Anxiety, panic disorder and coronary artery disease: issues concerning physical exercise and cognitive behavioral therapy

Experiences of unexplained chest pain and physical activity: A Meta-Ethnography

AIMS AND OBJECTIVES

The aim was to examine the experiences of physical activity in the patients with unexplained chest pain.

BACKGROUND

Previous qualitative studies have compiled data on the physical activity experiences of people with unexplained chest pain. Nevertheless, no meta-synthesis exists on this topic to advance the theoretical development of future-related studies.

DESIGN

A meta-ethnographic synthesis of qualitative studies was conducted. Original qualitative studies on the physical activity experiences of people with unexplained chest pain were identified and systematically synthesised using a meta-ethnographic approach.

METHODS

Seven databases were searched for relevant full-text articles in English, Danish, Norwegian and Swedish. There were no limitations concerning year of publication. Articles were first screened against inclusion criteria for eligibility and then assessed for quality and analysed using Noblit and Hare's seven-step meta-ethnography process. The ENTREQ checklist for systematic reviews was used.

RESULTS

Nine qualitative studies were included in the analysis. The physical activity experiences of people with unexplained chest pain illuminates the metaphor: "Physical activity means balancing uncertainty" with four themes: looking for possible explanations, feeling vulnerable, feeling uncertain of consequences and being physically active may mean becoming more capable.

CONCLUSION

For people with unexplained chest pain, being physically active meant moving toward being more capable. The participants felt vulnerable and physical activity helped in balancing uncertainty. A comprehensive model illustrates the antecedents and succedent for the physical activity experiences of individuals with unexplained chest pains.

RELEVANCE TO CLINICAL PRACTICE

An approach to care which considers the patient's experience might be applicable; however, it needs to be accompanied with a biomedical perspective. Nurses and other health professionals need to provide a bridge between the patient's experiences and health professionals' advice and recommendations.

Asthma and early smoking associated with high risk of panic disorder in adolescents and young adults

PURPOSE

Studies have reported a strong link between asthma and panic disorder. We conducted a 17-year community-based large cohort study to examine the relationship between asthma, early smoking initiation, and panic disorder during adolescence and early adulthood.

METHODS

A total of 162,766 participants aged 11-16 years were categorized into asthma and nonasthma groups at baseline and compared within the observation period. Covariates during late childhood or adolescence included parental education, cigarette smoking by family members of participants, and participant's gender, age, alcohol consumption, smoking, and exercise habits. Data for urbanicity, prednisone use, allergic comorbidity, and Charlson comorbidity index were acquired from the National Health Insurance Research Database. The Cox proportional-hazards model was used to evaluate the association between asthma and panic disorder.

RESULTS

Our findings revealed that asthma increased the risk of panic disorder after adjustment for key confounders in the Cox proportional hazard regression model (adjusted HR: 1.70, 95% CI 1.28-2.26). Hospitalizations or visits to the emergency department for asthma exhibited a dose-response effect on the panic disorder (adjusted HR: 2.07, 95% CI 1.30-3.29). Patients with asthma with onset before 20 years of age who smoked during late childhood or adolescence had the greatest risk for panic disorder (adjusted HR: 4.95, 95% CI 1.23-19.90).

CONCLUSIONS

Patients newly diagnosed with asthma had a 1.7-times higher risk of developing panic disorder. Smoking during late childhood or adolescence increased the risk for developing the panic disorder in patients with asthma.

