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Sherwood A, Ulmer C, Wu JQ, Blumenthal JA, Herold E, Smith PJ, Koch GG, Johnson K, Viera A, Edinger J, Hinderliter A. Cognitive behavior therapy for insomnia for untreated hypertension with comorbid insomnia disorder: The SLEEPRIGHT clinical trial. J Clin Hypertens (Greenwich) 2024; 26:441-447. [PMID: 38468418 PMCID: PMC11007791 DOI: 10.1111/jch.14763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/27/2023] [Accepted: 12/02/2023] [Indexed: 03/13/2024]
Abstract
Insomnia and poor sleep are associated with an increased risk of developing cardiovascular disease (CVD) and its precursors, including hypertension. In 2022, the American Heart Association (AHA) added inadequate sleep to its list of health behaviors that increase the risk for CVD. It remains unknown, however, whether the successful treatment of insomnia and inadequate sleep can reduce heightened CVD risk. SLEEPRIGHT is a single-site, prospective clinical trial designed to evaluate whether the successful treatment of insomnia results in improved markers of CVD risk in patients with untreated hypertension and comorbid insomnia disorder. Participants (N = 150) will undergo baseline assessments, followed by a 6-week run-in period after which they will receive cognitive behavior therapy for insomnia (CBT-I), comprised of 6 hourly sessions with an experienced CBT-I therapist over a 6-week period. In addition to measures of insomnia severity, as well as both subjective and objective measures of sleep, the primary outcome measures are nighttime blood pressure (BP) and BP dipping assessed by 24-h ambulatory BP monitoring (ABPM). Secondary outcomes include several CVD risk biomarkers, including clinic BP, lipid profile, vascular endothelial function, arterial stiffness, and sympathetic nervous system (SNS) activity. Data analysis will evaluate the association between improvements in insomnia and sleep with primary and secondary CVD risk biomarker outcomes. The SLEEPRIGHT trial (ClinicalTrials.Gov NCT04009447) will utilize CBT-I, the current gold standard treatment for insomnia disorder, to evaluate whether reducing insomnia severity and improving sleep are accompanied by improved biomarkers of CVD risk in patients with untreated hypertension.
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Affiliation(s)
| | - Christi Ulmer
- Duke University Medical CenterDurhamNorth CarolinaUSA
| | - Jade Q. Wu
- Duke University Medical CenterDurhamNorth CarolinaUSA
| | | | - Emma Herold
- Duke University Medical CenterDurhamNorth CarolinaUSA
| | - Patrick J. Smith
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Gary G. Koch
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | | | - Anthony Viera
- Duke University Medical CenterDurhamNorth CarolinaUSA
| | | | - Alan Hinderliter
- University of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Blumenthal JA, Smith PJ, Mabe S, Hinderliter A, Craighead L, Watkins LL, Ingle K, Tyson CC, Lin PH, Kraus WE, Liao L, Sherwood A. Effects of Lifestyle Modification on Psychosocial Function in Patients With Resistant Hypertension: SECONDARY OUTCOMES FROM THE TRIUMPH RANDOMIZED CLINICAL TRIAL. J Cardiopulm Rehabil Prev 2024; 44:64-70. [PMID: 37220236 PMCID: PMC10667561 DOI: 10.1097/hcr.0000000000000801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE In a secondary analysis of the TRIUMPH clinical trial, psychological outcomes in patients with resistant hypertension (RH) receiving a diet and exercise intervention delivered in a cardiac rehabilitation setting were compared with those receiving a similar prescription of diet and exercise provided in a single counseling session by a health educator. METHODS One hundred forty patients with RH were randomly assigned to a 4-mo program of dietary counseling, behavioral weight management, and exercise (C-LIFE) or a single counseling session providing standardized education and physician advice (SEPA). Participants completed a battery of questionnaires to assess psychological functioning before and after the intervention. A global measure of psychological functioning was derived from the General Health Questionnaire (GHQ), Perceived Stress Scale (PSS), Medical Outcomes Study 36-item Short Form Health Survey, Spielberger State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory-II, and Patient-Reported Outcomes Measurement Information System (PROMIS) Anger scale. RESULTS Participants in the C-LIFE intervention achieved greater improvements in psychological functioning compared with SEPA (C-LIFE: 58.9 [56.1, 61.8] vs SEPA: 66.5 [62.1, 70.9]; P = .024). Greater improvements were especially evident for the GHQ, PSS, and HADS. Examination of mediation revealed that greater weight loss ( B =-0.17, P = .004) and improved oxygen uptake ( B =-0.12, P = .044) were associated with improved psychological functioning. CONCLUSION Compared with standard education and physician advice, a structured program of diet and exercise not only reduced blood pressure but also improved psychological functioning in patients with RH.
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Affiliation(s)
- James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Alan Hinderliter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Linda Craighead
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Lana L. Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Krista Ingle
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Crystal C. Tyson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Pao-Hwa Lin
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - William E. Kraus
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Lawrence Liao
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Drs Blumenthal, Watkins, Ingle, and Sherwood and Ms Mabe); Departments of Psychiatry (Dr Smith) and Medicine (Dr Hinderliter), University of North Carolina at Chapel Hill, Chapel Hill; Department of Psychology, Emory University, Atlanta, Georgia (Dr Craighead), and Department of Medicine, Duke University Medical Center, Durham, North Carolina (Drs Tyson, Lin, Kraus, and Liao)
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Abstract
PURPOSE OF REVIEW Approximately 10% of the adults with hypertension fail to achieve the recommended blood pressure treatment targets on 3 antihypertensive medications or require ≥ 4 medications to achieve goal. These patients with 'resistant hypertension' have an increased risk of target organ damage, adverse clinical events, and all-cause mortality. Although lifestyle modification is widely recommended as a first-line approach for the management of high blood pressure, the effects of lifestyle modifications in patients with resistant hypertension has not been widely studied. This review aims to provide an overview of the emerging evidence on the benefits of lifestyle modifications in patients with resistant hypertension, reviews potential mechanisms by which lifestyles may reduce blood pressure, and discusses the clinical implications of the recent findings in this field. RECENT FINDINGS Evidence from single-component randomized clinical trials demonstrated that aerobic exercise, weight loss and dietary modification can reduce clinic and ambulatory blood pressure in patients with resistant hypertension. Moreover, evidence from multi-component trials involving exercise and dietary modification and weight management can facilitate lifestyle change, reduce clinic and ambulatory blood pressure, and improve biomarkers of cardiovascular risk. This new evidence supports the efficacy of lifestyle modifications added to optimized medical therapy in reducing blood pressure and improving cardiovascular risk biomarkers in patients with resistant hypertension. These findings need to be confirmed in larger studies, and the persistence of benefit over extended follow-up needs further study.
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Affiliation(s)
- Fernando Ribeiro
- Institute of Biomedicine (iBiMED), School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Manuel Teixeira
- Institute of Biomedicine (iBiMED), School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Alberto J Alves
- University of Maia, Research Center in Sports Sciences, Health Sciences and Human Development, Castêlo da Maia, Portugal
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, 27710, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, 27710, USA.
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Sherwood A, Blumenthal JA, Mentz RJ, Koch GG, Rogers JG, Chang PP, Chien C, Adams KF, Rose-Jones LJ, Jensen BC, Johnson KS, Hinderliter AL. Association of Depression Symptoms and Biomarkers of Risk on Clinical Outcomes in HFrEF. medRxiv 2023:2023.09.26.23296194. [PMID: 37808654 PMCID: PMC10557801 DOI: 10.1101/2023.09.26.23296194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND Prior studies have demonstrated an association of depression with adverse clinical outcomes in patients with HFrEF, but the possible mechanisms responsible for the association are not unserstood. METHODS 142 men and women with HFrEF were enrolled through HF clinics and followed over time. At baseline and 6-months, depression was assessed by the Beck Depression Inventory (BDI-II) and disease activity by B-type natriuretic peptide (BNP). Proportional Hazards Regression Models assessed the contribution of depressive symptoms and HFrEF disease biomarkers on death or cardiovascular hospitalization. RESULTS Over a median follow-up period of 4 years, 42 patients (30%) died, and 84 (60%) had cardiovascular hospitalizations. A 10-point higher baseline BDI-II score was associated with a 35% higher hazard of death or cardiovascular hospitalization. Greater baseline BDI-II scores were associated with poorer HF self-care maintenance (R=-0.30, p<0.001) and fewer daily steps (R=-0.19, p=0.04), suggesting that depression may adversely affect important health behaviors. Increases in plasma BNP over 6 months were associated with worse outcomes. Changes in BDI-II score and plasma BNP over 6 months were positively correlated (R=0.25, p=0.004). CONCLUSIONS This study underscores the importance of elevated depression symptoms and their association with an increased likelihood of adverse clinical outcomes in patients with HFrEF. Health behaviors may play a greater role than direct biobehavioral pathways in the adverse effects of depression on the HF disease trajectory and resultant clinical outcomes.
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Affiliation(s)
- Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | | | - Gary G. Koch
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Joseph G. Rogers
- Department of Medicine, Duke University Medical Center
- Department of Cardiology, The Texas Heart Institute
| | | | - Christopher Chien
- Department of Medicine, University of North Carolina at Chapel Hill
- UNC Rex Healthcare, Raleigh, NC, USA
| | | | | | - Brian C. Jensen
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Kristy S. Johnson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
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Marx W, Manger SH, Blencowe M, Murray G, Ho FYY, Lawn S, Blumenthal JA, Schuch F, Stubbs B, Ruusunen A, Desyibelew HD, Dinan TG, Jacka F, Ravindran A, Berk M, O'Neil A. Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) taskforce. World J Biol Psychiatry 2023; 24:333-386. [PMID: 36202135 PMCID: PMC10972571 DOI: 10.1080/15622975.2022.2112074] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/24/2022] [Accepted: 08/07/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The primary objectives of these international guidelines were to provide a global audience of clinicians with (a) a series of evidence-based recommendations for the provision of lifestyle-based mental health care in clinical practice for adults with Major Depressive Disorder (MDD) and (b) a series of implementation considerations that may be applicable across a range of settings. METHODS Recommendations and associated evidence-based gradings were based on a series of systematic literature searches of published research as well as the clinical expertise of taskforce members. The focus of the guidelines was eight lifestyle domains: physical activity and exercise, smoking cessation, work-directed interventions, mindfulness-based and stress management therapies, diet, sleep, loneliness and social support, and green space interaction. The following electronic bibliographic databases were searched for articles published prior to June 2020: PubMed, EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), CINAHL, PsycINFO. Evidence grading was based on the level of evidence specific to MDD and risk of bias, in accordance with the World Federation of Societies for Biological Psychiatry criteria. RESULTS Nine recommendations were formed. The recommendations with the highest ratings to improve MDD were the use of physical activity and exercise, relaxation techniques, work-directed interventions, sleep, and mindfulness-based therapies (Grade 2). Interventions related to diet and green space were recommended, but with a lower strength of evidence (Grade 3). Recommendations regarding smoking cessation and loneliness and social support were based on expert opinion. Key implementation considerations included the need for input from allied health professionals and support networks to implement this type of approach, the importance of partnering such recommendations with behaviour change support, and the need to deliver interventions using a biopsychosocial-cultural framework. CONCLUSIONS Lifestyle-based interventions are recommended as a foundational component of mental health care in clinical practice for adults with Major Depressive Disorder, where other evidence-based therapies can be added or used in combination. The findings and recommendations of these guidelines support the need for further research to address existing gaps in efficacy and implementation research, especially for emerging lifestyle-based approaches (e.g. green space, loneliness and social support interventions) where data are limited. Further work is also needed to develop innovative approaches for delivery and models of care, and to support the training of health professionals regarding lifestyle-based mental health care.
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Affiliation(s)
- Wolfgang Marx
- Deakin University, Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine, Barwon Health, Geelong, Australia
| | - Sam H Manger
- College of Medicine and Dentistry, James Cook University, Queensland, Australia
- Australasian Society of Lifestyle Medicine, Melbourne, Australia
| | - Mark Blencowe
- Australasian Society of Lifestyle Medicine, Melbourne, Australia
| | - Greg Murray
- Centre for Mental Health, Swinburne University of Technology, Melbourne, Australia
| | - Fiona Yan-Yee Ho
- Department of Psychology, The Chinese University of Hong Kong, Hong Kong SAR
| | - Sharon Lawn
- Lived Experience Australia Ltd, Adelaide, Australia
- Flinders University, College of Medicine and Public Health, Adelaide, Australia
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham NC 27710
| | - Felipe Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
| | - Anu Ruusunen
- Deakin University, Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine, Barwon Health, Geelong, Australia
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
- Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland
| | - Hanna Demelash Desyibelew
- Department of Nutrition and Dietetics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Felice Jacka
- Deakin University, Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine, Barwon Health, Geelong, Australia
| | - Arun Ravindran
- Department of Psychiatry & Institute of Medical Sciences, University of Toronto. Centre for Addiction and Mental Health, Toronto, Canada
| | - Michael Berk
- Deakin University, Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine, Barwon Health, Geelong, Australia
| | - Adrienne O'Neil
- Deakin University, Institute for Mental and Physical Health and Clinical Translation (IMPACT), Food & Mood Centre, School of Medicine, Barwon Health, Geelong, Australia
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Stonerock GL, Gupta RP, Blumenthal JA. Is exercise a viable therapy for anxiety? Systematic review of recent literature and critical analysis. Prog Cardiovasc Dis 2023:S0033-0620(23)00054-3. [PMID: 37244402 PMCID: PMC10674039 DOI: 10.1016/j.pcad.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVES Exercise has been promoted as a treatment for a variety of psychiatric conditions. The benefits of exercise for depression are widely recognized, but the benefits of exercise for anxiety are uncertain. Although several reviews promoted exercise as a treatment for anxiety, concerns about the quality of studies prompted us to provide a critical review of the recent literature to re-assess the value of exercise for treating anxiety. METHODS AND MATERIALS We conducted a systematic review of all peer-reviewed randomized clinical trials (RCTs) among adults, published between January 2014 and December 2021, with an exercise intervention and anxiety as the a priori primary outcome. Two reviewers independently extracted data from studies meeting inclusion criteria, including sample characteristics, exercise intervention, control conditions, primary anxiety measure, relevant findings, and methodological quality quantified by PEDro scores. RESULTS 7240 published studies from CINAHL, EMBASE, MEDLINE, and PsycINFO were screened in April 2022, with 1831 participants across 25 eligible RCTs, of which 13 included elevated anxiety at study entry as an eligibility criterion. Only two of these 13 studies, and five of 12 studies of non-anxious individuals, found anxiety to be reduced unequivocally with exercise. Most studies suffered from significant methodological limitations including concurrent therapies and lack of intention-to-treat analyses. CONCLUSION There remains considerable uncertainty about the value of exercise in reducing symptoms of anxiety, particularly among anxious individuals. The paucity of methodologically sound studies of patients with anxiety represents a significant gap in our knowledge and calls for more research in the area. Word count: 249.
