking distance were related to anxiety and depression scores. Thus, early detection of mental health problems such as depression and anxiety should be detected in PAH patients. Meanwhile, interventions against these problems should be used to improve such patients' mental status.

Impact of SARS-CoV-2-Pandemic on Mental Disorders and Quality of Life in Patients With Pulmonary Arterial Hypertension

Background/Objective: Covid-19 pandemic may affect mental health and quality of life (QoL) in patients with pulmonary arterial hypertension (PAH). We assessed changes in anxiety and depression, quality of life (QoL) and self-described impact of Covid-19 in patients with PAH during the Covid-19 pandemic. Methods: This study included 152 patients with PAH from two German referral centers. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS-A and HADS-D) at two different timepoints before and during the Covid-19 pandemic with a median of 232 days between baseline and follow-up. QoL was assessed using EQ-5D and emPHasis-10. Perceived impact of Covid-19 and related regulations and measures were assessed using a set of specific questions and statements. Results: More than two thirds of patients had an unsuspicious HADS-A and HADS-D. Median scores did not differ from baseline for both HADS-A and HADS-D (p = 0.202; p = 0.621). Overall, no significant changes in HADS-A or HADS-D categories from baseline to follow up were observed (p = 0.07; p = 0.13). QoL did not change between baseline and follow-up. The Covid-19 pandemic had little impact on access to medical care and established PAH therapy. Patients were in agreement with governmental measures and regulations and felt sufficiently safe. Conclusion: First waves of Covid-19 pandemic had little impact on anxiety, depression and QoL in patient with PAH. Established PAH therapy and access to medical care were not affected. Further studies on the impact of prolonged duration of the ongoing Covid-19 pandemic are needed.

Prevalence of Mental Disorders and Impact on Quality of Life in Patients With Pulmonary Arterial Hypertension

Objective: Mental health may affect the quality of life (QoL) in patients with pulmonary arterial hypertension (PAH). However, mental disorders have not been systematically assessed in these patients. We examined the prevalence of mental disorders using structured interviews and determined their impact on QoL in patients with PAH. Methods: This study included 217 patients with PAH from two German referral centers. Psychiatric disorders were assessed using the structured clinical interview for DSM-V. QoL was assessed using the WHO Quality of Life questionnaire (short form). The diagnostic value of the Hospital Anxiety and Depression Scale was evaluated by receiver operating characteristic curve analysis. Results: More than one third of the patients had psychological disorders with current or past adjustment disorder (38.2%), current major depressive disorder (23.0%), and panic disorder (15.2%) being the most prevalent mental illnesses. About half of the patients with a history of adjustment disorder developed at least one other mental illness. The presence of mental disorders had a profound impact on QoL. The Hospital Anxiety and Depression Scale ruled out panic disorder and depression disorder with negative predictive values of almost 90%. Conclusion: Mental disorders, in particular adjustment disorder, major depression, and panic disorder, are common in patients with PAH and contribute to impaired QoL in these patients. The Hospital Anxiety and Depression Scale may be used as a screening tool for the most common mental health disorders. Future studies need to address interventional strategies targeting mental disorders in patients with PAH.

Physical Activity and Mental Health of Patients with Pulmonary Hypertension during the COVID-19 Pandemic

The aim of the study was to analyze the effect of personal restrictions on physical activity, mental health, stress experience, resilience, and sleep quality in patients with pulmonary hypertension (PH) during the “lockdown” period of the COVID-19 pandemic. In total, 112 PH patients and 52 age-matched healthy control subjects completed a questionnaire on the topics of physical activity, mental health, resilience, and sleep quality. PH patients had significantly lower physical activity, mental health, and sleep quality compared to age-matched healthy controls. Physical activity positively correlated with mental health and sleep quality in the PH group. Mental wellbeing and life satisfaction could be predicted by total physical activity, sleep, stress level, and resilience. PH patients appeared as an especially vulnerable group, demanding interventions to promote an active lifestyle and protect mental health in these patients. This could be helpful in counseling on how to carry out physical activity while maintaining infection control.