Internet-assisted cognitive behavioural therapy for non-cardiac chest pain: a pilot and feasibility study

Nearly half of patients with non-cardiac chest pain (NCCP) experience significant complaints after a negative cardiac evaluation, at considerable costs for society. Due to the lack of treatment capacity and low interest for psychological treatment among patients with somatic complaints, only a minority receive effective treatment. The aim of this study was to assess the feasibility and usefulness of internet-assisted cognitive behavioural therapy (I-CBT), including encouragement of physical activity for this condition. Ten patients with NCCP received a six-session I-CBT intervention with minimal support from a therapist. Questionnaires assessing cardiac anxiety, fear of bodily sensations, depression, interpretation of symptoms, frequency of chest pain and impact of chest pain symptoms were collected at baseline, post-treatment and at 3-month follow-up. Semi-structured interviews employing a phenomenological hermeneutic approach assessed the participants’ experience of the intervention. Quantitative results showed clear improvements in several measures both at end of treatment and at 3-month follow-up. The retention rate was 100% and client satisfaction was high. The intervention was feasible to implement in a cardiac setting. This setting made it easier for patients to accept a psychological approach. Qualitative interviews revealed that the participants felt respected and taken care of, and they obtained a better understanding of their chest pain and how to cope with it. This pilot study yielded promising results regarding feasibility, clinical effect and patient satisfaction from a brief I-CBT intervention for NCCP in a cardiac setting. These results indicate that a randomized controlled trial with a larger sample size is warranted.

Key learning aims

(1)

WeChat-based education and rehabilitation program in unprotected left main coronary artery disease patients after coronary artery bypass grafting: an effective approach in reducing anxiety, depression, loss to follow-up, and improving quality of life

This study aimed to investigate the effect of WeChat-based education and rehabilitation program (WERP) on anxiety, depression, health-related quality of life (HRQoL), major adverse cardiac/cerebrovascular events (MACCE)-free survival, and loss to follow-up rate in unprotected left main coronary artery disease (ULMCAD) patients after coronary artery bypass grafting (CABG). In this randomized controlled study, 140 ULMCAD patients who underwent CABG were randomly assigned to WERP group (n=70) or control care (CC) group (n=70). During the 12-month intervention period, anxiety and depression (using hospital anxiety and depression scale (HADS)) and HRQoL (using 12-Item Short-Form Health Survey (SF-12)) were assessed longitudinally. During the total 36-month follow-up period (12-month intervention and 24-month non-intervention periods), MACCE and loss to follow-up were recorded. During the intervention period, HADS-anxiety score at month 9 (M9) (P=0.047) and month 12 (M12) (P=0.034), anxiety rate at M12 (P=0.028), and HADS-D score at M12 (P=0.048) were all reduced in WERP group compared with CC group. As for HRQoL, SF-12 physical component summary score at M9 (P=0.020) and M12 (P=0.010) and SF-12 mental component summary score at M9 (P=0.040) and M12 (P=0.028) were all increased in WERP group compared with CC group. During the total follow-up period, WERP group displayed a trend of longer MACCE-free survival than that in CC group but without statistical significance (P=0.195). Additionally, loss to follow-up rate was attenuated in WERP group compared with CC group (P=0.033). WERP serves as an effective approach in optimizing mental health care and promoting life quality in ULMCAD patients after CABG.

Gender differences in screening for glucose perturbations, cardiovascular risk factor management and prognosis in patients with dysglycaemia and coronary artery disease: results from the ESC-EORP EUROASPIRE surveys

Background

Gender disparities in the management of dysglycaemia, defined as either impaired glucose tolerance (IGT) or type 2 diabetes (T2DM), in coronary artery disease (CAD) patients are a medical challenge. Recent data from two nationwide cohorts of patients suggested no gender difference as regards the risk for diabetes-related CV complications but indicated the presence of a gender disparity in risk factor management. The aim of this study was to investigate gender differences in screening for dysglycaemia, cardiovascular risk factor management and prognosis in dysglycemic CAD patients.

Methods

The study population (n = 16,259; 4077 women) included 7998 patients from the ESC-EORP EUROASPIRE IV (EAIV: 2012–2013, 79 centres in 24 countries) and 8261 patients from the ESC-EORP EUROASPIRE V (EAV: 2016–2017, 131 centres in 27 countries) cross-sectional surveys. In each centre, patients were investigated with standardised methods by centrally trained staff and those without known diabetes were offered an oral glucose tolerance test (OGTT). The first of CV death or hospitalisation for non-fatal myocardial infarction, stroke, heart failure or revascularization served as endpoint. Median follow-up time was 1.7 years. The association between gender and time to the occurrence of the endpoint was evaluated using Cox survival modelling, adjusting for age.