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Affiliation(s)
- Gregory L Stonerock
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rahul P Gupta
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.
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Smith PJ, Sherwood A, Avorgbedor F, Ingle KK, Kraus WE, Hinderliter AE, Blumenthal JA. Sleep Quality, Metabolic Function, Physical Activity, and Neurocognition Among Individuals with Resistant Hypertension. J Alzheimers Dis 2023:JAD230029. [PMID: 37212110 DOI: 10.3233/jad-230029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Resistant hypertension (RH) is a major risk factor for stroke, cognitive decline, and dementia. Sleep quality is increasingly suggested to play an important role linking RH to cognitive outcomes, although the mechanisms linking sleep quality to poor cognitive function have yet to be fully delineated. OBJECTIVE To delineate biobehavioral mechanisms linking sleep quality, metabolic function, and cognitive function among 140 overweight/obese adults with RH in the TRIUMPH clinical trial. METHODS Sleep quality was indexed using actigraphy measures of sleep quality and sleep fragmentation, as well as self-reported sleep quality from the Pittsburgh Sleep Quality Index (PSQI). Cognitive function was assessed using a 45-minute battery assessing executive function, processing speed, and memory. Participants were randomized to a cardiac rehabilitation-based lifestyle program (C-LIFE) or a standardized education and physician advice condition (SEPA) for 4 months. RESULTS Better sleep quality at baseline was associated with better executive function (B = 0.18 p = 0.027), as well as greater fitness (B = 0.27, p = 0.007) and lower HBA1c (B = -0.25, p = 0.010). Cross-sectional analyses revealed that the sleep quality executive function association was mediated by HBA1c (B = 0.71 [0.05, 2.05]). C-LIFE improved sleep quality (-1.1 [-1.5, -0.6] versus+-0.1 [-0.8, 0.7]) and actigraphy steps (+922 [529, 1316] versus+56 [-548, 661]), with actigraphy mediating improvements in executive function (B = 0.40 [0.02, 1.07]). CONCLUSION Better metabolic function and improved physical activity patterns levels play important roles linking sleep quality and executive function in RH.
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Affiliation(s)
- Patrick J Smith
- Department of Psychiatry, University of North Carolina at Chapel Hill, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Forgive Avorgbedor
- Department of Nursing, University of North Carolina at Greensboro, NC, USA
| | - Krista K Ingle
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - William E Kraus
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alan E Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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9
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Rozanski A, Blumenthal JA, Hinderliter AL, Cole S, Lavie C. Cardiology and lifestyle medicine. Prog Cardiovasc Dis 2023; 77:4-13. [PMID: 37059409 DOI: 10.1016/j.pcad.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/09/2023] [Indexed: 04/16/2023]
Abstract
Poor lifestyle habits, such as physical inactivity and poor diets, are highly prevalent within society and even more so among patients with chronic disease. The need to stem poor lifestyle habits has led to the development of a new field of Lifestyle Medicine, whose mission is to prevent, treat, and even reverse chronic diseases through lifestyle interventions. Three fields within Cardiology relate to this mission: Cardiac Rehabilitation, Preventive Cardiology, and Behavioral Cardiology. Each of these three fields have contributed substantially to the reduction of cardiovascular disease (CVD) morbidity and mortality. The historic contributions of these three cardiac fields are reviewed as well as the challenges each of these fields has faced in optimizing the application of lifestyle medicine practices. A shared agenda between Cardiology and the American College of Lifestyle Medicine could further the utilization of behavioral interventions. This review suggests seven steps that could be shared by these organizations and other medical societies. First, there is a need to develop and promulgate the assessment of lifestyle factors as "vital signs" during patient visits. Second, developing a strong partnership between the fields of Cardiology and Physiatry could improve important aspects of cardiac care, including a potential redesign of cardiac stress testing. Third, behavioral evaluations should be optimized at patients' entrée points into medical care since these may be considered "windows of opportunity". Fourth, there is a need to broaden cardiac rehabilitation into inexpensive programs and make this program eligible for patients with risk factors but no known CVD. Fifth, lifestyle medicine education should be integrated into the core competencies for relevant specialties. Sixth, there is a need for inter-societal advocacy to promote lifestyle medicine practices. Seventh, the well-being effects of healthy lifestyle behaviors, such as their impact on one's sense of vitality, should be emphasized.
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Affiliation(s)
- Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, and the Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Alan L Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Steven Cole
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, United States of America
| | - Carl Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-the UQ School of Medicine, New Orleans, LA, United States of America
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10
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Avorgbedor F, McCoy TP, Silva S, Blumenthal JA, Merwin E, Yeo S, Holditch-Davis D. Infant Outcomes in Hypertensive Women: Are there Moderating Effects of Prenatal Care and Race/Ethnicity? Matern Child Health J 2023:10.1007/s10995-023-03661-0. [PMID: 37022515 DOI: 10.1007/s10995-023-03661-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Hypertensive disorders of pregnancy is one of the leading causes of adverse infant outcomes. Black women are disproportionately affected by hypertensive disorders of pregnancy, and it associated adverse outcomes. Adequate prenatal care may improve adverse infant outcomes. However, the evidence on adequate prenatal care improving birth outcomes for women with hypertensive disorders of pregnancy especially for Blacks is limited. This study examined the role of adequate prenatal care and race/ethnicity as moderators of hypertensive disorders of pregnancy on infant outcomes. METHODS The sample was obtained from the 2016-2019 Pregnancy Risk Assessment Monitoring Surveillance dataset from North Carolina. We compared adequate prenatal care among women with hypertensive disorders of pregnancy (n = 610) to women without(n = 2,827), and women with hypertensive disorders of pregnancy with adequate prenatal care to women hypertensive disorders of pregnancy with inadequate prenatal care. RESULTS The weighted prevalence of hypertensive disorders of pregnancy was 14.1%. Adequate prenatal care was associated with better infant outcomes for low birth weight (AOR = 0.72; 95% CI = 0.58, 0.90) and preterm birth (AOR = 0.62; 95% CI = 0.46, 0.82). Although these effects were not moderated by Black race/ethnicity, Black women independently also had worse outcomes for preterm birth (AOR = 1.59; 95% CI = 1.11, 2.28) and low birth weight (AOR = 1.81; 95% CI = 1.42, 2.29). CONCLUSIONS Moderation of hypertensive disorders of pregnancy effects on infant outcomes by prenatal care and race/ethnicity was not found. Women with hypertensive disorders of pregnancy who received inadequate prenatal care experienced worse adverse birth outcomes compared to women without hypertensive disorders of pregnancy. Strategies to improve prenatal care, particularly among underserved populations at risk for hypertensive disorders of pregnancy, need to be a public health priority.
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Affiliation(s)
- Forgive Avorgbedor
- School of Nursing, Duke University Medical Center, Durham, NC, England.
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, England.
- University of North Carolina at Greensboro School of Nursing, Greensboro, 27412, NC, USA.
| | - Thomas P McCoy
- University of North Carolina at Greensboro School of Nursing, Greensboro, 27412, NC, USA
| | - Susan Silva
- School of Nursing, Duke University Medical Center, Durham, NC, England
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, England
| | - Elizabeth Merwin
- School of Nursing, Duke University Medical Center, Durham, NC, England
| | - Seonae Yeo
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC, USA
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11
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Blumenthal JA, Rozanski A. Exercise as a therapeutic modality for the prevention and treatment of depression. Prog Cardiovasc Dis 2023; 77:50-58. [PMID: 36848966 DOI: 10.1016/j.pcad.2023.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023]
Abstract
While maintaining an active lifestyle and engaging in regular exercise are known to promote cardiovascular (CV) health, increasing evidence has emerged to indicate that these lifestyle behaviors also can promote psychological health and well-being. This has led to research to determine if exercise can serve as a potential therapeutic modality for major depressive disorder (MDD), which is a leading cause of mental-health impairment and overall disability worldwide. The strongest evidence to support this use comes from an increasing number of randomized clinical trials (RCTs) that have compared exercise to usual care, placebo controls, or established therapies in healthy adults and in various clinical populations. The relatively large number of RCTs has led to numerous reviews and meta-analyses, which generally have been concordant in indicating that exercise ameliorates depressive symptoms, improves self-esteem, and enhances various aspects of quality of life. Together, these data indicate that exercise should be considered as a therapeutic modality for improving CV health and psychological well-being. The emerging evidence also has led to a new proposed subspecialty of "lifestyle psychiatry", which promotes the use of exercise as an adjunctive treatment for patients with MDD. Indeed, some medical organizations have now endorsed lifestyle-based approaches as foundational aspects of depression management, with adoption of exercise as a treatment option for MDD. This review summarizes research in the area and provides practical suggestions for the use of exercise in clinical practice.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA.
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai Morningside Hospital, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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12
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Avorgbedor F, Blumenthal JA, Hinderliter A, Ingle K, Lin P, Craighead L, Tyson C, Kraus W, Sherwood A, Smith PJ. Inflammation moderates the effects of lifestyle modification on neurocognition among individuals with resistant hypertension. J Clin Hypertens (Greenwich) 2022; 25:106-110. [PMID: 36541028 PMCID: PMC9832225 DOI: 10.1111/jch.14591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/06/2022] [Accepted: 10/09/2022] [Indexed: 12/24/2022]
Abstract
Individuals with resistant hypertension (RH) have the greatest risk of cerebrovascular disease and cognitive impairment among individuals with hypertension. Elevated levels of pro-inflammatory cytokines may represent a critical yet unexamined factor influencing the impact of healthy lifestyle changes on cognitive function. We explored the influence of inflammation on changes in cognition following lifestyle modification among individuals with RH participating in the TRIUMPH clinical trial. One hundred forty participants with RH completed a battery of neurocognitive tests along with the inflammatory marker C-reactive protein (hsCRP) and were subsequently randomized to an intensive 4-month lifestyle modification intervention or to education and physician advice control. Results indicated that the effects of lifestyle modification on Executive Function and Learning were moderated by pre-intervention hsCRP levels (P = .049), with treatment efficacy increasing across levels of baseline inflammation levels (low: d = 0.12; mild: d = 0.43; moderate: d = 0.81). We conclude that inflammatory profiles may help identify individuals more likely to improve executive functioning resulting from lifestyle modification.
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Affiliation(s)
- Forgive Avorgbedor
- School of NursingUniversity of North Carolina at GreensboroNorth CarolinaUSA,Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Alan Hinderliter
- Department of MedicineUniversity of North Carolina at Chapel HillNorth CarolinaUSA
| | - Krista Ingle
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Pao‐Hwa Lin
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | | | - Crystal Tyson
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - William Kraus
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
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13
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Blumenthal JA, Smith PJ, Jiang W, Hinderliter A, Watkins LL, Hoffman BM, Kraus WE, Mabe S, Liao L, Davidson J, Sherwood A. Longer term benefits of exercise and escitalopram in the treatment of anxiety in patients with coronary heart disease: Six month follow-up of the UNWIND randomized clinical trial. Am Heart J 2022; 251:91-100. [PMID: 35609671 PMCID: PMC9473683 DOI: 10.1016/j.ahj.2022.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/18/2022] [Indexed: 06/01/2023]
Abstract
BACKGROUND Anxiety is a common comorbidity in patients with coronary heart disease (CHD) and is associated with worse prognosis. However, effective treatment for anxiety in CHD patients is uncertain. The UNWIND randomized clinical trial showed that 12-week treatment of escitalopram was better than exercise training or placebo in reducing anxiety in anxious CHD patients. The longer-term benefits of treatment for anxiety are not known. METHODS Patients were randomized to 12 weeks of Escitalopram (up to 20 mg), Exercise (3 times/wk), or placebo pill. At the conclusion of treatment, participants were followed for 6-months to determine the persistence of benefit on the primary anxiety endpoint assessed by the Hospital Anxiety and Depression Scale-Anxiety scale (HADS-A) and to assess the effects of treatment on major adverse cardiac events over a follow-up period of up to 6 years. RESULTS Of the 128 participants initially randomized, 120 (94%) were available for follow-up. Participants randomized to the Escitalopram condition exhibited lower HADS-A scores (3.9 [3.1, 4.7]) compared to those randomized to Exercise (5.5 [4.6, 6.3]) (P = .007) and Placebo (5.3 [4.1, 6.5]) (P = .053). Over a median follow-up of 3.2 years (IQR: 2.3, 4.5), there were 29 adverse events but no significant between-group differences. CONCLUSION In the UNWIND trial, 12 weeks of escitalopram treatment was effective in reducing anxiety. These beneficial effects were sustained for 6 months posttreatment. Although moderate or vigorous physical activity has a number of health benefits, exercise was not an effective treatment for anxiety in patients with CHD.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Wei Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lana L Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Benson M Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - William E Kraus
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Lawrence Liao
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Jonathan Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
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14
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Avorgbedor F, Silva S, McCoy TP, Blumenthal JA, Merwin E, Seonae Y, Holditch-Davis D. Hypertension and Infant Outcomes: North Carolina Pregnancy Risks Assessment Monitoring System Data. Pregnancy Hypertens 2022; 28:189-193. [DOI: 10.1016/j.preghy.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 04/08/2022] [Accepted: 05/05/2022] [Indexed: 10/18/2022]
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15
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Smith PJ, Sherwood A, Hinderliter AL, Mabe S, Tyson C, Avorgbedor F, Watkins LL, Lin PH, Kraus WE, Blumenthal JA. Cerebrovascular Function, Vascular Risk, and Lifestyle Patterns in Resistant Hypertension. J Alzheimers Dis 2022; 87:345-357. [PMID: 35275539 DOI: 10.3233/jad-215522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Impaired cerebrovascular reactivity (CVR) and blunted cerebral hemodynamic recruitment are thought to be important mechanisms linking hypertension to cerebrovascular and cognitive outcomes. Few studies have examined cardiovascular or dietary correlates of CVR among hypertensives. OBJECTIVE To delineate associations between cardiometabolic risk, diet, and cerebrovascular functioning among individuals with resistant hypertension from the TRIUMPH trial (n = 140). METHODS CVR was assessed by examining changes in tissue oxygenation (tissue oxygenation index [TOI] and oxygenated hemoglobin [HBO2]) using functional near-infrared spectroscopy (fNIRS) during a breath holding test, a standardized CVR assessment to elicit a hypercapnic response. Participants also underwent fNIRS during three cognitive challenge tasks. Vascular function was assessed by measurement of brachial artery flow mediated dilation and hyperemic flow response. Cardiometabolic fitness was assessed from peak VO2 on an exercise treadmill test and body mass index. Dietary patterns were quantified using the DASH eating score. Cognitive function was assessed using a 45-minute test battery assessing Executive Function, Processing Speed, and Memory. RESULTS Greater levels fitness (B = 0.30, p = 0.011), DASH compliance (B = 0.19, p = 0.045), and lower obesity (B = -0.30, p = 0.004), associated with greater changes in TOI, whereas greater flow-mediated dilation (B = 0.19, p = 0.031) and lower stroke risk (B = -0.19, p = 0.049) associated with greater HBO2. Similar associations were found for cerebral hemodynamic recruitment, and associations between CVR and cognition were moderated by duration of hypertension. CONCLUSION Impaired CVR elevated cardiometabolic risk, obesity, vascular function, and fitness among hypertensives.