Adults' experiences of living with pulmonary hypertension: a thematic synthesis of qualitative studies

OBJECTIVES

Pulmonary hypertension is a life-shortening disease that has a considerable impact on quality of life. Improving our understanding of how individuals are affected and cope with the disease will help to improve services and outcomes. This review synthesises the published qualitative research that has listened to adults discuss their experiences of living with the disease.

DESIGN

A comprehensive systematic search of four databases was conducted in May 2020: Web of Science, PubMed, PsycINFO and Cochrane Library. Suitable studies were evaluated using the Critical Appraisal Skills programme. Findings from the studies were extracted and subjected to a thematic synthesis.

RESULTS

Nineteen articles were identified reflecting the experiences of over 1900 individuals impacted by pulmonary hypertension from Europe, North and South America and Asia. Ten studies did not report participant's WHO functional class of pulmonary hypertension, which resulted in comparing experiences between different severity difficult. All studies met the majority of the quality assessment items. Six descriptive themes emerged discussing participant's experiences of diagnosis, treatment, prognosis, healthcare professionals, impact and coping with pulmonary hypertension. Four higher order analytical themes were developed from the descriptive themes, reflecting: (i) uncertainties and anxiety that participants encountered related to pulmonary hypertension; (ii) lack of recognition of the impact of the condition; (iii) frustration at the paucity of awareness of pulmonary hypertension in society and healthcare settings and (iv) participant's accounts of transitioning through different stages of living with the disease.

CONCLUSIONS

These findings form the first synthesis of experiences of life in individuals impacted by pulmonary hypertension and illustrate the multifaceted impact of the condition. The voices of numerous groups are missing from the literature highlighting the need for additional research. The results have implications for clinical practice emphasising the role of educational and psychological therapies to support those with the disease.

Depression and Anxiety in patients undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome

Background and Objective

Depression and anxiety are very common in patients with cardiac diseases. Percutaneous coronary intervention (PCI) has not only decreased mortality but angina, heart failure and recurrent hospitalization all are improved. Therefore, anxiety and depression associated with fibrinolytic therapy in acute coronary syndrome (ACS) are expected to be decreased in the patient undergoing PCI. Therefore, the aim of this study was to determine prevalence of depression and anxiety in patients undergoing percutaneous coronary intervention for acute coronary syndrome.

Methods

This study was conducted at Larkana Satellite Center of National Institute of Cardiovascular Diseases (NICVD), Pakistan from August 2018 to December 2018. Patients who underwent cardiac intervention within one month were enrolled in this study. Patients were interviewed regarding their basic demographics, indication for intervention and procedure details. Symptoms of anxiety were assessed using the translation of inventory of SAS (Zung's Self-Rating Anxiety Scale). Patients were interviewed for depression by using Becks depression inventory (BDI).

Results

A total of 153 patients were included in this study out of which 118 (77.1%) were males and 35 (22.5%) were females. All were married except one. Diabetes mellitus (DM) was present in 61 (39.9%), hypertension (HTN) in 69 (45.15%), obesity in 15 (9.8%), and 40 (26.1%) were smokers. Depression was present in 16 (10.5%) patients and anxiety was present in 12 (7.5%) of patients. On analysis of the association of various factor with depression; non-diabetics, housewives, laborers and uneducated were found to be more depressed. While those who smoke or earn more than 50 thousand were found less likely to be depressed.

Conclusion

Both depression and anxiety were present in only 10.5% and 7.5% of the patients after percutaneous coronary intervention for acute coronary syndrome.

Cortisol/cortisone levels and quality of life in individuals with pulmonary arterial hypertension

Individuals with pulmonary arterial hypertension experience debilitating symptoms and psychological distress which may influence their cortisol regulation. We describe associations between diurnal salivary cortisol/cortisone levels and quality of life in adults with pulmonary arterial hypertension. Findings suggest potential clinical utility of cortisol/cortisone assessment as applied to a pulmonary arterial hypertension population.