Results

Known diabetes was more common among women (32.9%) than men (28.4%, p < 0.0001). OGTT (n = 8655) disclosed IGT in 17.2% of women vs. 15.1% of men (p = 0.004) and diabetes in 13.4% of women vs. 14.6% of men (p = 0.078). In both known diabetes and newly detected dysglycaemia groups, women were older, with higher proportions of hypertension, dyslipidaemia and obesity. HbA1c was higher in women with known diabetes. Recommended targets of physical activity, blood pressure and cholesterol were achieved by significantly lower proportions of women than men. Women with known diabetes had higher risk for the endpoint than men (age-adjusted HR 1.22; 95% CI 1.04–1.43).

Conclusions

Guideline-recommended risk factor control is poorer in dysglycemic women than men. This may contribute to the worse prognosis in CAD women with known diabetes.

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study

Background

Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress.

Design/Method

This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files.

Discussion

This study will provide essential information on the prevalence and incidence of anxiety disorders in patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions.

To make a run for IT - A feasibility study of ICBT combined with physical exercise for patients with panic disorder

BACKGROUND

Guided Internet-based cognitive behavioural therapy (ICBT) is a recommended treatment for panic disorder promising to increase treatment availability, but there are some concerns regarding adherence, including adherence to the in vivo exposure given as home assignments. The aim of this study was to assess the feasibility of combining ICBT with physical exercise with the aim of improving adherence and treatment response to ICBT.

METHOD

12 participants were included via routine clinical practice to an open pre- post trial of feasibility using ICBT and an aerobe exercise protocol. We used a mixed model design investigating multiple areas of adherence, participants' experience and clinical outcome.

RESULTS

90.9% of the participants was considered completers in the ICBT program and the average adherence to the physical exercise was 93.1%. The experience of participating was summarized as "Hard work but worth it". Clinical outcomes effect sizes (d) ranged from 2.79 (panic severity) to .64 (Beck's anxiety index).

CONCLUSION

The sum results on adherence, qualitative and quantitative data all suggest that augmenting ICBT with an aerobic exercise protocol is feasible. We conclude that further research is warranted.

Outcomes of a randomised pilot trial of a nurse-led clinic for patients after percutaneous coronary intervention

BACKGROUND

Hospitalisation for percutaneous coronary intervention (PCI) in Australia is reducing. Patients who undergo PCI may be discharged home without a post-discharge health management plan, referral for secondary prevention, or understand their chronic condition. Subsequently, negative psychological symptoms such as anxiety and depression may be experienced in the post-discharge period.

OBJECTIVES

This study assessed the effectiveness of a nurse-led clinic on patients' cardiac self-efficacy and negative psychological symptoms of anxiety and depression 1-week post-PCI discharge.

METHODS

One-hundred and eighty-eight potential participants were screened, and 33 participants were block-randomised to study groups. The nurse-led clinic used a person-centred approach and delivered tailored education, health assessment, and post-discharge support. In Phase 1, the Cardiac Self-efficacy Scale and State-Trait Anxiety Inventory measured primary outcomes, while the Cardiac Depression Scale was used to measure secondary outcomes. Phase 2 evaluated participants' experiences and healthcare professionals' perceptions of the intervention through semi-structured interviews.

RESULTS

In Phase 1, intervention group participants did not show improvements in mental health indicators compared to standard care group participants, except for a moderate reduction in anxiety levels (d = 0.50). Phase 2 qualitative findings; however, highlighted the benefits of the nurse-led clinic.

CONCLUSIONS

Overall, findings suggest that nurse-led clinics may be valuable to reduce anxiety and act as a supportive measure in the early post-discharge period until commencement of a secondary prevention program. Further research with a more powered sample is needed to determine the significance of the findings.