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Affiliation(s)
- Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Alan L Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Crystal Tyson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Forgive Avorgbedor
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Lana L Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Pao-Hwa Lin
- Department of Medicine and Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - William E Kraus
- Department of Medicine and Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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16
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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17
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Zhu Y, Li C, Xie W, Zhong B, Wu Y, Blumenthal JA. Trajectories of depressive symptoms and subsequent cognitive decline in older adults: a pooled analysis of two longitudinal cohorts. Age Ageing 2022; 51:6398536. [PMID: 34657957 DOI: 10.1093/ageing/afab191] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND the course of depression is variable, but it is unknown how this variability over time affects long-term cognitive decline. OBJECTIVE to examine the relationship of different trajectories of depressive symptoms on rates of subsequent cognitive decline in older adults. DESIGN population-based cohort study. SETTING communities in the USA and England. SUBJECTS 17,556 older adults from the Health and Retirement Study and the English Longitudinal Study of Ageing. METHODS depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale, and trajectories were calculated using group-based trajectory modelling. Global cognitive function and three cognitive domains of memory, executive function and temporal orientation were assessed for up to 18 years. RESULTS five trajectories of depressive symptoms were identified. Compared with the 'non-depressed' trajectory, the 'worsening depressive symptoms' trajectory (pooled β = -0.016 standard deviation (SD)/year, 95% confidence interval (CI): -0.021 to -0.010), 'persistent depressive symptoms' trajectory (pooled β = -0.016 SD/year, 95% CI: -0.024 to -0.008), and 'mild depressive symptoms' trajectory (pooled β = -0.008 SD/year, 95% CI: -0.014 to -0.003) were associated with faster rates of cognitive decline, while no such association was found for the 'improving depressive symptoms' trajectory (pooled β = 0.001 SD/year, 95% CI: -0.010 to 0.012). CONCLUSIONS subthreshold depressive symptoms are associated with an increased rate of cognitive decline, while individuals who show improving depressive symptoms do not exhibit accelerated cognitive decline. These findings raise the possibility that maintaining depressive symptoms as low as possible and ignoring the clinical threshold, might mitigate cognitive decline in older adults.
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Affiliation(s)
- Yidan Zhu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Chenglong Li
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Wuxiang Xie
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Baoliang Zhong
- Affiliated Wuhan Mental Health Center, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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18
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Somers TJ, Blumenthal JA, Dorfman CS, Huffman KM, Edmond SN, Miller SN, Wren AA, Caldwell D, Keefe FJ. Effects of a Weight and Pain Management Program in Patients With Rheumatoid Arthritis With Obesity: A Randomized Controlled Pilot Investigation. J Clin Rheumatol 2022; 28:7-13. [PMID: 34670994 DOI: 10.1097/rhu.0000000000001793] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity is associated with poor outcomes for patients with rheumatoid arthritis (RA). Effective weight management is imperative. Although traditional lifestyle behavioral weight loss programs have demonstrated efficacy for reducing weight, these interventions do not meet the pain-related weight loss challenges of RA patients with obesity. OBJECTIVE A 12-session group program (90 minutes per session) was developed integrating pain coping skills training into a lifestyle behavioral weight loss intervention. In addition to the weekly group sessions, participants engaged in supervised exercise sessions 3 times per week. METHODS Through a small, pilot randomized trial, 50 participants were randomized to receive the intervention (n = 29) or standard care of RA (n = 21). Feasibility data (i.e., accrual, attrition, adherence) was examined using descriptive statistics (e.g., percent). We examined patterns of change in study outcomes from baseline to follow-up separately for the intervention and standard care arms using descriptive statistics and paired t tests. Effect sizes are also presented. RESULTS Of those randomized to the intervention group,79.3% initiated treatment, with participants attending 74.3% of group skills sessions and 64.2% of exercise sessions. Intervention participants evidenced reductions in weight (mean, -2.28 kg) and waist circumference (mean, -4.76 cm) and improvements in physical functioning, eating behaviors, pain, and self-efficacy for weight control. CONCLUSIONS Findings suggest that incorporating a combined pain coping skills training and behavioral weight loss intervention into medical management of RA may improve outcomes. Study accrual and attrition, as well as intervention adherence, will inform future, larger randomized efficacy trials of the intervention.Retrospectively registered: January 29, 2020, NCT04246827.
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Affiliation(s)
| | | | | | - Kim M Huffman
- Medicine, Duke University Medical Center, Durham, NC
| | | | | | - Anava A Wren
- Department of Pediatrics, Stanford Medical Center, Stanford, CA
| | - David Caldwell
- Division of Rheumatology, Duke University Medical Center, Durham, NC
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19
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Saco-Ledo G, Valenzuela PL, Ramírez-Jiménez M, Morales JS, Castillo-García A, Blumenthal JA, Ruilope LM, Lucia A. Acute Aerobic Exercise Induces Short-Term Reductions in Ambulatory Blood Pressure in Patients With Hypertension: A Systematic Review and Meta-Analysis. Hypertension 2021; 78:1844-1858. [PMID: 34719262 DOI: 10.1161/hypertensionaha.121.18099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Gonzalo Saco-Ledo
- Bioenergy and Motion Analysis Laboratory, National Research Center on Human Evolution (CENIEH), Burgos, Spain (G.S.-L.)
| | - Pedro L Valenzuela
- Faculty of Sport Sciences, European University of Madrid, Spain (P.L.V., L.M.R., A.L.)
| | - Miguel Ramírez-Jiménez
- Exercise Physiology Laboratory, University of Castilla-La Mancha, Toledo, Spain (M.R.-J.).,Faculty of Social Sciences and Law, Catholic University of Avila, Avila, Spain (M.R.-J.)
| | - Javier S Morales
- MOVE-IT Research Group, Department of Physical Education, Faculty of Education Sciences, University of Cadiz, Spain (J.S.M.)
| | | | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC (J.A.B.)
| | - Luis M Ruilope
- Faculty of Sport Sciences, European University of Madrid, Spain (P.L.V., L.M.R., A.L.).,Hypertension Unit and Cardiorenal Translational Laboratory, Madrid, Spain (L.M.R.).,Research Institute of the Hospital Universitario 12 de Octubre ('imas12'), Madrid, Spain (L.M.R., A.L.)
| | - Alejandro Lucia
- Faculty of Sport Sciences, European University of Madrid, Spain (P.L.V., L.M.R., A.L.).,Research Institute of the Hospital Universitario 12 de Octubre ('imas12'), Madrid, Spain (L.M.R., A.L.)
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20
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Blumenthal JA, Smith PJ, Jiang W, Hinderliter A, Watkins LL, Hoffman BM, Kraus WE, Liao L, Davidson J, Sherwood A. Effect of Exercise, Escitalopram, or Placebo on Anxiety in Patients With Coronary Heart Disease: The Understanding the Benefits of Exercise and Escitalopram in Anxious Patients With Coronary Heart Disease (UNWIND) Randomized Clinical Trial. JAMA Psychiatry 2021; 78:1270-1278. [PMID: 34406354 PMCID: PMC8374738 DOI: 10.1001/jamapsychiatry.2021.2236] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Anxiety is common among patients with coronary heart disease (CHD) and is associated with worse health outcomes; however, effective treatment for anxiety in patients with CHD is uncertain. OBJECTIVE To determine whether exercise and escitalopram are better than placebo in reducing symptoms of anxiety as measured by the Hospital Anxiety and Depression-Anxiety Subscale (HADS-A) and in improving CHD risk biomarkers. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted between January 2016 and May 2020 in a tertiary care teaching hospital in the US and included 128 outpatients with stable CHD and a diagnosed anxiety disorder or a HADS-A score of 8 or higher who were older than 40 years, sedentary, and not currently receiving mental health treatment. INTERVENTIONS Twelve weeks of aerobic exercise 3 times per week at an intensity of 70% to 85% heart rate reserve, escitalopram (up to 20 mg per day), or placebo pill equivalent. MAIN OUTCOMES AND MEASURES The primary outcome was HADS-A score. CHD biomarkers included heart rate variability, baroreflex sensitivity, and flow-mediated dilation, along with 24-hour urinary catecholamines. RESULTS The study included 128 participants. The mean (SD) age was 64.6 (9.6) years, and 37 participants (29%) were women. Participants randomized to the exercise group and escitalopram group reported greater reductions in HADS-A (exercise, -4.0; 95% CI, -4.7 to -3.2; escitalopram, -5.7; 95% CI, -6.4 to -5.0) compared with those randomized to placebo (-3.5; 95% CI, -4.5 to -2.4; P = .03); participants randomized to escitalopram reported less anxiety compared with those randomized to exercise (-1.67; 95% CI, -2.68 to -0.66; P = .002). Significant postintervention group differences in 24-hour urinary catecholamines were found (exercise z score = 0.05; 95% CI, -0.2 to 0.3; escitalopram z score = -0.24; 95% CI, -0.4 to 0; placebo z score = 0.36; 95% CI, 0 to 0.7), with greater reductions in the exercise group and escitalopram group compared with the placebo group (F1,127 = 4.93; P = .01) and greater reductions in the escitalopram group compared with the exercise group (F1,127 = 4.37; P = .04). All groups achieved comparable but small changes in CHD biomarkers, with no differences between treatment groups. CONCLUSIONS AND RELEVANCE Treatment of anxiety with escitalopram was safe and effective for reducing anxiety in patients with CHD. However, the beneficial effects of exercise on anxiety symptoms were less consistent. Exercise and escitalopram did not improve CHD biomarkers of risk, which should prompt further investigation of these interventions on clinical outcomes in patients with anxiety and CHD. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02516332.
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Affiliation(s)
- James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Wei Jiang
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Lana L. Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Benson M. Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - William E. Kraus
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lawrence Liao
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jonathan Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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21
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Blumenthal JA, Hinderliter AL, Smith PJ, Mabe S, Watkins LL, Craighead L, Ingle K, Tyson C, Lin PH, Kraus WE, Liao L, Sherwood A. Effects of Lifestyle Modification on Patients With Resistant Hypertension: Results of the TRIUMPH Randomized Clinical Trial. Circulation 2021; 144:1212-1226. [PMID: 34565172 DOI: 10.1161/circulationaha.121.055329] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Although lifestyle modifications generally are effective in lowering blood pressure (BP) among patients with unmedicated hypertension and in those treated with 1 or 2 antihypertensive agents, the value of exercise and diet for lowering BP in patients with resistant hypertension is unknown. METHODS One hundred forty patients with resistant hypertension (mean age, 63 years; 48% female; 59% Black; 31% with diabetes; 21% with chronic kidney disease) were randomly assigned to a 4-month program of lifestyle modification (C-LIFE [Center-Based Lifestyle Intervention]) including dietary counseling, behavioral weight management, and exercise, or a single counseling session providing SEPA (Standardized Education and Physician Advice). The primary end point was clinic systolic BP; secondary end points included 24-hour ambulatory BP and select cardiovascular disease biomarkers including baroreflex sensitivity to quantify the influence of the baroreflex on heart rate, high-frequency heart rate variability to assess vagally mediated modulation of heart rate, flow-mediated dilation to evaluate endothelial function, pulse wave velocity to assess arterial stiffness, and left ventricular mass to characterize left ventricular structure. RESULTS Between-group comparisons revealed that the reduction in clinic systolic BP was greater in C-LIFE (-12.5 [95% CI, -14.9 to -10.2] mm Hg) compared with SEPA(-7.1 [-95% CI, 10.4 to -3.7] mm Hg) (P=0.005); 24-hour ambulatory systolic BP also was reduced in C-LIFE (-7.0 [95% CI, -8.5 to -4.0] mm Hg), with no change in SEPA (-0.3 [95% CI, -4.0 to 3.4] mm Hg) (P=0.001). Compared with SEPA, C-LIFE resulted in greater improvements in resting baroreflex sensitivity (2.3 ms/mm Hg [95% CI, 1.3 to 3.3] versus -1.1 ms/mm Hg [95% CI, -2.5 to 0.3]; P<0.001), high-frequency heart rate variability (0.4 ln ms2 [95% CI, 0.2 to 0.6] versus -0.2 ln ms2 [95% CI, -0.5 to 0.1]; P<0.001), and flow-mediated dilation (0.3% [95% CI, -0.3 to 1.0] versus -1.4% [95% CI, -2.5 to -0.3]; P=0.022). There were no between-group differences in pulse wave velocity (P=0.958) or left ventricular mass (P=0.596). CONCLUSIONS Diet and exercise can lower BP in patients with resistant hypertension. A 4-month structured program of diet and exercise as adjunctive therapy delivered in a cardiac rehabilitation setting results in significant reductions in clinic and ambulatory BP and improvement in selected cardiovascular disease biomarkers. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02342808.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., L.L.W., K.I., A.S.), Duke University Medical Center, Durham, NC
| | - Alan L Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill (A.L.H.)