Anxiety and depression in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension: Results from a Chinese survey

Limited studies have focused on mental symptoms (anxiety and depression) and their impact on quality of life (QoL) in patients with pulmonary hypertension (PH). The objective of the present study was to assess the prevalence of anxiety and depression and their association with QoL in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) in a Chinese population. Patients diagnosed with PH by right heart catheterization between March 2015 and February 2016 were recruited. QoL [short form 36 Health Survey Questionnaire (SF-36)] and depression (Patient Health Questionnaire depression scale-9) and anxiety (Generalized Anxiety Disorder-7) were assessed at baseline. Patients were followed up every 3 months. A total of 36 patients with PAH and 62 patients with CTEPH were enrolled. According to the results of the clinical examination and the questionnaires for depression and anxiety, patients were divided into two groups: Group 1, with depression and/or anxiety (n=65, 66.3%) and group 2, without depression or anxiety (n=33, 33.7%). At baseline, the two groups did not differ in their hemodynamics. Patients with depression and/or anxiety (group 1) had a significantly lower score in all subscales of SF-36 (P<0.05). The impairment of QoL significantly correlated with the severity of depression (P<0.001) and anxiety (P<0.05). During the follow-up period, end-point events (death or admission due to deterioration) occurred in 17 patients (17.3%); 8 patients (8.1%) were lost to follow-up. The end-point event-free survival rate in group 2 was significantly higher than that in group 1. Multivariate logistic regression analysis suggested that the financial situation and right ventricular enlargement were influencing factors of depression and/or anxiety. In conclusion, in patients with PH from a Chinese population, anxiety and depression were frequently encountered and significantly correlated with QoL. The significant relevant factors influencing anxiety/depression were the financial situation and right ventricular enlargement and patients with depression had a worse prognosis than those without.

Systemic Consequences of Pulmonary Hypertension and Right-Sided Heart Failure

Pulmonary hypertension (PH) is a feature of a variety of diseases and continues to harbor high morbidity and mortality. The main consequence of PH is right-sided heart failure which causes a complex clinical syndrome affecting multiple organ systems including left heart, brain, kidneys, liver, gastrointestinal tract, skeletal muscle, as well as the endocrine, immune, and autonomic systems. Interorgan crosstalk and interdependent mechanisms include hemodynamic consequences such as reduced organ perfusion and congestion as well as maladaptive neurohormonal activation, oxidative stress, hormonal imbalance, and abnormal immune cell signaling. These mechanisms, which may occur in acute, chronic, or acute-on-chronic settings, are common and precipitate adverse functional and structural changes in multiple organs which contribute to increased morbidity and mortality. While the systemic character of PH and right-sided heart failure is often neglected or underestimated, such consequences place additional burden on patients and may represent treatable traits in addition to targeted therapy of PH and underlying causes. Here, we highlight the current state-of-the-art understanding of the systemic consequences of PH and right-sided heart failure on multiple organ systems, focusing on self-perpetuating pathophysiological mechanisms, aspects of increased susceptibility of organ damage, and their reciprocal impact on the course of the disease.

My life with pulmonary arterial hypertension: a patient perspective

In recent years, there has been an increase in therapeutic options and treatment strategies for pulmonary arterial hypertension (PAH). However, patients still report delays in receiving a diagnosis, which is a significant burden associated with the disease, and which shows a general lack of disease awareness. This review has been written by two PAH patients to describe the patient experience and explore the ways in which patients are increasingly being given a voice in developing approaches to treatment. As patients with PAH are living longer, it is important that they work with healthcare professionals to develop treatment strategies that improve and maintain quality of life. Healthcare professionals should consider a holistic approach to disease management, including dietary recommendations, individually adapted exercise, and options for counselling where available, alongside therapeutic treatments. The experiences of patients with PAH are important not just for individual patient treatment but should also be considered in clinical trial design and guideline development. Patient representatives and patient associations can play an influential role in improving the treatment and management of PAH. In this review, we use our experiences as patient representatives to describe the current situation of patients with PAH from first experiencing symptoms to receiving treatment, using two patient cases as examples. We also discuss the role of patient advocacy in improving PAH care and future roles for patient associations and patient representatives in the design of clinical trials and development of new treatment guidelines.

Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation

BACKGROUND

Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis.

OBJECTIVES

To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research.

DATA SOURCES

Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field.