Effectiveness of Cognitive Behavioral Therapy for Depression and Anxiety in Patients With Cardiovascular Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Depression and anxiety are highly prevalent in patients with cardiovascular disease (CVD) and influence their mental well-being and CVD prognosis. The primary objective was to assess the effectiveness of cognitive behavioral therapy (CBT) for depression and anxiety in patients with CVD. Secondary objectives were to assess the impact of CBT on cardiovascular mortality, cardiovascular events, patient satisfaction, and quality of life.

METHODS

MEDLINE, PsycINFO, CINAHL, CENTRAL, and alternative sources were searched for randomized controlled trials and observational studies with a control. Studies were required to assess CBT in coronary heart disease, acute coronary syndrome, atrial fibrillation, or postmyocardial infarction patients, with anxiety and/or depression. Studies were independently screened by two reviewers and critically appraised using the Cochrane Risk of Bias tool. The random-effects model was used to pool standardized mean differences (SMD).

RESULTS

Twelve randomized controlled trials were included. At follow-up, depression (SMD = -0.35, 95% confidence interval [CI] = -0.52 to -0.17, p < .001, I = 59%) and anxiety (SMD = -0.34, 95% CI = -0.65 to -0.03, p = .03, I = 71%) scores were significantly lower in CBT patients compared with controls. Change in mental health quality of life (SF-12) was also significantly greater for CBT patients, compared with controls (mean difference = 3.62, 95% CI = 0.22 to 7.02, p = .04, I = 0%). No differences in patient satisfaction or cardiovascular events were evident between CBT and control groups. Among the study reports included in this meta-analysis, data specific to cardiovascular mortality were not reported.

CONCLUSIONS

Cognitive behavioral therapy seems to be an effective treatment for reducing depression and anxiety in patients with CVD and should be considered in standard clinical care.

A good time to panic? Premorbid and postmorbid panic disorder in heart failure affects cardiac and psychiatric cause admissions

OBJECTIVE

The authors sought to identify characteristics associated with premorbid and postmorbid panic disorder onset in relation to heart failure (HF) onset, and examine the effect on unplanned hospital admissions.

METHODS

In a two-stage screening process, 404 HF patients admitted to three hospitals in South Australia were referred for structured psychiatric interview when any of the following four criteria were met: (a) Patient Health Questionnaire≥10; (b) Generalized Anxiety Disorder Questionnaire≥7); (c) positive response to one-item panic attack screener; (d) or evidence of suicidality.

RESULTS

A total of 73 referred HF patients (age 60.6±13.4, 47.9% female) were classified into three groups: premorbid panic disorder (27.4%), postmorbid panic disorder (24.7%), and no panic disorder (47.9%). Postmorbid panic disorder was associated with more psychiatric admissions and longer hospital stay in the 6 months prior to the index psychiatric assessment, and also in the 6 months after the index psychiatric assessment (all p<.05 unadjusted). In sensitivity analysis, years since panic disorder onset were associated with longer cardiac length of stay (β=.34, p=.03).

CONCLUSIONS

Panic disorder onset in relation to HF diagnosis was associated with discrete patterns of hospital admissions for cardiac and psychiatric causes.

Panic disorder and incident coronary heart disease: a systematic review and meta-analysis protocol

BACKGROUND

The clinical presentation of panic disorder and panic attack overlaps many symptoms typically experienced in coronary heart disease (CHD). Etiological links between panic disorder and CHD are controversial and remain largely tenuous. This systematic review aims to pool together data regarding panic disorder with respect to incident CHD or myocardial infarction.

METHODS/DESIGN

Electronic databases (MEDLINE, EMBASE, PsycINFO and SCOPUS) will be searched using a search strategy exploding the topics for CHD and panic disorder. Authors and reference lists of included studies will also be contacted to identify additional published and unpublished studies. Eligibility criteria are as follows:

POPULATION

persons without CHD who meet criteria for panic disorder, panic attack, anxiety neurosis or elevated panic disorder symptoms; Comparison: persons without CHD who do not meet criteria for panic disorder, panic attack, anxiety neurosis or elevated panic disorder symptoms;

OUTCOME

verified fatal and non-fatal CHD at follow-up; including coronary revascularization procedure, coronary artery disease, and myocardial infarction. Studies adopting self-report CHD will be ineligible. Screening will be undertaken by two independent reviewers with disagreements resolved through discussion. Data extraction will include original data specified as hazard ratios, risk ratios, and original cell data if available. Risk of bias assessment will be undertaken by two independent reviewers. Meta-analytic methods will be used to synthesize the data collected relating to the CHD outcomes with Cochrane Review Manager 5.3.