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., L.L.W., K.I., A.S.), Duke University Medical Center, Durham, NC
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., L.L.W., K.I., A.S.), Duke University Medical Center, Durham, NC
| | - Lana L Watkins
- Department of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., L.L.W., K.I., A.S.), Duke University Medical Center, Durham, NC
| | - Linda Craighead
- Department of Psychology, Emory University, Atlanta, GA (L.C.)
| | - Krista Ingle
- Department of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., L.L.W., K.I., A.S.), Duke University Medical Center, Durham, NC
| | - Crystal Tyson
- Department of Medicine (C.T., P.-H.L., W.E.K., L.L.), Duke University Medical Center, Durham, NC
| | - Pao-Hwa Lin
- Department of Medicine (C.T., P.-H.L., W.E.K., L.L.), Duke University Medical Center, Durham, NC
| | - William E Kraus
- Department of Medicine (C.T., P.-H.L., W.E.K., L.L.), Duke University Medical Center, Durham, NC
| | - Lawrence Liao
- Department of Medicine (C.T., P.-H.L., W.E.K., L.L.), Duke University Medical Center, Durham, NC
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., L.L.W., K.I., A.S.), Duke University Medical Center, Durham, NC
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22
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Malian HM, Smith PJ, Hoffman B, Jiang W, Ammerman K, Kraus WE, Hinderliter A, Sherwood A, Blumenthal JA. Effects of Acute Exercise on Anxiety Ratings in Patients With Coronary Heart Disease and Elevated Anxiety. J Cardiopulm Rehabil Prev 2021; 41:277-281. [PMID: 34158457 PMCID: PMC9558052 DOI: 10.1097/hcr.0000000000000579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To explore individual differences in state anxiety following a single, acute bout of aerobic exercise among anxious patients with diagnosed coronary heart disease (CHD). METHODS One hundred eighteen CHD patients with elevated symptoms of anxiety enrolled in the UNderstanding the Benefits of Exercise and Escitalopram in Anxious Patients WIth coroNary Heart Disease (UNWIND) clinical trial rated their level of anxiety using a 100-mm visual analog scale before and after a symptom-limited exercise treadmill test. A number of exercise (eg, peak oxygen uptake, exercise duration, maximum heart rate, anaerobic threshold) and psychological variables were examined as potential predictors of exercise response. Changes in anxiety and their association with psychological variables were examined using general linear models. RESULTS Fifty patients (42%) rated a reduction in anxiety relative to their pre-exercise ratings following the exercise treadmill test. While a number of factors were examined, the only factor that distinguished those individuals who reported a reduction in anxiety symptoms compared with those who either remained the same or actually reported an increase in anxiety was a higher pre-exercise visual analog scale anxiety rating. No differences were observed as a function of sex, severity of trait anxiety, the presence of an anxiety disorder, exercise test duration, or age. CONCLUSIONS Although many variables were examined, only higher baseline anxiety distinguished those who showed a reduction in their visual analog scale ratings from those whose anxiety remained the same or got worse. The extent to which the response to acute exercise predicts the anxiolytic effects of chronic exercise needs further study.
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Affiliation(s)
- Hannah M Malian
- Departments of Psychiatry and Behavioral Sciences (Mss Malian and Ammerman and Drs Smith, Hoffman, Jiang, Sherwood, and Blumenthal) and Medicine (Dr Kraus), Duke University Medical Center, Durham, North Carolina; and Department of Medicine (Dr Hinderliter), University of North Carolina Hospitals, Chapel Hill, North Carolina
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23
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Hill LK, Wu JQ, Hinderliter AL, Blumenthal JA, Sherwood A. Actigraphy-Derived Sleep Efficiency Is Associated With Endothelial Function in Men and Women With Untreated Hypertension. Am J Hypertens 2021; 34:207-211. [PMID: 33048161 DOI: 10.1093/ajh/hpaa167] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/21/2020] [Accepted: 10/07/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Poor sleep quality is increasingly recognized as an important and potentially modifiable risk factor for cardiovascular disease (CVD). Impaired endothelial function may be 1 mechanism underlying the association between poor sleep and CVD risk. The present study examined the relationship between objective measures of sleep quality and endothelial function in a sample of untreated hypertensive adults. METHODS Participants were 127 men (N = 74) and women (N = 53), including 55 African Americans and 72 White Americans, aged 40-60 years (mean age, 45.3 ± 8.5 years), with untreated hypertension (systolic blood pressure 130-159 mm Hg and/or diastolic blood pressure 85-99 mm Hg). Noninvasive brachial artery flow-mediated dilation (FMD) was assessed by ultrasound. Sleep parameters, including sleep efficiency (SE), total sleep time (TST), and subjective sleep quality, were assessed over 7 consecutive days by wrist actigraphy. RESULTS Participants averaged 7.76 ± 1 hours in bed, with an average SE of 78 ± 9%, and TST of 6 ± 1 hours. Brachial FMD averaged 3.5 ± 3.1%. In multivariate analyses controlling for sex, race, body mass index, clinic blood pressure, income, smoking, alcohol use, and baseline arterial diameter, SE was positively associated with FMD (β = 0.28, P = 0.012). Subjective sleep quality (β = -0.04, P = 0.63) and TST (β = -0.11, P = 0.25) were unrelated to FMD. CONCLUSIONS Poor sleep as indicated by low SE was associated with impaired FMD. These findings for SE are consistent with previous observations of other measures implicating poor sleep as a CVD risk factor. Interventions that improve sleep may also help lower CVD risk.
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Affiliation(s)
- LaBarron K Hill
- Department of Psychiatry and Behavioral Sciences Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jade Q Wu
- Department of Psychiatry and Behavioral Sciences Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Alan L Hinderliter
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences Medicine, Duke University Medical Center, Durham, North Carolina, USA
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24
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Hayano J, Ueda N, Kisohara M, Yuda E, Watanabe E, Carney RM, Blumenthal JA. Risk stratification after acute myocardial infarction by amplitude-frequency mapping of cyclic variation of heart rate. Ann Noninvasive Electrocardiol 2021; 26:e12825. [PMID: 33527584 PMCID: PMC8164146 DOI: 10.1111/anec.12825] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/02/2020] [Accepted: 12/16/2020] [Indexed: 01/19/2023] Open
Abstract
Background Blunted cyclic variation of heart rate (CVHR), measured as a decrease in CVHR amplitude (Acv), predicts mortality risk after acute myocardial infarction (AMI). However, Acv also can be reduced in mild sleep apnea with mild O2 desaturation. We investigated whether Acv's predictive power for post‐AMI mortality could be improved by considering the effect of sleep apnea severity. Methods In 24‐hr ECG in 265,291 participants of the Allostatic State Mapping by Ambulatory ECG Repository project, sleep apnea severity was estimated by the frequency of CVHR (Fcv) measured by an automated algorithm for auto‐correlated wave detection by adaptive threshold (ACAT). The distribution of Acv on the Acv–Fcv relation map was modeled by percentile regression, and a function converting Acv into percentile value was developed. In the retrospective cohort of the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, consisting of 673 survivors and 44 non‐survivors after AMI, the mortality predictive power of percentile Acv calculated by the function was compared with that of unadjusted Acv. Results Among the ALLSTAR ECG data, low Acv values appeared more likely when Fcv was low. The logistic regression analysis for mortality in the ENRICHD cohort showed c‐statistics of 0.667 (SE, 0.041), 0.817 (0.035), and 0.843 (0.030) for Fcv, unadjusted Acv, and the percentile Acv, respectively. Compared with unadjusted Acv, the percentile Acv showed a significant net reclassification improvement of 0.90 (95% CI, 0.51–1.42). Conclusions The predictive power of Acv for post‐AMI mortality is improved by considering its relation to sleep apnea severity estimated by Fcv.
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Affiliation(s)
- Junichiro Hayano
- Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Norihiro Ueda
- Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaya Kisohara
- Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Emi Yuda
- Tohoku University Graduate School of Engineering, Sendai, Japan
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Robert M Carney
- Department of Psychiatry, Washington University School of Medicine, St Louis, MI, USA
| | - James A Blumenthal
- Department of Psychiatry, Duke University Medical Center, Durham, NC, USA
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25
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Blumenthal JA, Babyak MA, Craighead WE, Davidson J, Hinderliter A, Hoffman B, Doraiswamy PM, Sherwood A. The role of comorbid anxiety in exercise and depression trials: Secondary analysis of the SMILE-II randomized clinical trial. Depress Anxiety 2021; 38:124-133. [PMID: 32790020 PMCID: PMC7878576 DOI: 10.1002/da.23088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/02/2020] [Accepted: 07/29/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To explore the anxiolytic effects of a 4-month randomized, placebo-controlled trial of exercise and antidepressant medication in patients with major depressive disorder (MDD), and to examine the potential modifying effects of anxiety in treating depressive symptoms. MATERIALS AND METHODS In this secondary analysis of the SMILE-II trial, 148 sedentary adults with MDD were randomized to: (a) supervised exercise, (b) home-based exercise, (c) sertraline, or (d) placebo control. Symptoms of state anxiety measured by the Spielberger Anxiety Inventory were examined before and after 4 months of treatment. Depressive symptoms were assessed by the Hamilton Depression Rating Scale (HAMD) and Beck Depression Inventory-II (BDI-II). Analyses were carried out using general linear models. RESULTS Compared to placebo controls, the exercise and sertraline groups had lower state anxiety scores (standardized difference = 0.3 [95% CI = -0.6, -0.04]; p = 0.02) after treatment. Higher pretreatment state anxiety was associated with poorer depression outcomes in the active treatments compared to placebo controls for both the HAMD (p = .004) and BDI-II (p = .02). CONCLUSION Aerobic exercise as well as sertraline reduced symptoms of state anxiety in patients with MDD. Higher levels of pretreatment anxiety attenuated the effects of the interventions on depressive symptoms, however, especially among exercisers. Patients with MDD with higher comorbid state anxiety appear to be less likely to benefit from exercise interventions in reducing depression and thus may require supplemental treatment with special attention to anxiety.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Michael A Babyak
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Wade Edward Craighead
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia
| | - Jonathan Davidson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Alan Hinderliter
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Benson Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | | | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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26
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Hayano J, Ueda N, Kisohara M, Yuda E, Carney RM, Blumenthal JA. Survival Predictors of Heart Rate Variability After Myocardial Infarction With and Without Low Left Ventricular Ejection Fraction. Front Neurosci 2021; 15:610955. [PMID: 33633535 PMCID: PMC7901937 DOI: 10.3389/fnins.2021.610955] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/06/2021] [Indexed: 01/01/2023] Open
Abstract
Background Heart rate variability (HRV) and heart rate (HR) dynamics are used to predict the survival probability of patients after acute myocardial infarction (AMI), but the association has been established in patients with mixed levels of left ventricular ejection fraction (LVEF). Objective We investigated whether the survival predictors of HRV and HR dynamics depend on LVEF after AMI. Methods We studied 687 post-AMI patients including 147 with LVEF ≤35% and 540 with LVEF >35%, of which 23 (16%) and 22 (4%) died during the 25 month follow-up period, respectively. None had an implanted cardioverter-defibrillator. From baseline 24 h ECG, the standard deviation (SDNN), root mean square of successive difference (rMSSD), percentage of successive difference >50 ms (pNN50) of normal-to-normal R-R interval, ultra-low (ULF), very-low (VLF), low (LF), and high (HF) frequency power, deceleration capacity (DC), short-term scaling exponent (α1), non-Gaussianity index (λ25s), and the amplitude of cyclic variation of HR (Acv) were calculated. Results The predictors were categorized into three clusters; DC, SDNN, α1, ULF, VLF, LF, and Acv as Cluster 1, λ25s independently as Cluster 2, and rMSSD, pNN50, and HF as Cluster 3. In univariate analyses, mortality was best predicted by indices belonging to Cluster 1 regardless of LVEF. In multivariate analyses, however, mortality in patients with low LVEF was best predicted by the combinations of Cluster 1 predictors or Cluster 1 and 3 predictors, whereas in patients without low LVEF, it was best predicted by the combinations of Cluster 1 and 2 predictors. Conclusion The mortality risk in post-AMI patients with low LVEF is predicted by indices reflecting decreased HRV or HR responsiveness and cardiac parasympathetic dysfunction, whereas in patients without low LVEF, the risk is predicted by a combination of indices that reflect decreased HRV or HR responsiveness and indicator that reflects abrupt large HR changes suggesting sympathetic involvement.