REVIEW METHODS

Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services.

RESULTS

Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%.

LIMITATIONS

Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling.

CONCLUSIONS

Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain.

FUTURE WORK

Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017058688.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Neuroprotective Effects of Ginseng Phytochemicals: Recent Perspectives

As our global population ages, the treatment of neurodegenerative diseases is critical to our society. In recent years, researchers have begun to study the role of biologically active chemicals from plants and herbs to gain new inspiration and develop new therapeutic drugs. Ginseng (Panax ginseng C.A. Mey.) is a famous Chinese herbal medicine with a variety of pharmacological activities. It has been used to treat various diseases since ancient times. Extensive research over the years has shown that ginseng has potential as a neuroprotective drug, and its neuroprotective effects can be used to treat and prevent neurological damage or pathologically related diseases (such as Alzheimer's disease, Parkinson's disease, Huntington's disease, depression symptoms, and strokes). Moreover, evidence for the medicinal and health benefits of ginsenoside, its main active ingredient, in the prevention of neurodegenerative diseases is increasing, and current clinical results have not reported any serious adverse reactions to ginseng. Therefore, we briefly review the recent research and development on the beneficial effects and mechanisms of ginseng and its main active ingredient, ginsenoside, in the prevention and treatment of neurodegenerative diseases, hoping to provide some ideas for the discovery and identification of ginseng neuroprotection.

Anxiety and depression in patients with pulmonary hypertension: impact and management challenges

Background

Anxiety and depression are frequent disorders in patients with pulmonary arterial hypertension (PAH), but despite this only less than one-fourth of them is treated. Our aim was to review the studies regarding the prevalence and the impact of anxiety and depression and to propose management challenges.

Methods

A literature review regarding 1) anxiety and depression studies in PAH patients and caregivers, 2) psychological interventions, 3) slow breathing approach, and 4) pharmacological approach was performed, based on evidence of effectiveness through a search of the most well-known databases (Cochrane Library, Medline, PsychINFO [2004–2018]).

Results

The prevalence of mental disorders in PAH patients lies between 7.5% and 53% for depression and 19% and 51% for anxiety and panic disorders. The latest guidelines of the European Society of Cardiology recommend a psychological support with a class of recommendation I and a level of evidence c. The analysis of psychological intervention shows that at present there is no evidence of specific psychological interventions in these patients. However, treatment approaches based on other chronic illnesses are suggested, especially based on relaxation training, slow breathing, and cognitive behavioral therapy. Finally, data concerning the use of antidepressant drugs are conflicting.

Conclusion

Firstly, our data demonstrate a common underestimation of mental disorders by health professionals and secondly, the need of implementing appropriate methods of screening for mental disorders in PAH patients. However, the paucity of large observational studies in this area requires the attention of researchers. The evidence about optimal approaches for managing anxiety and depression in PAH also remains unclear and largely speculative. The challenge is the introduction of routine psychological intervention, as suggested by the European Society of Cardiology and already applied in other chronic disease.

Exercise Training and Rehabilitation in Pulmonary Hypertension

Within the last years, exercise training and rehabilitation as add-on to medical treatment has become an emerging field in pulmonary hypertension. Owing to the beneficial effects of exercise training in pulmonary hypertension, the new European Respiratory Society/European Society of Cardiology guidelines for pulmonary hypertension recommended a supervised and closely monitored exercise and respiratory training/rehabilitation as add-on to medical therapy (class IIa, level of evidence B). In this article, different training modalities, effects of exercise training, possible pathobiological mechanisms of action, and future research questions are discussed.

Rivaroxaban and macitentan can be coadministered without dose adjustment but the combination of rivaroxaban and St John's wort should be avoided

AIMS

We assessed the potential mutual interaction of oral macitentan (cytochrome P450 (CYP) 3A4 substrate) at steady-state with single-dose oral rivaroxaban (CYP3A4 and P-glycoprotein substrate) and evaluated the effect of the CYP3A and P-glycoprotein inducer St John's wort (SJW) on the pharmacokinetics of these drugs in healthy volunteers.