DISCUSSION

This systematic review aims to clarify whether panic disorder is associated with elevated risk for subsequent CHD. An evaluation of the etiological links between panic disorder with incident CHD might inform evidence-based clinical practice and policy concerning triaging chest pain patients, diagnostic assessment, and psychiatric intervention with panic disorder patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014891 .

The anxious heart in whose mind? A systematic review and meta-regression of factors associated with anxiety disorder diagnosis, treatment and morbidity risk in coronary heart disease

OBJECTIVE

To (1) report the prognostic association between anxiety disorder subtypes and major adverse cardiac events (MACE), (2) report anxiety disorder prevalence in coronary heart disease (CHD), and (3) report the efficacy of anxiety disorder treatments in CHD.

METHODS

A comprehensive electronic database search was performed in November 2013 for studies reporting anxiety disorder prevalence according to structured interview in CHD samples or MACE, and randomized controlled trials (RCTs) comparing anxiety disorder treatment with placebo or usual care. From 4041 articles 42 samples were selected for extraction (8 for MACE prognosis, 39 for prevalence, no RCTs were eligible).

RESULTS

Five generalized anxiety disorder (GAD) studies reported 883 MACE events (combined n=2851). There was a non-significant association between GAD and MACE (risk ratio=1.20, 95% CI .86-1.68, P=.28) however the effect size was highly significant in outpatient samples (adjusted hazard ratio=1.94, 95% CI 1.45-2.60, P<.001). No other anxiety disorder subtype was associated with MACE. Prevalence data showed high comorbidity with depression (49.06%; 95% CI 34.28-64.01) and substantial heterogeneity between studies. Panic disorder prevalence was higher in psychiatrist/psychologist raters (9.92% vs. 4.74%) as was GAD (18.45% vs. 13.01%). Panic and GAD estimates were also heterogeneous according to DSM-III-R versus DSM-IV taxonomies.

CONCLUSIONS

The paucity of extant anxiety disorder RCTs, alongside MACE risk for GAD outpatients, should stimulate further anxiety disorder intervention in CHD populations. Research should focus on depression and anxiety, thereby unraveling disorder specific and more generic pathways.

Cardiorespiratory optimal point: a submaximal exercise variable to assess panic disorder patients

Panic disorder (PD) patients often report respiratory symptoms and tend to perform poorly during maximal cardiopulmonary exercise testing (CPX), at least partially, due to phobic anxiety. Thus, we hypothesized that a submaximal exercise variable, minimum VE/VO2 - hereafter named cardiorespiratory optimal point (COP) -, may be useful in their clinical assessment. Data from 2,338 subjects were retrospectively analyzed and 52 (2.2%) patients diagnosed with PD (PDG) (70% women; aged 48±13 years). PD patients were compared with a healthy control group (CG) precisely matched to number of cases, age and gender profiles. PDG was further divided into two subgroups, based on having achieved a maximal or a submaximal CPX (unwilling to continue until exhaustion). We compared COP, VO2 max, maximum heart rate (HR max) between PDG and CG, and also COP between maximal and submaximal PD subgroups. COP was similar between PDG and CG (21.9±0.5 vs. 23.4±0.6; p = 0.07), as well as, for PD subgroups of maximal and submaximal CPX (22.0±0.5 vs. 21.6±1.3; p = 0.746). Additionally, PD patients completing a maximal CPX obtained VO2 max (mL x kg-1 x min-1) (32.9±1.57 vs 29.6±1.48; p = 0.145) and HR max (bpm) similar to controls (173±2.0 vs 168±2.7; p = 0.178). No adverse complications occurred during CPX. Although clinically safe, it is sometimes difficult to obtain a true maximal CPX in PD patients. Normalcy of cardiorespiratory interaction at submaximal effort as assessed by COP may contribute to reassure both patients and physicians that there is no physiological substrate for exercise-related respiratory symptoms often reported by PD patients.