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Affiliation(s)
- Junichiro Hayano
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Norihiro Ueda
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaya Kisohara
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Emi Yuda
- Tohoku University Graduate School of Engineering, Sendai, Japan
| | - Robert M Carney
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - James A Blumenthal
- Department of Psychiatry, Duke University Medical Center, Durham, NC, United States
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27
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Chen L, Zhu H, Su S, Harshfield G, Sullivan J, Webb C, Blumenthal JA, Wang X, Huang Y, Treiber FA, Kapuku G, Li W, Dong Y. High-Mobility Group Box-1 Is Associated With Obesity, Inflammation, and Subclinical Cardiovascular Risk Among Young Adults: A Longitudinal Cohort Study. Arterioscler Thromb Vasc Biol 2020; 40:2776-2784. [PMID: 32814439 PMCID: PMC7578115 DOI: 10.1161/atvbaha.120.314599] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE We aimed to characterize circulating HMGB1 (high-mobility group box-1) levels, one of the better-characterized damage-associated molecular patterns, with respect to age, sex, and race in the general population, and investigate the longitudinal associations of HMGB1 with inflammatory markers, obesity, and preclinical markers of cardiovascular disease. Approach and Results: The analyses included 489 participants (50% Blacks, aged 24.6±3.3 years at the first visit) with up to 4 follow-up visits (1149 samples) over a maximum of 8.5 years. Systolic blood pressure, diastolic blood pressure, carotid-femoral pulse wave velocity, and carotid intima-media thickness together with plasma HMGB1, hs-CRP (high-sensitivity C-reactive protein), IFN-γ (interferon-γ), IL-6 (interleukin-6), IL-10 (interleukin-10), and TNF-α (tumor necrosis factor-α) were measured at each visit. At baseline, plasma HMGB1 concentrations were higher in Blacks compared with Whites (3.86 versus 3.20 ng/mL, P<0.001), and in females compared with males (3.75 versus 3.30 ng/mL, P=0.005). HMGB1 concentrations increased with age (P=0.007), and higher levels of obesity measures (P<0.001). Without adjustment for age, sex, race, and body mass index, HMGB1 concentrations were positively associated with hs-CRP, IL-6, TNF-α, systolic blood pressure, diastolic blood pressure, and carotid-femoral pulse wave velocity (P<0.05) but not IL-10, IFN-γ or carotid intima-media thickness. After covariate adjustments, the associations of HMGB1 with hs-CRP, and carotid-femoral pulse wave velocity remained statistically significant (P<0.05). CONCLUSIONS This study demonstrates the age, sex, and race differences in circulating HMGB1. The increasing circulating concentrations of HMGB1 with age suggest a potential role of HMGB1 in the pathogenesis of chronic low-grade inflammation, obesity, and subclinical cardiovascular disease risk.
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Affiliation(s)
- Li Chen
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Haidong Zhu
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Shaoyong Su
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Gregory Harshfield
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Jennifer Sullivan
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Clinton Webb
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Xiaoling Wang
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Ying Huang
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Frank A. Treiber
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Gaston Kapuku
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Yanbin Dong
- Georgia Prevention Institute, Department of Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
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28
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Chu MC, Smith PJ, Reynolds JM, Palmer SM, Snyder LD, Gray AL, Blumenthal JA. Depression, Immunosuppressant Levels, and Clinical Outcomes in Postlung Transplant Recipients. Int J Psychiatry Med 2020; 55:421-436. [PMID: 32052665 DOI: 10.1177/0091217420906637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Posttransplant depression has been linked to increased risk for adverse outcomes in lung transplant patients. Maintaining target serum immunosuppressant levels is also essential for optimal lung transplant clinical outcome and may be a crucial predictor of outcomes. Because depression could affect medication nonadherence, resulting in out-of-range immunosuppressant levels, we examined the relationship between posttransplant depression, immunosuppressant medication trough level variability, indexed by out-of-range values on clinical outcomes and coefficient of variability, and clinical outcomes. METHOD A consecutive series of 236 lung transplant recipients completed the Center for Epidemiological Studies-Depression two-month posttransplant. Immunosuppressant trough levels (i.e., tacrolimus or cyclosporine) within the range of individualized immunosuppressant targets were obtained at three-, six-, nine-month follow-up clinic visits. Clinical outcomes including hospitalizations and mortality were obtained from medical records. RESULTS Fourteen percent of patients were classified as depressed (Center for Epidemiological Studies-Depression ≥16), 144 (61%) of patients had at least 25% out-of-range immunosuppressant values, and the average coefficient of variability was 36%. Over a median of 2.6 years (interquartile range = 1.2), 32 participants died (14%) and 144 (61%) had at least one unplanned, transplant-related hospitalization. Both depression (hazard ratio = 1.45 (1.19, 1.76), p < . 01) and immunosuppressant variation (immunosuppressant out-of-range: hazard ratio = 1.41 (1.10, 1.81), p < .01) independently predicted more frequent hospitalizations and higher mortality. CONCLUSIONS Early posttransplant depression was associated with significantly worse clinical outcomes. While immunosuppressant level variability is also related to adverse outcomes, such variability does not account for increased risk observed with depression.
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Affiliation(s)
- Michael C Chu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - John M Reynolds
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Scott M Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alice L Gray
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Yano Y, Viera AJ, Hinderliter AL, Watkins LL, Blumenthal JA, Johnson KS, Hill LK, Sherwood A. Vascular α1-Adrenergic Receptor Responsiveness in Masked Hypertension. Am J Hypertens 2020; 33:713-717. [PMID: 32128568 PMCID: PMC7402222 DOI: 10.1093/ajh/hpaa032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Masked hypertension (nonhypertensive in the clinic setting but hypertensive outside the clinic during wakefulness) is characterized by increased blood pressure in response to physical and emotional stressors that activate the sympathetic nervous system (SNS). However, no studies have assessed vascular reactivity to a pharmacological SNS challenge in individuals with masked hypertension. METHODS We analyzed data from 161 adults aged 25 to 45 years (mean ± standard deviation age 33 ± 6 years; 48% were African American and 43% were female). Participants completed ambulatory blood pressure monitoring, and a standardized α 1-adrenergic agonist phenylephrine test that determines the dose of phenylephrine required to increase a participant's mean arterial pressure by 25 mm Hg (PD25). RESULTS Twenty-one participants were considered to have masked hypertension (clinic systolic blood pressure (SBP) <140 and diastolic blood pressure (DBP) <90 mm Hg but awake SBP ≥135 or DBP ≥85 mm Hg), 28 had sustained hypertension (clinic SBP ≥140 or DBP ≥90 mm Hg and awake SBP ≥135 or DBP ≥85 mm Hg), and 106 had sustained normotension (clinic SBP <140 and DBP <90 mm Hg and awake SBP <135 and DBP <85 mm Hg). After multivariable adjustment, the mean (±SE) PD25 was less in participants with masked hypertension compared with their counterparts with sustained normotension (222.1 ± 33.2 vs. 328.7 ± 15.0; P = 0.012), but similar to that observed in subjects with sustained hypertension (254.8 ± 31.0; P =0.12). CONCLUSIONS Among young and middle-aged adults, masked hypertension is associated with increased vascular reactivity to a SNS challenge, which may contribute to elevated awake BPs as well as to increased cardiovascular disease risk.
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Affiliation(s)
- Yuichiro Yano
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Anthony J Viera
- Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Alan L Hinderliter
- Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lana L Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kristy S Johnson
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - LaBarron K Hill
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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30
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Willeit P, Tschiderer L, Allara E, Reuber K, Seekircher L, Gao L, Liao X, Lonn E, Gerstein HC, Yusuf S, Brouwers FP, Asselbergs FW, van Gilst W, Anderssen SA, Grobbee DE, Kastelein JJP, Visseren FLJ, Ntaios G, Hatzitolios AI, Savopoulos C, Nieuwkerk PT, Stroes E, Walters M, Higgins P, Dawson J, Gresele P, Guglielmini G, Migliacci R, Ezhov M, Safarova M, Balakhonova T, Sato E, Amaha M, Nakamura T, Kapellas K, Jamieson LM, Skilton M, Blumenthal JA, Hinderliter A, Sherwood A, Smith PJ, van Agtmael MA, Reiss P, van Vonderen MGA, Kiechl S, Klingenschmid G, Sitzer M, Stehouwer CDA, Uthoff H, Zou ZY, Cunha AR, Neves MF, Witham MD, Park HW, Lee MS, Bae JH, Bernal E, Wachtell K, Kjeldsen SE, Olsen MH, Preiss D, Sattar N, Beishuizen E, Huisman MV, Espeland MA, Schmidt C, Agewall S, Ok E, Aşçi G, de Groot E, Grooteman MPC, Blankestijn PJ, Bots ML, Sweeting MJ, Thompson SG, Lorenz MW. Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients. Circulation 2020; 142:621-642. [PMID: 32546049 DOI: 10.1161/circulationaha.120.046361] [Citation(s) in RCA: 212] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND To quantify the association between effects of interventions on carotid intima-media thickness (cIMT) progression and their effects on cardiovascular disease (CVD) risk. METHODS We systematically collated data from randomized, controlled trials. cIMT was assessed as the mean value at the common-carotid-artery; if unavailable, the maximum value at the common-carotid-artery or other cIMT measures were used. The primary outcome was a combined CVD end point defined as myocardial infarction, stroke, revascularization procedures, or fatal CVD. We estimated intervention effects on cIMT progression and incident CVD for each trial, before relating the 2 using a Bayesian meta-regression approach. RESULTS We analyzed data of 119 randomized, controlled trials involving 100 667 patients (mean age 62 years, 42% female). Over an average follow-up of 3.7 years, 12 038 patients developed the combined CVD end point. Across all interventions, each 10 μm/y reduction of cIMT progression resulted in a relative risk for CVD of 0.91 (95% Credible Interval, 0.87-0.94), with an additional relative risk for CVD of 0.92 (0.87-0.97) being achieved independent of cIMT progression. Taken together, we estimated that interventions reducing cIMT progression by 10, 20, 30, or 40 μm/y would yield relative risks of 0.84 (0.75-0.93), 0.76 (0.67-0.85), 0.69 (0.59-0.79), or 0.63 (0.52-0.74), respectively. Results were similar when grouping trials by type of intervention, time of conduct, time to ultrasound follow-up, availability of individual-participant data, primary versus secondary prevention trials, type of cIMT measurement, and proportion of female patients. CONCLUSIONS The extent of intervention effects on cIMT progression predicted the degree of CVD risk reduction. This provides a missing link supporting the usefulness of cIMT progression as a surrogate marker for CVD risk in clinical trials.
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Affiliation(s)
- Peter Willeit
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., L.T., L.S., S.K., G.K.)
| | - Lena Tschiderer
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., L.T., L.S., S.K., G.K.)
| | - Elias Allara
- Department of Public Health and Primary Care, University of Cambridge, United Kingdom (P.W., E.A., M.J.S., S.G.T.)
| | - Kathrin Reuber
- Department of Neurology, Goethe University, Frankfurt am Main, Germany (K.R., X.L., M. Sitzer., M.W.L.)
| | - Lisa Seekircher
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., L.T., L.S., S.K., G.K.)
| | - Lu Gao
- MRC Biostatistics Unit, University of Cambridge, United Kingdom (L.G.)
| | - Ximing Liao
- Department of Neurology, Goethe University, Frankfurt am Main, Germany (K.R., X.L., M. Sitzer., M.W.L.)
| | - Eva Lonn
- Department of Medicine and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (E.L., H.C.G., S.Y.)
| | | | - Salim Yusuf
- Hamilton General Hospital, Ontario, Canada (E.L., H.C.G., S.Y.)
| | - Frank P Brouwers
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands (F.P.B.)
| | - Folkert W Asselbergs
- Department of Cardiology (F.W.A.), University Medical Center Utrecht, The Netherlands
| | - Wiek van Gilst
- Department of Experimental Cardiology, University Medical Center Groningen, The Netherlands (W.v.G.)
| | - Sigmund A Anderssen
- Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway (S.A.A.)
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care (D.E.G., M.L.B.), University Medical Center Utrecht, The Netherlands
| | - John J P Kastelein
- Department of Vascular Medicine (J.J.P.K., E.S.), Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine (F.L.J.V.), University Medical Center Utrecht, The Netherlands
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N.)
| | - Apostolos I Hatzitolios
- 1st Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Greece (A.I.H., C.S.)
| | - Christos Savopoulos
- 1st Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Greece (A.I.H., C.S.)
| | - Pythia T Nieuwkerk
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., L.T., L.S., S.K., G.K.)
| | - Erik Stroes
- Department of Vascular Medicine (J.J.P.K., E.S.), Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Matthew Walters
- School of Medicine, Dentistry and Nursing (M.W.), University of Glasgow, United Kingdom
| | - Peter Higgins
- Institute of Cardiovascular and Medical Sciences (P.H., J.D.), University of Glasgow, United Kingdom
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences (P.H., J.D.), University of Glasgow, United Kingdom
| | - Paolo Gresele
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Italy (P.G., G.G.)
| | - Giuseppe Guglielmini
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Italy (P.G., G.G.)
| | - Rino Migliacci
- Division of Internal Medicine, Cortona Hospital, Italy (R.M.)
| | - Marat Ezhov
- Laboratory of Lipid Disorders, National Medical Research Center of Cardiology, Moscow, Russia (M.E.), National Medical Research Center of Cardiology, Moscow, Russia
| | - Maya Safarova
- Atherosclerosis Department (M. Safarova), National Medical Research Center of Cardiology, Moscow, Russia
| | - Tatyana Balakhonova
- Ultrasound Vascular Laboratory (T.B.), National Medical Research Center of Cardiology, Moscow, Russia
| | - Eiichi Sato
- Division of Nephrology, Shinmatsudo Central General Hospital, Chiba, Japan (E.S., M.A., T.N.)
| | - Mayuko Amaha
- Division of Nephrology, Shinmatsudo Central General Hospital, Chiba, Japan (E.S., M.A., T.N.)
| | - Tsukasa Nakamura
- Division of Nephrology, Shinmatsudo Central General Hospital, Chiba, Japan (E.S., M.A., T.N.)
| | - Kostas Kapellas
- Australian Research Centre for Population Oral Health, University of Adelaide, SA, Australia (K.K., L.M.J.)
| | - Lisa M Jamieson
- Australian Research Centre for Population Oral Health, University of Adelaide, SA, Australia (K.K., L.M.J.)
| | - Michael Skilton
- Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, University of Sydney, NSW, Australia (M.Skilton)
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, (J.A.B., A.S., P.J.S.)
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina, Chapel Hill (A.H.)
| | - Andrew Sherwood
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., L.T., L.S., S.K., G.K.)