METHODS

Twelve healthy volunteers completed this open-label, monocentre, two-period, one-sequence phase I clinical trial. The pharmacokinetics of macitentan (10 mg) was assessed on study days 3 (single dose), 15 (steady-state), 16 (impact of rivaroxaban) and 29 (after induction by oral SJW), and of rivaroxaban on days 2 (single dose), 16 (impact of macitentan at steady-state) and 29 (after induction by SJW). Concurrently, we quantified changes of CYP3A activity using oral microdoses of midazolam (30 μg).

RESULTS

Rivaroxaban and macitentan did not significantly change the pharmacokinetics of each other. After induction with SJW, CYP3A activity increased by 272% and geometric mean ratios of macitentan AUC decreased by 48% and of C_max by 45%. Concurrently, also geometric mean ratios of rivaroxaban AUC and C_max decreased by 25%.

CONCLUSIONS

There is no evidence for a relevant pharmacokinetic interaction between macitentan and rivaroxaban suggesting that these two drugs can be combined without dose adjustment. SJW strongly increased CYP3A activity and substantially reduced rivaroxaban and macitentan exposure while estimated net endothelin antagonism only decreased by 20%, which is considered clinically irrelevant. The combination of SJW with rivaroxaban should be avoided.

General measures and supportive therapy for pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018

In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines aiming at their practical implementation, considering country-specific issues, and including new evidence, where available. To this end, a number of working groups was initiated, one of which was specifically dedicated to general measures (i.e. physical activity/supervised rehabilitation, pregnancy/contraception, elective surgery, infection prevention, psychological support, travel) and supportive therapy (i.e. anticoagulants, diuretics, oxygen, cardiovascular medications, anaemia/iron deficiency, arrhythmias) for PAH. While the European guidelines provide detailed recommendations for the use of targeted PAH therapies as well as supportive care, detailed treatment decisions in routine clinical care may be challenging, and the relevance of supportive care is often not sufficiently considered. In addition, new evidence became available, thus requiring a thorough reevaluation of specific recommendations. The detailed results and recommendations of the working group on general measures and supportive therapy for PAH, which were last updated in the spring of 2018, are summarized in this article.

Sexual health and health-related quality of life among women with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is characterized by progressive limitations in physical activity and health-related quality of life (HRQoL). HRQoL deficits may extend beyond the traditional domains of physical activity, psychological health, and emotional wellbeing to sexual health and function. Sexual HRQoL has not been studied in PAH, nor has the impact of PAH therapies themselves on sexual health and intimacy. In this initial investigation, we sought to explore HRQoL among women diagnosed with PAH and to determine if PAH treatment type (intravenous or subcutaneous prostanoids versus oral medications) was associated with levels of self-reported HRQoL assessed by validated measures for PAH-specific, general, and sexual HRQoL. We administered the emPHasis-10, Short Form (SF)-36, Female Sexual Dysfunction Scale-Revised (FSDS-R), and the Arizona Sexual Experience Scale (ASEX) to 35 women with self-reported World Health Organization Group 1 PAH at the 2016 Pulmonary Hypertension Association International Conference and Scientific Sessions. HRQoL instruments demonstrated excellent internal reliability. Women with PAH had high levels of sexual distress captured with the FSDS-R scale. The FSDS-R (but not ASEX) was significantly correlated to emPHasis-10 (r = 0.64, p < 0.01) and most SF-36 domains (r = − 0.36 to − 0.64, p < 0.05). Participants treated with intravenous or subcutaneous prostanoids had higher (worse) FSDS-R scores than those on oral therapies while ASEX, emPHasis-10, and SF-36 scores were similar across treatment types. Sexual HRQoL may impact overall quality of life in PAH and specific assessment of sexual health and functioning within intimate relationships may detect deficits in wellbeing not addressed by established HRQoL metrics. Further study to address all aspects of HRQoL in PAH is required.