Brazilian Portuguese validated version of the Cardiac Anxiety Questionnaire

Background

Cardiac Anxiety (CA) is the fear of cardiac sensations, characterized by recurrent anxiety symptoms, in patients with or without cardiovascular disease. The Cardiac Anxiety Questionnaire (CAQ) is a tool to assess CA, already adapted but not validated to Portuguese.

Objective

This paper presents the three phases of the validation studies of the Brazilian CAQ.

Methods

To extract the factor structure and assess the reliability of the CAQ (phase 1), 98 patients with coronary artery disease were recruited. The aim of phase 2 was to explore the convergent and divergent validity. Fifty-six patients completed the CAQ, along with the Body Sensations Questionnaire (BSQ) and the Social Phobia Inventory (SPIN). To determine the discriminative validity (phase 3), we compared the CAQ scores of two subgroups formed with patients from phase 1 (n = 98), according to the diagnoses of panic disorder and agoraphobia, obtained with the MINI - Mini International Neuropsychiatric Interview.

Results

A 2-factor solution was the most interpretable (46.4% of the variance). Subscales were named "Fear and Hypervigilance" (n = 9; alpha = 0.88), and "Avoidance", (n = 5; alpha = 0.82). Significant correlation was found between factor 1 and the BSQ total score (p < 0.01), but not with factor 2. SPIN factors showed significant correlations with CAQ subscales (p < 0.01). In phase 3, "Cardiac with panic" patients scored significantly higher in CAQ factor 1 (t = -3.42; p < 0.01, CI = -1.02 to -0.27), and higher, but not significantly different, in factor 2 (t = -1.98; p = 0.51, CI = -0.87 to 0.00).

Conclusions

These results provide a definite Brazilian validated version of the CAQ, adequate to clinical and research settings.

Social anxiety in physical activity participation in patients with mental illness: a cross-sectional multicenter study

BACKGROUND

Social anxiety (SA) is a frequent comorbid condition in patients with mental illness. However, no data exist regarding SA in physical activity (PA) situations. The aim of the present study was to measure the level of self-reported SA in PA participation in patients with mental illness compared to healthy controls.

METHODS

Six hundred ninety-three patients with mental illness and 2,888 controls aged between 18 and 65 years completed the Physical Activity and Sport Anxiety Scale (PASAS). Group and gender differences in PASAS scores were tested by ANOVA and Scheffé's post hoc test.

RESULTS

After controlling for gender (P < .05), the patient group (men 40.2 ± 14.4; women 49.2 ± 17) scored higher on the PASAS compared to control group (men 30.6 ± 12.2; women 37.3 ± 13.7). Within both groups, women reported higher levels of SA compared to men.

CONCLUSIONS

Our data indicate that patients with mental illness reported higher levels of SA in PA situations compared to healthy control subjects. Health professionals should consider SA when trying to improve outcome and adherence of patients with mental illness to PA interventions.

Compromised cerebrovascular modulation in chronic anxiety: evidence from cerebral blood flow velocity measured by transcranial Doppler sonography

OBJECTIVE

Cerebral autoregulation (CA) is the mechanism by which constant cerebral blood flow is maintained despite changes in cerebral perfusion pressure. CA can be evaluated by dynamic monitoring of cerebral blood flow velocity (CBFV) with transcranial Doppler sonography (TCD). The present study aimed to explore CA in chronic anxiety.

METHODS

Subjects with Hamilton anxiety scale scores ≥14 were enrolled and the dynamic changes of CBFV in response to an orthostatic challenge were investigated using TCD.