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, (J.A.B., A.S., P.J.S.)
| | - Michiel A van Agtmael
- Department of Internal Medicine (M.A.v.A.) Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Peter Reiss
- Amsterdam Institute for Global Health and Development, University of Amsterdam, The Netherlands (P.R.)
| | - Marit G A van Vonderen
- Department of Internal Medicine, Medical Center Leeuwarden, The Netherlands (M.G.A.v.V.)
| | - Stefan Kiechl
- VASCage GmbH, Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria (S.K.)
| | - Gerhard Klingenschmid
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., L.T., L.S., S.K., G.K.)
| | - Matthias Sitzer
- Department of Neurology, Klinikum Herford, Herford, Germany (M. Sitzer)
| | - Coen D A Stehouwer
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, The Netherlands (C.D.A.S.)
| | - Heiko Uthoff
- Department of Angiology, University Hospital Basel, Switzerland (H.U.)
| | - Zhi-Yong Zou
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, China (Z.-Y.Z.)
| | - Ana R Cunha
- Department of Clinical Medicine, State University of Rio de Janeiro, Brazil (A.R.C., M.F.N.)
| | - Mario F Neves
- Department of Clinical Medicine, State University of Rio de Janeiro, Brazil (A.R.C., M.F.N.)
| | - Miles D Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle-upon-Tyne Hospitals Trust, United Kingdom (M.D.W.)
| | - Hyun-Woong Park
- Department of Internal Medicine, Gyeongsang National University Hospital, Daejeon, South Korea (H.-W.P., M.-S.L.)
| | - Moo-Sik Lee
- Department of Preventive Medicine, Konyang University, Jinju, South Korea (M.-S.L.)
| | - Jang-Ho Bae
- Heart Center, Konyang University Hospital, Daejeon, South Korea (J.-H.B.)
| | - Enrique Bernal
- Infectious Diseases Unit, Reina Sofia Hospital, Murcia, Spain (E.B.)
| | - Kristian Wachtell
- Department of Cardiology, Oslo University Hospital, Norway (K.W., S.E.K.)
| | - Sverre E Kjeldsen
- Department of Cardiology, Oslo University Hospital, Norway (K.W., S.E.K.)
| | - Michael H Olsen
- Department of Internal Medicine, Holbaek Hospital, University of Southern Denmark, Odense (M.H.O.)
| | - David Preiss
- MRC Population Health Research Unit, Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom (D.P.)
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre (N.S.), University of Glasgow, United Kingdom
| | - Edith Beishuizen
- Infectious Diseases Unit, Reina Sofia Hospital, Murcia, Spain (E.B.)
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands (M.V.H.)
| | - Mark A Espeland
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC (M.A.E.)
| | - Caroline Schmidt
- Wallenberg Laboratory for Cardiovascular Research, University of Gothenburg, Sweden (C.S.)
| | - Stefan Agewall
- Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Norway (S.A.)
| | - Ercan Ok
- Nephrology Department, Ege University School of Medicine, Bornova-Izmir, Turkey (E.O, G.A.)
| | - Gülay Aşçi
- Nephrology Department, Ege University School of Medicine, Bornova-Izmir, Turkey (E.O, G.A.)
| | - Eric de Groot
- Imagelabonline & Cardiovascular, Eindhoven and Lunteren, the Netherlands (E.d.G.)
| | - Muriel P C Grooteman
- Department of Nephrology (M.P.C.G.), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Peter J Blankestijn
- Department of Nephrology (P.J.B.), University Medical Center Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care (D.E.G., M.L.B.), University Medical Center Utrecht, The Netherlands
| | - Michael J Sweeting
- Department of Health Sciences, University of Leicester, United Kingdom (M.J.S.)
| | - Simon G Thompson
- Department of Public Health and Primary Care, University of Cambridge, United Kingdom (P.W., E.A., M.J.S., S.G.T.)
| | - Matthias W Lorenz
- Department of Neurology, Goethe University, Frankfurt am Main, Germany (K.R., X.L., M. Sitzer., M.W.L.)
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Blumenthal JA, Smith PJ, Sherwood A, Mabe S, Snyder L, Frankel C, McKee DC, Hamilton N, Keefe FJ, Shearer S, Schwartz J, Palmer S. Remote Therapy to Improve Outcomes in Lung Transplant Recipients: Design of the INSPIRE-III Randomized Clinical Trial. Transplant Direct 2020; 6:e535. [PMID: 32195326 PMCID: PMC7056276 DOI: 10.1097/txd.0000000000000979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/21/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Impaired functional capacity and emotional distress are associated with lower quality of life (QoL) and worse clinical outcomes in post lung transplant patients. Strategies to increase physical activity and reduce distress are needed. METHODS The Investigational Study of Psychological Interventions in Recipients of Lung Transplant-III study is a single site, parallel group randomized clinical trial in which 150 lung transplant recipients will be randomly assigned to 3 months of telephone-delivered coping skills training combined with aerobic exercise (CSTEX) or to a Standard of Care plus Education control group. The primary endpoints are a global measure of distress and distance walked on the 6-Minute Walk Test. Secondary outcomes include measures of transplant-specific QoL, frailty, health behaviors, and chronic lung allograft dysfunction-free survival. RESULTS Participants will be evaluated at baseline, at the conclusion of 3 months of weekly treatment, at 1-year follow-up, and followed annually thereafter for clinical events for up to 4 years (median = 2 y). We also will determine whether functional capacity, distress, and health behaviors (eg, physical activity, medication adherence, and volume of air forcefully exhaled in 1 second (FEV1), mediate the effects of the CSTEX intervention on clinical outcomes. CONCLUSIONS Should the CSTEX intervention result in better outcomes compared with the standard of care plus post-transplant education, the remotely delivered CSTEX intervention can be made available to all lung transplant recipients as a way of enhancing their QoL and improving clinical outcomes.
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Affiliation(s)
- James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Laurie Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Courtney Frankel
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Daphne C. McKee
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Natalie Hamilton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Francis J. Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Sheila Shearer
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Jeanne Schwartz
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Scott Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC
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Smith PJ, Mabe SM, Sherwood A, Doraiswamy PM, Welsh-Bohmer KA, Burke JR, Kraus WE, Lin PH, Browndyke JN, Babyak MA, Hinderliter AL, Blumenthal JA. Metabolic and Neurocognitive Changes Following Lifestyle Modification: Examination of Biomarkers from the ENLIGHTEN Randomized Clinical Trial. J Alzheimers Dis 2020; 77:1793-1803. [PMID: 32925039 PMCID: PMC9999371 DOI: 10.3233/jad-200374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies have demonstrated that aerobic exercise (AE) and the Dietary Approaches to Stop Hypertension (DASH) diet can improve neurocognition. However, the mechanisms by which lifestyle improves neurocognition have not been widely studied. We examined the associations between changes in metabolic, neurotrophic, and inflammatory biomarkers with executive functioning among participants from the Exercise and Nutritional Interventions for Neurocognitive Health Enhancement (ENLIGHTEN) trial. OBJECTIVE To examine the association between changes in metabolic function and neurocognition among older adults with cognitive impairment, but without dementia (CIND) participating in a comprehensive lifestyle intervention. METHODS ENLIGHTEN participants were randomized using a 2×2 factorial design to receive AE, DASH, both AE+DASH, or a health education control condition (HE) for six months. Metabolic biomarkers included insulin resistance (homeostatic model assessment [HOMA-IR]), leptin, and insulin-like growth factor (IGF-1); neurotrophic biomarkers included brain derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF); and inflammatory biomarkers included interleukin-6 (IL-6) and C-Reactive Protein (CRP). RESULTS Participants included 132 sedentary older adults (mean age = 65 [SD = 7]) with CIND. Results demonstrated that both AE (d = 0.48, p = 0.015) and DASH improved metabolic function (d = 0.37, p = 0.039), without comparable improvements in neurotrophic or inflammatory biomarkers. Greater improvements in metabolic function, including reduced HOMA-IR (B = -2.3 [-4.3, -0.2], p = 0.033) and increased IGF-1 (B = 3.4 [1.2, 5.7], p = 0.004), associated with increases in Executive Function. CONCLUSION Changes in neurocognition after lifestyle modification are associated with improved metabolic function.
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Affiliation(s)
- Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Stephanie M Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - P Murali Doraiswamy
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kathleen A Welsh-Bohmer
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - James R Burke
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - William E Kraus
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Pao-Hwa Lin
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Michael A Babyak
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Alan L Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Blumenthal JA, Smith PJ, Mabe S, Hinderliter A, Welsh-Bohmer K, Browndyke JN, Doraiswamy PM, Lin PH, Kraus WE, Burke JR, Sherwood A. Longer Term Effects of Diet and Exercise on Neurocognition: 1-Year Follow-up of the ENLIGHTEN Trial. J Am Geriatr Soc 2019; 68:559-568. [PMID: 31755550 DOI: 10.1111/jgs.16252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 10/02/2019] [Accepted: 10/13/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the longer term changes in executive functioning among participants with cardiovascular disease (CVD) risk factors and cognitive impairments with no dementia (CIND) randomized to a diet and exercise intervention. DESIGN A 2 (Exercise) × 2 (Dietary Approaches to Stop Hypertension [DASH] eating plan) factorial randomized clinical trial. SETTING Academic tertiary care medical center. PARTICIPANTS Volunteer sample of 160 older sedentary adults with CIND and at least one additional CVD risk factor enrolled in the ENLIGHTEN trial between December 2011 and March 2016. INTERVENTIONS Six months of aerobic exercise (AE), DASH diet counseling, combined AE + DASH, or health education (HE) controls. MEASUREMENTS Neurocognitive battery recommended by the Neuropsychological Working Group for Vascular Cognitive Disorders including measures of executive function, memory, and language/verbal fluency. Secondary outcomes included the Clinical Dementia Rating-Sum of Boxes (CDR-SB), Six-Minute Walk Distance (6MWD), and CVD risk including blood pressure, body weight, and CVD medication burden. RESULTS Despite discontinuation of lifestyle changes, participants in the exercise groups retained better executive function 1 year post-intervention (P = .041) compared with non-exercise groups, with a similar, albeit weaker, pattern in the DASH groups (P = .054), without variation over time (P's > .867). Participants in the exercise groups also achieved greater sustained improvements in 6MWD compared with non-Exercise participants (P < .001). Participants in the DASH groups exhibited lower CVD risk relative to non-DASH participants (P = .032); no differences in CVD risk were observed for participants in the Exercise groups compared with non-Exercise groups (P = .711). In post hoc analyses, the AE + DASH group had better performance on executive functioning (P < .001) and CDR-SB (P = .011) compared with HE controls. CONCLUSION For participants with CIND and CVD risk factors, exercise for 6 months promoted better executive functioning compared with non-exercisers through 1-year post-intervention, although its clinical significance is uncertain. J Am Geriatr Soc 68:559-568, 2020.
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Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Patrick J Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathleen Welsh-Bohmer
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey N Browndyke
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - P Murali Doraiswamy
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Pao-Hwa Lin
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - William E Kraus
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - James R Burke
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
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Wu Y, Yu X, Zhu Y, Shi C, Li X, Jiang R, Gao P, Gao R, Blumenthal JA. P3623Integrating depression and acute coronary syndrome care in low-resource hospitals in china: primary results from the I-Care randomised clinical trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Depression and acute coronary syndromes (ACS) are significant public health challenges. Patients with ACS often experience depression, which adversely affects prognosis. Low-cost, sustainable, and effective service models that integrate depression care into the management of ACS patients to reduce depression and improve ACS outcomes are critically needed.
Purpose
I-CARE study is a multi-center, randomised clinical trial (RCT) to evaluate the efficacy of an 11-month integrated care (IC) intervention compared to usual care (UC) in the management of ACS patients.
Methods
The I-CARE RCT was conducted between October 2014 and March 2018 in 16 rural Chinese hospitals. A total of 4041 patients with ACS were consecutively enrolled and randomly assigned in a 1:1 ratio to an IC intervention consisting of nurse-led risk factor management, group-based counseling supplemented by individual problem solving therapy and antidepressant medications as needed, or UC. The primary outcome was change in Patient Health Questionnaire-9 (PHQ-9) scores from baseline to 6 and 12 months. Secondary outcomes included incidence of major adverse events (MAEs) after discharge, quality of life (EQ5D), and adherence to ACS secondary prevention medications. Data analysis used a multilevel mixed-effects model with hospital-level and subject-level random-effect intercepts and hospital-level random slope incorporated to adjust for clustering effect. Primary analyses followed the intent-to-treat principle.
Results
The mean age of the patients was 61±10 years and 63% were men; however, only 3.3% were classified as depressed based upon a cutoff of ≥10 on the PHQ-9, and 26.9% had PHQ-9 scores between 5 to 9 at the baseline. There were no significant differences in patients' clinical characteristics between IC and UC groups. Changes in PHQ-9 scores from baseline to 6- and 12-months did not differ between treatment groups (−1.47 in IC group vs −1.40 in UC group; adjusted mean difference, −0.04; 95% CI, −0.17 to 0.08 at 6-months; −1.62 in IC group vs −1.54 in UC group; adjusted mean difference, −0.06; 95% CI: −0.19 to 0.06 at 12-months).The risk of MAEs after discharge between IC and UC groups also did not differ significantly (42.1% vs 43.1%; p=0.307).
Conclusions
Results from the I-CARE trial showed that a nurse-coordinated ACS and depression IC intervention did not reduce depression or improve clinical outcomes among patients with ACS compared to usual care controls. The low prevalence of depression was unexpected and may have minimized the potential added benefits of the IC intervention on depression and clinical outcomes compared to UC.
Acknowledgement/Funding
This study is supported by a grant from the National Institute of Mental Health (R01MH100332).