Health-related quality of life, treatment adherence and psychosocial support in patients with pulmonary arterial hypertension or chronic thromboembolic pulmonary hypertension

Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) share similar quality of life impairment. The aim of the present study was to investigate health-related quality of life (HRQoL) and its relation to the perception of treatment and psychosocial support among PAH and CTEPH patients. All adult PAH or CTEPH patients in the Swedish Pulmonary Arterial Hypertension Register were invited to participate in a national cohort survey. The survey included the EuroQol 5-dimensions (EQ-5D) instrument that measures an individual’s HRQoL; the Beliefs about Medicines Questionnaire-Specific Scale that assesses the perception of PAH-specific treatment; the Mastery scale that evaluates the feeling of control and ability to cope with the disease; and the Social Network and Support Scale that maps the social support network. Of the 440 invited patients, 74% responded. Mean age was 66 ± 14 years, 58% were female and 69% diagnosed with PAH. Patients with PAH were younger, more often female and had a lower EQ-5D index (0.67 ± 0.29 vs. 0.73 ± 0.25, p = 0.050) than patients with CTEPH. Patients with a low EQ-5D index had more concerns about treatment (p = 0.004), lower coping ability (p < 0.001), less emotional support (p = 0.003) and less accessible social network (p = 0.002). In conclusion, patients with an impaired HRQoL also reported negative effects on their social support network, ability to handle stressors and concerns about treatment.

Exploring the experiences and psychosocial stresses of Taiwanese patients with pulmonary hypertension: a qualitative interview study

About half of all patients with pulmonary hypertension (PH) experience psychological and emotional disturbances that affect their quality of life (QOL). There is a lack of studies exploring how psychiatric professionals can provide specific and effective mental health treatment to patients with PH. This study aimed to explore and understand the treatment experiences of patients with PH in Taiwan. We employed an exploratory qualitative design involving interviews with 17 patients with PH who were treated at Kaohsiung Veterans General Hospital in Taiwan. Participants were interviewed by a psychiatrist; the interviews were audiotaped and transcribed for thematic analysis by two researchers. We corroborate earlier findings showing that patients who have the rare disease PH often experience psychological or emotional disturbances throughout the treatment process. This study explored a model for psychiatric intervention based on patients' experience of having PH. We find that assessing and strengthening links to external resources can enhance patients' long-term coping abilities, and thereby help reduce their psychological and emotional disturbances and improve their QOL.

A pilot randomised controlled trial investigating a mindfulness-based stress reduction (MBSR) intervention in individuals with pulmonary arterial hypertension (PAH): the PATHWAYS study

BACKGROUND

Pulmonary arterial hypertension (PAH) is an uncommon condition with progressive heart failure and premature death. Treatment costs up to £120,000 per patient per year, and the psychological burden of PAH is substantial. Mindfulness-based stress reduction (MBSR) is an intervention with the potential to reduce this burden, but to date, it has not been applied to people with pulmonary hypertension. We wished to determine whether a trial of MBSR for people with PAH would be feasible.

METHODS

A customised gentle MBSR programme of eight sessions was developed for people with physical disability due to PAH, and they were randomised to group-based MBSR or treatment as usual. The completeness of outcome measures including Beck Anxiety Index, Beck Depression Inventory and standard physical assessment at 3 months after randomisation were recorded. Health care utilisation was measured. Attendance at the sessions and the costs involved in delivering the intervention were assessed. Semi-structured interviews were conducted to explore the acceptability of the MBSR intervention and when appropriate the reasons for trial non-participation.

RESULTS

Fifty-two patients were recruited, but only 34 were randomised due to patients finding it difficult to travel to sessions. Twenty-two completed all questionnaires and attended all clinics, both routine and additional in order to collect outcomes measures. The MSBR sessions were delivered in Bristol, Cardiff and London, costing, on average, between £2234 (Cardiff) and £4128 (London) per patient to deliver. Attendance at each session averaged between two patients in Bristol and Cardiff and three in London. For those receiving treatment as usual, clinician blinding was achievable. Interviews revealed that people who attended MBSR found it interesting and helpful in managing their symptoms and minimising the psychological component of their disease.

CONCLUSIONS

We found that attendance at group MBSR was poor in people with chronic PAH within the context of a trial. Achieving better MBSR intervention attendance or use of an Internet-based programme might maximise the benefit of MBSR.