RESULTS

In both the anxious and the healthy subjects, the mean CBFV was significantly lower in the upright position than when supine. However, the CBFV changes from supine to upright differed between the anxious and the healthy groups. Anxious subjects showed more pronounced decreases in CBFV with abrupt standing.

CONCLUSION

Our results indicate that cerebrovascular modulation is compromised in chronic anxiety; anxious subjects have some insufficiency in maintaining cerebral perfusion after postural change. Given the fact that anxiety and impaired CA are associated with cardiovascular disease, early ascertainment of compromised cerebrovascular modulation using TCD might suggest interventional therapies in the anxious population, and improve the primary prevention of cardiovascular disease.

Effects of exercise in renal transplant recipients

Even after a successful renal transplantation, the renal transplant recipients (RTRs) keeps on suffering the consequences of the uremic sickness. Cardiovascular risk, work capacity, and quality of life do not improve according to expectations since biological and psychological problems are not completely solved by pharmacological treatment. Furthermore, post-transplant treatment, per se, induces additional problems (i.e., side effects of drugs). It becomes, indeed, very important to insert “non-pharmacological” therapies able to reverse this trend. Exercise may represent an important contribution in the solution of this problem. In fact, many studies have demonstrated, in the last two decades, that physical training is able both, to improve graft function, work capacity and quality of life, and to reduce cardiovascular risk. In conclusion, if the analysis of the available data suggests that an appropriate dose of physical training represent a useful, safe and non-pharmacologic contribution to RTR treatment, it becomes a kidney transplantologist responsibility to introduce exercise in the current therapy of RTRs.

Psychiatric disorders and cardiac anxiety in exercising and sedentary coronary artery disease patients: a case-control study

Regular physical exercise has been shown to favorably influence mood and anxiety; however, there are few studies regarding psychiatric aspects of physically active patients with coronary artery disease (CAD). The objective of the present study was to compare the prevalence of psychiatric disorders and cardiac anxiety in sedentary and exercising CAD patients. A total sample of 119 CAD patients (74 men) were enrolled in a case-control study. The subjects were interviewed to identify psychiatric disorders and responded to the Cardiac Anxiety Questionnaire. In the exercise group (N = 60), there was a lower prevalence (45 vs 81%; P < 0.001) of at least one psychiatric diagnosis, as well as multiple comorbidities, when compared to the sedentary group (N = 59). Considering the Cardiac Anxiety Questionnaire, sedentary patients presented higher scores compared to exercisers (mean ± SEM = 55.8 ± 1.9 vs 37.3 ± 1.6; P < 0.001). In a regression model, to be attending a medically supervised exercise program presented a relevant potential for a 35% reduction in cardiac anxiety. CAD patients regularly attending an exercise program presented less current psychiatric diagnoses and multiple mental-related comorbidities and lower scores of cardiac anxiety. These salutary mental effects add to the already known health benefits of exercise for CAD patients.

The role of anxiety in metabolic syndrome

Metabolic syndrome (MS) seems to be associated with both depression and increased cardiovascular risk. This article emphasizes the most relevant findings on the link between MS and psychological cardiovascular risk factors, focusing on the impact of anxiety. There is evidence for an association between psychological disorders and the development of MS, which could eventually increase cardiovascular risk. However, the coexistence of anxiety in MS patients seems to be a byproduct of anxiety-depression comorbidity, stress and negative health behaviors. Endocannabinoid receptors, and hypothalamic-pituitary-adrenal axis dysregulation and sympathetic hyperactivation are the most commonly mentioned plausible underlying pathways.

Treinamento físico intervalado como ferramenta na terapia cognitivo-comportamental do transtorno de pânico

Este trabalho consiste no relato da utilização de um programa de exercícios físicos aeró-bicos intervalados no contexto da terapia cognitivo-comportamental em um caso de transtorno de pânico e agorafobia. São descritos os procedimentos utilizados, bem como os resultados positivos obtidos na redução da ansiedade cardíaca e na ansiedade cotidiana em relação a situações que exigem esforço físico.