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Affiliation(s)
- Y Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - X Yu
- Peking University Sixth Hospital, beijing, China
| | - Y Zhu
- Peking University, School of Public Health, Department of Epidemiology and Biostatistics, beijing, China
| | - C Shi
- Peking University Sixth Hospital, beijing, China
| | - X Li
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - R Jiang
- Chinese PLA (People's Liberation Army) General Hospital, Beijing, China
| | - P Gao
- Peking University, School of Public Health, Department of Epidemiology and Biostatistics, beijing, China
| | - R Gao
- Fuwai Hospital- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - J A Blumenthal
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Durham, United States of America
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Blumenthal JA, Sherwood A, Smith PJ, Hinderliter A. The Role of Salt Reduction in the Management of Hypertension. J Am Coll Cardiol 2019; 71:1597-1598. [PMID: 29622170 DOI: 10.1016/j.jacc.2018.01.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/18/2018] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
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Blumenthal JA, Zhu Y, Koch GG, Smith PJ, Watkins LL, Hinderliter AL, Hoffman BM, Rogers JG, Chang PP, O'Connor C, Johnson KS, Sherwood A. The modifying effects of social support on psychological outcomes in patients with heart failure. Health Psychol 2019; 38:502-508. [PMID: 30998063 DOI: 10.1037/hea0000716] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE We examined the modifying effects of social support on depressive symptoms and health-related quality of life (QoL) in patients receiving coping skills training (CST). METHOD We considered the modifying effects of social support in the Coping Effectively with Heart Failure clinical trial, which randomized 179 heart failure (HF) patients to either 4 months of CST or usual care enhanced by HF education (HFE). CST involved training in specific coping techniques, whereas HFE involved education about HF self-management. Social support was assessed by the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Inventory, QoL was assessed with the Kansas City Cardiomyopathy Questionnaire (KCCQ), and depression was assessed with the Beck Depression Inventory-II (BDI-II). RESULTS Linear regression models revealed a significant Intervention Group × Baseline Social Support interaction for change in KCCQ total scores (p = .006) and BDI-II scores (p < .001). Participants with low social support assigned to the CST intervention showed large improvements in KCCQ scores (M = 11.2, 95% CI [5.7, 16.8]), whereas low-social-support patients assigned to the HFE controls showed no significant change (M = -0.8, 95% CI [-7.2, 5.6]). Similarly, BDI-II scores in participants with low social support in the CST group showed large reductions (M = -8.7, 95% CI [-11.3, -6.1]) compared with low-social-support HFE participants (M = -3.0, 95% CI [-6.0, -0.1]). CONCLUSIONS HF patients with low social support benefit substantially from telephone-based CST interventions. Targeting HF patients with low social support for behavioral interventions could prove to be a cost-effective strategy for improving QoL and reducing depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
| | - Yidan Zhu
- Department of Psychiatry and Behavioral Sciences
| | - Gary G Koch
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | | | | | | | | | | | - Patricia P Chang
- Department of Medicine, University of North Carolina at Chapel Hill
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Avorgbedor F, Silva S, Merwin E, Blumenthal JA, Holditch-Davis D. Health, Physical Growth, and Neurodevelopmental Outcomes in Preterm Infants of Women With Hypertensive Disorders of Pregnancy. J Obstet Gynecol Neonatal Nurs 2019; 48:69-77. [PMID: 30502314 PMCID: PMC6321773 DOI: 10.1016/j.jogn.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare the health, physical growth, and developmental outcomes in preterm infants of women with and without hypertensive disorders of pregnancy (HDP). DESIGN Cross-sectional analysis of health outcomes; physical growth (head circumference, height, and weight) collected at birth and 2 months, corrected for prematurity; and cognitive, language, and motor skills of preterm infants of women with and without HDP. SETTING Four NICUs in the United States. PARTICIPANTS Women (n = 221) and their preterm infants who weighed less than 1,750 g were enrolled in a multicenter, randomized trial of two interventions administered by each infant's mother when the infant was no longer critically ill. METHODS Women and their preterm infants were categorized into groups with (n = 80) and without (control, n = 141) HDP. Data were extracted from infants' medical records, and the women completed questionnaires. RESULTS The infants of women with HDP were more likely to be small for gestational age than the infants of women without HDP (31.7% vs. 10.6%, p < .002). The proportion of infants with greater neurologic risk, patent ductus arteriosus, intraventricular hemorrhage, and days on a ventilator did not differ between the groups. Although mean infant height at 2 months was less in the HDP group than the control group, other growth and neurodevelopmental outcomes did not differ between the groups. CONCLUSION Among preterm infants admitted to NICUs, those born to women with HDP were more likely to be small for gestational age than those born to normotensive women. Additional research is needed to optimize care for infants born to women with HDP.
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MESH Headings
- Cross-Sectional Studies
- Female
- Gestational Age
- Humans
- Hypertension/complications
- Hypertension/diagnosis
- Hypertension, Pregnancy-Induced/diagnosis
- Infant Health/statistics & numerical data
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature/growth & development
- Infant, Premature/physiology
- Infant, Premature/psychology
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/etiology
- Intensive Care Units, Neonatal/statistics & numerical data
- Male
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Outcome/epidemiology
- United States/epidemiology
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Farquhar JM, Stonerock GL, Blumenthal JA. When Something is Better Than Nothing: Response to Tully and Cosh. Psychosomatics 2019; 60:98-99. [PMID: 29891256 DOI: 10.1016/j.psym.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 04/25/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Julia M Farquhar
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3119, Durham, NC27770, United Kingdom.
| | - Gregory L Stonerock
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3119, Durham, NC27770, United Kingdom
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3119, Durham, NC27770, United Kingdom
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39
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Smith PJ, Mabe S, Sherwood A, Babyak MA, Murali Doraiswamy P, Welsh-Bohmer KA, Kraus W, Burke J, Hinderliter A, Blumenthal JA. Association Between Insulin Resistance, Plasma Leptin, and Neurocognition in Vascular Cognitive Impairment. J Alzheimers Dis 2019; 71:921-929. [PMID: 31476159 PMCID: PMC10840083 DOI: 10.3233/jad-190569] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Greater body weight has been associated impairments in neurocognition and greater dementia risk, although the mechanisms linking weight and neurocognition have yet to be adequately delineated. OBJECTIVE To examine metabolic mechanisms underlying the association between obesity and neurocognition. METHODS We conducted a secondary analysis of weight, neurocognition, and the potentially mediating role of metabolic and inflammatory biomarkers among 160 participants from the ENLIGHTEN trial of vascular cognitive impairment, no dementia (CIND). Neurocognition was assessed using a 45-minute assessment battery assessing Executive Function, Verbal and Visual Memory. We considered three metabolic biomarkers: insulin resistance (homeostatic model assessment [HOMA-IR]), plasma leptin, and insulin-like growth factor (IGF-1). Inflammation was assessed using C-reactive protein. Multiple regression analyses were used. RESULTS Participants included 160 sedentary older adults with CIND. Participants tended to be overweight or obese (mean BMI = 32.5 [SD = 4.8]). Women exhibited higher BMI (p = 0.043), CRP (p < 0.001), and leptin (p < 0.001) compared with men. Higher BMI levels were associated with worse performance on measures of Executive Function (β= -0.16, p = 0.024) and Verbal Memory (β= -0.16, p = 0.030), but not Visual Memory (β= 0.05, p = 0.500). Worse metabolic biomarker profiles also were associated with lower Executive Function (β= -0.12, p = 0.050). Mediation analyses suggested leptin was a plausible candidate as a mediator between BMI and Executive Function. CONCLUSIONS In overweight and obese adults with vascular CIND, the association between greater weight and poorer executive function may be mediated by higher leptin resistance.
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Affiliation(s)
- Patrick J. Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Stephanie Mabe
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Michael A. Babyak
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - P. Murali Doraiswamy
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Kathleen A. Welsh-Bohmer
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - William Kraus
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - James Burke
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
| | - Alan Hinderliter
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - James A. Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Sherwood A, Hill LK, Blumenthal JA, Hinderliter AL. The Effects of Ambulatory Blood Pressure Monitoring on Sleep Quality in Men and Women With Hypertension: Dipper vs. Nondipper and Race Differences. Am J Hypertens 2019; 32:54-60. [PMID: 30204833 DOI: 10.1093/ajh/hpy138] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/04/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The nondipping circadian blood pressure (BP) profile is associated with both poor sleep quality and increased cardiovascular risk. The present study aimed to clarify the potential confounding effects of 24-hour ambulatory blood pressure monitoring (ABPM) used to characterize the circadian BP profile by assessing its impact on sleep quality. METHODS Participants were 121 middle-aged men and women with untreated hypertension (age = 46 ± 8 years; 43% women; 45% African-American). Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index. Wrist actigraphy was used to measure sleep quality objectively as sleep efficiency (SE) and total sleep time (TST) on 7 consecutive non-ABPM days (baseline) and 3 subsequent 24-hour ABPM days. RESULTS Average ambulatory BP was 137.2 ± 10.8/84.3 ± 8.5 mm Hg during the day and 119.6 ± 12.4/69.5 ± 9.8 mm Hg at night. Using the criterion of <10% dip in systolic BP (SBP) to define nondippers, there were 40 nondippers (SBP dip = 7.3 ± 2.6%) and 81 dippers (SBP dip = 15.5 ± 3.4%). There was no effect of time on SE or TST over non-ABPM and ABPM days, suggesting that ABPM does not adversely affect sleep quality. Sleep quality was generally poorer (lower SE) in nondippers compared with dippers (P = 0.033), but differences were independent of whether or not participants were undergoing 24-hour ABPM. African-American race (P = 0.002) was also associated with lower SE. CONCLUSION Sleep quality generally appears to be poor in men and women with untreated hypertension and especially among African-Americans. Importantly, for both dippers and nondippers, we found no evidence that ABPM had an adverse effect on sleep quality.
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Affiliation(s)
| | | | | | - Alan L Hinderliter
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Das A, Roy B, Schwarzer G, Silverman MG, Ziegler O, Bandyopadhyay D, Philpotts LL, Sinha S, Blumenthal JA, Das S. Comparison of treatment options for depression in heart failure: A network meta-analysis. J Psychiatr Res 2019; 108:7-23. [PMID: 30419488 DOI: 10.1016/j.jpsychires.2018.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/18/2018] [Accepted: 10/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Depression independently predicts poor outcomes in heart failure (HF) patients, including increased mortality, morbidity and 30-day re-hospitalization. In this network meta-analysis, we compared different interventions designed to treat depression in HF. MATERIALS AND METHODS Electronic searches were conducted using Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and PsycINFO up to November 2016. Included randomized clinical trials (RCTs) compared interventions (Exercise therapy (ET), cognitive behavioral therapy (CBT) or antidepressant (AD) medications) for depression in heart failure patients. The primary outcome was change in depressive symptoms based on validated measures of depression. Network meta-analysis based on random effects model estimating standardized mean difference (SMD) with 95% confidence interval (CI), compared the effects of the 3 classes of interventions with respect to usual care or placebo control conditions. RESULTS A total of 21 RCTs (including 4563 HF patients) reporting the effects of treating depression in HF patients were included in the analysis. In comparison to placebo or usual standard of care, ET (SMD -0.38; 95% CI -0.54 to -0.22) and CBT (SMD -0.29; 95% CI -0.58 to -0.01) were associated with reduction in depressive symptoms whereas AD (SMD -0.16; 95% CI -0.44 to 0.11) was less effective. CONCLUSIONS This meta-analysis is suggestive of therapeutic benefit of ET and CBT in comparison to usual standard of care in treating depression in HF patients. However, comparison among the three interventions was not conclusive. Future randomized clinical trials are warranted to compare the therapeutic effects of ET, CBT and AD in such patients.
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Affiliation(s)
- Avash Das
- Division of Cardiology, Massachusetts General Hospital, Boston, USA.
| | - Bhaskar Roy
- Division of Neurology, Yale School of Medicine, Connecticut, USA
| | - Guido Schwarzer
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Germany
| | | | - Olivia Ziegler
- Division of Cardiology, Massachusetts General Hospital, Boston, USA
| | | | | | - Shirshendu Sinha
- Department of Psychiatry and Psychology, Mayo Clinic Health System and Mayo Clinic College of Medicine and Science, Mankato, MN, USA
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Saumya Das
- Division of Cardiology, Massachusetts General Hospital, Boston, USA
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Blumenthal JA, Smith PJ, Mabe S, Hinderliter A, Lin PH, Liao L, Welsh-Bohmer KA, Browndyke JN, Kraus WE, Doraiswamy PM, Burke JR, Sherwood A. Lifestyle and neurocognition in older adults with cognitive impairments: A randomized trial. Neurology 2018; 92:e212-e223. [PMID: 30568005 DOI: 10.1212/wnl.0000000000006784] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 09/18/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To determine the independent and additive effects of aerobic exercise (AE) and the Dietary Approaches to Stop Hypertension (DASH) diet on executive functioning in adults with cognitive impairments with no dementia (CIND) and risk factors for cardiovascular disease (CVD). METHODS A 2-by-2 factorial (exercise/no exercise and DASH diet/no DASH diet) randomized clinical trial was conducted in 160 sedentary men and women (age >55 years) with CIND and CVD risk factors. Participants were randomly assigned to 6 months of AE, DASH diet nutritional counseling, a combination of both AE and DASH, or health education (HE). The primary endpoint was a prespecified composite measure of executive function; secondary outcomes included measures of language/verbal fluency, memory, and ratings on the modified Clinical Dementia Rating Scale. RESULTS Participants who engaged in AE (d = 0.32, p = 0.046) but not those who consumed the DASH diet (d = 0.30, p = 0.059) demonstrated significant improvements in the executive function domain. The largest improvements were observed for participants randomized to the combined AE and DASH diet group (d = 0.40, p = 0.012) compared to those receiving HE. Greater aerobic fitness (b = 2.3, p = 0.049), reduced CVD risk (b = 2.6, p = 0.042), and reduced sodium intake (b = 0.18, p = 0.024) were associated with improvements in executive function. There were no significant improvements in the memory or language/verbal fluency domains. CONCLUSIONS These preliminary findings show that AE promotes improved executive functioning in adults at risk for cognitive decline. CLINICALTRIALSGOV IDENTIFIER NCT01573546. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that for adults with CIND, AE but not the DASH diet significantly improves executive functioning.