Impact of psychological factors on the health-related quality of life of patients treated for pulmonary arterial hypertension

OBJECTIVE

Pulmonary arterial hypertension (PAH) is a rare and life-threatening disease well-marked by under diagnosis, delayed diagnosis and atypical treatments. Few data are available on the quality of life (QoL) and psychosocial characteristics of patients with PAH. Our aim is to describe the impact of psychological factors on the health-related quality of life (HRQoL) of treated PAH patients in a cross-sectional study.

METHODS

Consecutive patients presenting at our Competency Centre for PAH were recruited. The aetiology, New York Heart Association (NYHA) stage, haemodynamics, 6-min walk distance (6MWD), delta SPO₂ (Pulse oximeter oxygen saturation; baseline lowest value during 6-min walk test (6MWT), current treatments and psychological history were recorded. HRQoL, anxiety, depression and coping strategies were explored using self-administered questionnaires (SF-36, HADS, STAI-Y, CHIP and WCC).

RESULTS

A total of 55 patients were included. The HRQoL of PAH patients was poor with altered results on several scales. Anxiety and depression were high and coping was focused on medical information strategies. Multivariate analysis indicated a positive relationship between 6MWD and the Physical Composite Score for QoL (p=0.004), as well as a negative relationship between delta SPO₂ and the Mental Composite Score (p=0.02), irrespective of other known prognostic factors (such as haemodynamics at right heart catheterization). Depression and Trait-Anxiety were associated with a lower physical (p=0.001) and mental (p<0.001) QoL, respectively.

CONCLUSIONS

Psychological factors impact the HRQoL of treated patients. A longitudinal and qualitative study should refine these results.

TRIAL REGISTRATION

Clinical trial N°: NCT01380054.

Exercise training in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is characterized by a continuous increase in pre-capillary pulmonary vascular resistance (PVR) with a progressive reduction of cardiac output (CO). Similar to what occurs in left heart failure (HF), this represents the initial phase of a syndrome characterized by the progressive development of dyspnea and fatigue with increasing deterioration of exercise tolerance. Although the therapies introduced in the last two decades have determined a significant improvement of the clinical conditions of PAH patients, they have a little impact on exercise capacity and prognosis. However, as previously demonstrated for HF, recent pilot studies have reported that physical and respiratory rehabilitation may have a specific role in the management of PAH. Despite potential risks, so far all studies agree that exercise training (ET) improves exercise capacity, quality of life (QoL), muscle function and pulmonary circulation. We will review the pathophysiological mechanisms underlying the functional incompetence of PAH patients, the effects of ET on clinical and functional parameters, the selection criteria for inclusion of patients in a training program, the suggested monitoring of beneficial effects or possible side effects induced by ET. Finally, we discuss of the possible exercise induced amelioration of prognosis in PAH.

Anxiety, Depression, and Health-Related QOL in Patients Diagnosed with PAH or CTEPH

BACKGROUND

Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are life-threatening diseases with a high burden of symptoms. Although depression, anxiety, and reduced health related quality of life (HRQOL) have also been reported, a comparative analysis which explores these traits and their underlying factors was lacking.

METHODS

A retrospective analysis of depression, anxiety, and health related QOL was conducted using a Hospital anxiety and depression scale (HADS) as well as the SF-36 HRQOL questionnaire. Results from these tools were compared with haemodynamic and functional parameters in 70 PAH and 23 CTEPH outpatients from a German tertiary care center specializing in pulmonary hypertension.

RESULTS

Although HRQOL was reduced in both cohorts of patients, individuals diagnosed with CTEPH scored lower in nearly all SF-36 parameters. Significance was noted in both "mental health" (p = 0.01) and "mental component summary score" (MCS) (p = 0.02). Depression was also more frequent in patients with CTEPH (56%) than in patients with PAH (30%), (p = 0.03). Overall, depression and anxiety correlated with most SF-36 scales in both PAH and CTEPH. In CTEPH, depression also correlated with the Borg Dyspnea Scale (r = 0.44, p = 0.01). These patients also had significantly lower pCO₂ levels than the PAH cohort reflecting more severe ventilation/perfusion mismatch. All other haemodynamic and functional parameters did not differ across the groups.