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Affiliation(s)
- James A Blumenthal
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill.
| | - Patrick J Smith
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Stephanie Mabe
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Alan Hinderliter
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Pao-Hwa Lin
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Lawrence Liao
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Kathleen A Welsh-Bohmer
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Jeffrey N Browndyke
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - William E Kraus
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - P Murali Doraiswamy
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - James R Burke
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
| | - Andrew Sherwood
- From the Departments of Psychiatry and Behavioral Sciences (J.A.B., P.J.S., S.M., K.A.W.-B., J.N.B., P.M.D., A.S.), Medicine (P.-H.L., L.L., W.E.K., P.M.D.), and Neurology (K.A.W.-B., J.R.B.), Duke University Medical Center, Durham; and Department of Medicine (A.H.), University of North Carolina at Chapel Hill
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Smith PJ, Blumenthal JA, Hinderliter AL, Watkins LL, Hoffman BM, Sherwood A. Microvascular Endothelial Function and Neurocognition Among Adults With Major Depressive Disorder. Am J Geriatr Psychiatry 2018; 26:1061-1069. [PMID: 30093218 PMCID: PMC6165686 DOI: 10.1016/j.jagp.2018.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiovascular risk factors (CVRFs) and endothelial dysfunction have been associated independently with poorer neurocognition in middle-aged adults, particularly on tests of frontal lobe function. However, to our knowledge, no studies have examined markers of microvascular dysfunction on neurocognition or the potential interaction between macro- and microvascular biomarkers on neurocognition in middle-aged and older adults with major depressive disorder (MDD). METHODS Participants included 202 adults with MDD who were not receiving mental health treatment. Microvascular endothelial function was assessed using a noninvasive marker of forearm reactive hyperemia velocity while macrovascular endothelial function was assessed using flow-mediated dilation (FMD) of the brachial artery. CVRFs were assessed using the Framingham Stroke Risk Profile and fasting lipid levels. A standardized neurocognitive assessment battery was used to assess three cognitive domains: executive function, working memory, and verbal memory. RESULTS Greater microvascular dysfunction was associated with poorer neurocognition across all three domains. Microvascular function continued to predict verbal memory performance after accounting for background factors and CVRFs. Macro- and microvascular function interacted to predict working memory performance (F = 4.511, 178, p = 0.035), with a similar nonsignificant association for executive function (F = 2.731, 178, p = 0.095), with moderate associations observed between microvascular function and neurocognition in the presence of preserved FMD (r61 = 0.40, p = 0.001), but not when FMD was impaired (r63 = -0.05, p = 0.675). CONCLUSION Greater microvascular dysfunction is associated with poorer neurocognition among middle-aged and older adults. This association was strongest in participants with preserved macrovascular function.
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Affiliation(s)
- PJ Smith
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA
| | - JA Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA
| | - AL Hinderliter
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - LL Watkins
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA
| | - BM Hoffman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA
| | - A Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA
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Li S, Blumenthal JA, Shi C, Millican D, Li X, Du X, Patel A, Gao P, Delong E, Maulik PK, Gao R, Yu X, Wu Y. I-CARE randomized clinical trial integrating depression and acute coronary syndrome care in low-resource hospitals in China: Design and rationale. Am Heart J 2018; 202:109-115. [PMID: 29933147 DOI: 10.1016/j.ahj.2018.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/16/2018] [Indexed: 12/18/2022]
Abstract
Depression and acute coronary syndromes (ACS) are both common public health challenges. Patients with ACS often develop depression, which in turn adversely affects prognosis. Low-cost, sustainable, and effective service models that integrate depression care into the management of ACS patients to reduce depression and improve ACS outcomes are critically needed. Integrating Depression Care in ACS patients in Low Resource Hospitals in China (I-CARE) is a multicenter, randomized controlled trial to evaluate the efficacy of an 11-month integrated care (IC) intervention compared to usual care (UC) in management of ACS patients. Four thousand inpatients will be recruited and then randomized in a 1:1 ratio to an IC intervention consisting of nurse-led risk factor management, group-based counseling supplemented by individual problem-solving therapy, and antidepressant medications as needed, or to UC. The primary outcomes are depression symptoms measured by the Patient Health Questionnaire-9 at 6 and 12 months. Secondary endpoints include anxiety measured by the Generalized Anxiety Disorder-7; quality of life measured by the EQ-5D at 6 and 12 months; and major adverse events including the combined end point of all-cause death, suicide attempts, nonfatal myocardial infarction, nonfatal stroke, and all-cause rehospitalization at yearly intervals for a median follow-up of 2 years. Analyses of the cost-effectiveness and cost-utility of IC also will be performed. I-CARE trial will be the largest study to test the effectiveness of an integrated care model on depression and cardiovascular outcomes among ACS patients in resource-limited clinical settings.
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Farquhar JM, Stonerock GL, Blumenthal JA. Treatment of Anxiety in Patients With Coronary Heart Disease: A Systematic Review. Psychosomatics 2018; 59:318-332. [PMID: 29735242 PMCID: PMC6015539 DOI: 10.1016/j.psym.2018.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/14/2018] [Accepted: 03/19/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Anxiety is common in patients with coronary heart disease (CHD) and is associated with an increased risk for adverse outcomes. There has been a relative paucity of studies concerning treatment of anxiety in patients with CHD. OBJECTIVE We conducted a systematic review to organize and assess research into the treatment of anxiety in patients with CHD. METHODS We searched CCTR/CENTRAL, MEDLINE, EMBASE, PsycINFO, and CINAHL for randomized clinical trials conducted before October 2016 that measured anxiety before and after an intervention for patients with CHD. RESULTS A total of 475 articles were subjected to full text review, yielding 112 publications that met inclusion criteria plus an additional 7 studies from reference lists and published reviews, yielding 119 studies. Sample size, country of origin, study quality, and demographics varied widely among studies. Most studies were conducted with nonanxious patients. The Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory were the most frequently used instruments to assess anxiety. Interventions included pharmacological, counseling, relaxation-based, educational, or "alternative" therapies. Forty (33% of total) studies reported that the interventions reduced anxiety; treatment efficacy varied by study and type of intervention. Elevated anxiety was an inclusion criterion in only 4 studies, with inconsistent results. CONCLUSION Although there have been a number of randomized clinical trials of patients with CHD that assessed anxiety, in most cases anxiety was a secondary outcome, and only one-third found that symptoms of anxiety were reduced with treatment. Future studies need to target anxious patients and evaluate the effects of treatment on anxiety and relevant clinical endpoints.
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Affiliation(s)
- Julia M Farquhar
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Gregory L Stonerock
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC.
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Smith PJ, Sherwood A, Blumenthal JA. Effects of aerobic exercise on white matter hyperintensities: An exploratory analysis. Gen Hosp Psychiatry 2018; 53:84-85. [PMID: 29402468 DOI: 10.1016/j.genhosppsych.2018.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 12/25/2022]
Affiliation(s)
- Patrick J Smith
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, United States.
| | - Andrew Sherwood
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, United States
| | - James A Blumenthal
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, United States
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Zhu Y, Blumenthal JA, Shi C, Jiang R, Patel A, Zhang A, Yu X, Gao R, Wu Y. Sedentary Behavior and the Risk of Depression in Patients With Acute Coronary Syndromes. Am J Cardiol 2018; 121:1456-1460. [PMID: 29709263 DOI: 10.1016/j.amjcard.2018.02.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/08/2018] [Accepted: 02/16/2018] [Indexed: 11/26/2022]
Abstract
Although there is good evidence that sedentary behavior is associated with poor health outcomes in healthy persons and patients with cardiovascular disease, the mental health consequences of sedentary behavior have not been widely studied. In this report, we conducted a cross-sectional analysis to examine the relation of self-reported sedentary behavior and depression in a sample of 4,043 hospitalized men and women with acute coronary syndrome enrolled in a randomized clinical trial in rural China. Sedentary behavior was assessed by self-report, and depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); a subset of 1,209 patients also completed the Beck Depression Inventory-II. Results revealed that greater sedentary behavior was associated with higher levels of depressive symptoms measured by both the PHQ-9 (p <0.001) and the Beck Depression Inventory-II (p <0.001). Compared with patients who reported that they were seldom sedentary, patients reporting that they were frequently sedentary were 4.7 times (odds ratio 4.73, 95% confidence interval 2.71 to 8.24) more likely to be clinically depressed defined as PHQ-9 scores ≥10 after adjusting for demographic factors, lifestyle behaviors, clinical characteristics, and in-hospital treatments. In conclusion, greater sedentary behavior is significantly related to greater depression in Chinese patients with acute coronary syndrome, independent of physical activity. These findings suggest that strategies to reduce sedentary behavior may improve medical outcomes and reduce risk for depression.
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Hayano J, Yasuma F, Watanabe E, Carney RM, Stein PK, Blumenthal JA, Arsenos P, Gatzoulis KA, Takahashi H, Ishii H, Kiyono K, Yamamoto Y, Yoshida Y, Yuda E, Kodama I. Blunted cyclic variation of heart rate predicts mortality risk in post-myocardial infarction, end-stage renal disease, and chronic heart failure patients. Europace 2018; 19:1392-1400. [PMID: 27789562 PMCID: PMC5834062 DOI: 10.1093/europace/euw222] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 06/27/2016] [Indexed: 11/22/2022] Open
Abstract
Aims Cyclic variation of heart rate (CVHR) associated with sleep-disordered breathing is thought to reflect cardiac autonomic responses to apnoeic/hypoxic stress. We examined whether blunted CVHR observed in ambulatory ECG could predict the mortality risk. Methods and results CVHR in night-time Holter ECG was detected by an automated algorithm, and the prognostic relationships of the frequency (FCV) and amplitude (ACV) of CVHR were examined in 717 patients after myocardial infarction (post-MI 1, 6% mortality, median follow-up 25 months). The predictive power was prospectively validated in three independent cohorts: a second group of 220 post-MI patients (post-MI 2, 25.5% mortality, follow-up 45 months); 299 patients with end-stage renal disease on chronic haemodialysis (ESRD, 28.1% mortality, follow-up 85 months); and 100 patients with chronic heart failure (CHF, 35% mortality, follow-up 38 months). Although CVHR was observed in ≥96% of the patients in all cohorts, FCV did not predict mortality in any cohort. In contrast, decreased ACV was a powerful predictor of mortality in the post-MI 1 cohort (hazard ratio [95% CI] per 1 ln [ms] decrement, 2.9 [2.2–3.7], P < 0.001). This prognostic relationship was validated in the post-MI 2 (1.8 [1.4–2.2], P < 0.001), ESRD (1.5 [1.3–1.8], P < 0.001), and CHF (1.4 [1.1–1.8], P = 0.02) cohorts. The prognostic value of ACV was independent of age, gender, diabetes, β-blocker therapy, left ventricular ejection fraction, sleep-time mean R-R interval, and FCV. Conclusion Blunted CVHR detected by decreased ACV in a night-time Holter ECG predicts increased mortality risk in post-MI, ESRD, and CHF patients.
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Affiliation(s)
- Junichiro Hayano
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya 467-8601, Japan
| | - Fumihiko Yasuma
- Departments of Medicine, Suzuka National Hospital, Suzuka, Japan
| | - Eiichi Watanabe
- Division of Cardiology, Department of Internal Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Robert M Carney
- Department of Psychiatry, Washington University School of Medicine, St Louis, MO 63108, USA
| | - Phyllis K Stein
- Departments of Medicine, Washington University School of Medicine, St Louis, MO 63108, USA
| | - James A Blumenthal
- Department of Psychiatry, Duke University Medical Center, Durham, NC 27710, USA
| | - Petros Arsenos
- First Cardiology Division, University of Athens Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantinos A Gatzoulis
- First Cardiology Division, University of Athens Medical School, Hippokration Hospital, Athens, Greece
| | - Hiroshi Takahashi
- Division of Medical Statistics, Fujita Health University, Toyoake, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University, Nagoya, Japan
| | - Ken Kiyono
- School of Engineering Science, Osaka University, Suita, Japan
| | - Yoshiharu Yamamoto
- Educational Physiology Laboratory, Graduate School of Education, University of Tokyo, Tokyo 113-0033, Japan
| | - Yutaka Yoshida
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya 467-8601, Japan
| | - Emi Yuda
- Department of Medical Education, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi Mizuho-cho Mizuho-ku, Nagoya 467-8601, Japan
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Smith PJ, Blumenthal JA, Hoffman BM, Davis RD, Palmer SM. Postoperative cognitive dysfunction and mortality following lung transplantation. Am J Transplant 2018; 18:696-703. [PMID: 29087035 PMCID: PMC5820215 DOI: 10.1111/ajt.14570] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/05/2017] [Accepted: 10/07/2017] [Indexed: 01/25/2023]
Abstract
Preliminary evidence suggests that postoperative cognitive dysfunction (POCD) is common after lung transplantation. The impact of POCD on clinical outcomes has yet to be studied. The association between POCD and longer-term survival was therefore examined in a pilot study of posttransplantation survivors. Forty-nine participants from a prior randomized clinical trial underwent a neurocognitive assessment battery pretransplantation and 6 months posttransplantation, including assessments of the domains of Executive Function (Trail Making Test, Stroop, Digit Span), Processing Speed (Ruff 2 and 7 Test, Digit Symbol Substitution Test), and Verbal Memory (Verbal Paired Associates, Logical Memory, Animal Naming, and Controlled Oral Word Association Test). During a 13-year follow-up, 33 (67%) participants died. Greater neurocognition was associated with longer survival (hazard ratio [HR] = 0.49 [0.25-0.96], P = .039), and this association was strongest on tests assessing Processing Speed (HR = 0.58 [0.36-0.95], P = .03) and Executive Function (HR = 0.52 [0.28-0.97], P = .040). In addition, unadjusted analyses suggested an association between greater Memory performance and lower risk of CLAD (HR = 0.54 [0.29-1.00], P = .050). Declines in Executive Function tended to be predictive of worse survival. These preliminary findings suggest that postoperative neurocognition is predictive of subsequent mortality among lung transplant recipients. Further research is needed to confirm these findings in a larger sample and to examine mechanisms responsible for this relationship.
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Affiliation(s)
- PJ Smith
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences
| | - JA Blumenthal
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences
| | - BM Hoffman
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences
| | | | - SM Palmer
- Duke University Medical Center, Department of Medicine
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Blumenthal JA, Sherwood A. Missing ingredients for a lifestyle recipe to treat hypertension. J Thorac Dis 2018; 10:653-656. [PMID: 29608194 PMCID: PMC5864654 DOI: 10.21037/jtd.2018.01.06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 12/28/2017] [Indexed: 03/22/2024]
Affiliation(s)
- James A Blumenthal
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Andrew Sherwood
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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