CONCLUSION

While both cohorts of patients suffer from a reduced HRQOL as well as depression and anxiety, decreases in mental health parameters are more pronounced in the CTEPH cohort. This suggests a strong effort to improve early detection, especially in dyspneic patients with classical risk factors for CTEPH and PAH and argues for mental illness interventions alongside routine clinical care provided to patients diagnosed with PAH or CTEPH.

Pathways to experiencing mental problems and need for mental support in patients with pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) affects the physical and emotional wellbeing of patients. More information is needed regarding mental problems and preferences for support. Qualitative interviews were used to explore mental problems and preference for support of PAH patients. Additionally, a survey was used to assess the presence of mental problems (Problem List), distress (Distress Thermometer) and the need for mental support. In 24 semi-structured interviews, the following problem themes were identified: energy balance; loss of abilities; feeling misunderstood; and handling of worries and emotions. Need for support was based on an interplay between resilience to psychological distress, additional life problems, age, disease status, attitude towards professional help, and experienced support from significant others. The results from the survey highlight the need for professional support, as 50.8% of the 67 patients who completed the survey would consider support when offered, specifically when offered by a pulmonary hypertension (PH) professional. Younger age (odds ratio [OR] = 0.97, P = 0.04), depression (OR = 11.435, P = 0.001) and possibly anxiety (OR = 3.831, P = 0.069) were related to need for support. In conclusion, many patients with PAH are in need of mental support, which should be offered by a PH professional and tailored to phase of the disease and personal characteristics.

RP5063, a novel, multimodal, serotonin receptor modulator, prevents monocrotaline-induced pulmonary arterial hypertension in rats

Pulmonary arterial hypertension (PAH), a condition characterized by pulmonary vasculature constriction and remodeling, involves dysregulation of the serotonin (5-HT) receptors 5-HT_2A and 5-HT_2B. A rat model of monocrotaline (MCT)-induced PAH was used to examine the potential beneficial effects of RP5063, a 5-HT receptor modulator. After a single 60mg/kg dose of MCT, rats were gavaged twice-daily (b.i.d.) with vehicle, RP5063 (1, 3, or 10mg/kg), or sildenafil (50mg/kg) for 28 days. RP5063 at a dose as low as 1mg/kg, b.i.d. reduced pulmonary resistance and increased systemic blood oxygen saturation. The highest dose of RP5063 (10mg/kg, b.i.d.) reduced diastolic, systolic, and mean pulmonary pressure, right systolic ventricular pressure, ventilatory pressure, and Fulton's index (ratio of right to left ventricular weight). Doses as low as 3mg/kg RP5063, b.i.d. also increased weight gain and body temperature, suggesting an improvement in overall health of MCT-treated animals. Similar reductions in pulmonary, right ventricular, and ventilatory pressure, pulmonary resistance, and Fulton's index as well as increased systemic blood oxygen saturation were observed in animals treated with the reference agent sildenafil at a higher dose (50mg/kg, b.i.d.). Histological examination revealed that RP5063 produced dose-dependent reductions in pulmonary blood vessel wall thickness and proportion of muscular vessels, similar to sildenafil. RP5063 completely blocked MCT-induced increases in the plasma cytokines TNFα, IL-1β, and IL-6 at all doses. In summary, RP5063 improved pulmonary vascular pathology and hemodynamics, right ventricular pressure and hypertrophy, systemic oxygen saturation, and overall health of rats treated with MCT.

Depressive Status in Patients With Chronic Thromboembolic Pulmonary Hypertension

BACKGROUND

The present comparative study with healthy volunteers was conducted to investigate the depressive status and temperament in patients with chronic thromboembolic pulmonary hypertension (CTEPH).Methods and Results:The results of the temperament and personality scale test, and the Quick Inventory of Depressive Symptomatology-Self Report revealed that CTEPH patients have a significantly higher depressive status than healthy volunteers.

CONCLUSIONS

It may be that CTEPH patients are more likely to have a depressive temperament in origin. It is expected that the relationship between the biological traits of CTEPH (e.g., genetics) and patients' depressive temperament will be elucidated in the future.