Computed tomography myocardial perfusion imaging to detect myocardial ischemia in patients with anxiety and obstructive coronary heart disease post-exposure to mental stressors

This study aims to measure myocardial blood flow (MBF) using dynamic CT- myocardial perfusion imaging (CT-MPI) combined with mental stressors in patients with obstructive coronary artery disease (OCAD) and in patients with anxiety and no obstructive coronary artery disease (ANOCAD). A total of 30 patients with OCAD with 30 patients with ANOCAD were included in this analysis. Using the 17-segment model, the rest and stress phase MBF of major coronary arteries in participants were recorded respectively. Compared with ANOCAD patients, OCAD patients were more likely to have localized reduction of MBF (p < 0.05). For patients with ANOCAD, both global MBF and MBF of the main coronary arteries in the stress phase were lower than those in the rest phase (all p < 0.05), but there was no significant difference in MBF among the main coronary arteries in the rest or stress phase (p = 0.25, p = 0.15). For patients with OCAD, the MBF of the target area was lower than that of the non-target area in both the rest and stress phase, and the MBF of the target area in the stress phase was lower than that in the rest phase (all p < 0.05). However, there was no significant difference in MBF between the rest or stress phase in the non-target area (p = 0.73). Under mental stress, the decrease in MBF in ANOCAD patients was diffuse, while the decrease in MBF in OCAD patients was localized. Dynamic CT-MPI combined with mental stressors can be used to detect MBF changes in anxiety patients.

Improving mental health in chronic care in general practice: study protocol for a cluster-randomised controlled trial of the Healthy Mind intervention

BACKGROUND

Mental health issues are common among patients with chronic physical conditions, affecting approximately one in five patients. Poor mental health is associated with worse disease outcomes and increased mortality. Problem-solving therapy (PST) may be a suitable treatment for targeting poor mental health in these patients. This study protocol describes a randomised controlled trial of the Healthy Mind intervention, a general practice-based intervention offering PST to patients with type 2 diabetes and/or ischaemic heart disease and poor mental well-being.

METHODS

A stepped-wedge cluster-randomised controlled trial with 1-year follow-up will be conducted in Danish general practice. At the annual chronic care consultation, patients with type 2 diabetes and/or chronic ischaemic heart disease will be screened for poor mental well-being. Patients in the control group will be offered usual care while patients in the intervention group will be offered treatment with PST provided by general practitioners (GPs) or general practice staff, such as nurses, who will undergo a 2-day PST course before transitioning from the control to the intervention group. The primary outcome is change in depressive symptoms after 6 and 12 months. Secondary outcomes include change in mental well-being, anxiety, and diabetes distress (patients with type 2 diabetes) after 6 and 12 months as well as change in total cholesterol levels, low-density lipoprotein (LDL) levels, and blood glucose levels (patients with diabetes) after 12 months. Process outcomes include measures of implementation and mechanisms of impact. We aim to include a total of 188 patients, corresponding to approximately 14 average-sized general practices.

DISCUSSION

The Healthy Mind trial investigates the impact of PST treatment for patients with chronic disease and poor mental well-being in general practice. This will be the first randomised controlled trial determining the effect of PST treatment for patients with chronic diseases in general practice. The results of this study will provide relevant insights to aid GPs, and general practice staff manage patients with poor mental well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.

Facial Emotion Expression and the Inducibility of Myocardial Ischemia During Cardiac Stress Testing: The Role of Psychological Background Factors

OBJECTIVE

Negative emotional states, such as anger and anxiety, are associated with the onset of myocardial infarction and other acute clinical manifestations of ischemic heart disease. The likelihood of experiencing these short-term negative emotions has been associated with long-term psychological background factors such as depression, generalized anxiety, and personality factors. We examined the association of acute emotional states preceding cardiac stress testing (CST) with inducibility of myocardial ischemia and to what extent psychological background factors account for this association.

METHODS

Emotional states were assessed in patients undergoing CST (n = 210; mean [standard deviation] age = 66.9 [8.2] years); 91 (43%) women) using self-report measures and video recordings of facial emotion expression. Video recordings were analyzed for expressed anxiety, anger, sadness, and happiness before CST. Psychological background factors were assessed with validated questionnaires. Single-photon emission computed tomography was used to evaluate inducibility of ischemia.

RESULTS

Ischemia occurred in 72 patients (34%). Emotional states were not associated with subsequent inducibility of ischemia during CST (odds ratio between 0.93 and 1.04; p values > .50). Psychological background factors were also not associated with ischemia (odds ratio between 0.96 and 1.06 per scale unit; p values > .20) and did not account for the associations of emotional states with ischemia.

CONCLUSIONS

Emotional states immediately before CST and psychological background factors were not associated with the inducibility of ischemia. These findings indicate that the well-documented association between negative emotions with acute clinical manifestations of ischemic heart disease requires a different explanation than a reduced threshold for inducible ischemia.

Anxiety and hemodynamic reactivity during cardiac stress testing: The role of gender and age in myocardial ischemia

BACKGROUND

The prevalence of myocardial ischemia is associated with anxiety. State and trait anxiety are more common in younger women compared to men, and high anxiety levels could affect hemodynamic reactivity during cardiac stress testing. The aim is to examine whether anxiety plays a role in gender differences in patients ≤ 65 and > 65 years in hemodynamic reactivity and ischemia during cardiac stress testing.

METHODS AND RESULTS

Included were 291 patients (66.8 ± 8.7 years, 45% women) with suspect ischemia undergoing myocardial perfusion single-photon emission computed tomography (MPI-SPECT). Primary outcomes were semi-quantitative summed difference score (SDS) and summed stress score (SSS), as continuous indicators of myocardial ischemia. Analyses were stratified by age. Trait anxiety was measured using a validated questionnaire (GAD-7) and state anxiety using facial expression analyses software. Overall, trait and state anxiety were not associated with the prevalence of ischemia (N = 107, 36%). A significant interaction was found between gender and trait anxiety in women ≤ 65 years for SDS (F(1,4) = 5.73, P = .019) and SSS (F(1,10) = 6.50, P = .012). This was not found for state anxiety.

CONCLUSION

SDS and SSS were significantly higher in women younger than 65 years with high trait anxiety. This interaction was not found in men and women over 65 years.

Association of Mental Stress-Induced Myocardial Ischemia With Cardiovascular Events in Patients With Coronary Heart Disease

IMPORTANCE

Mental stress-induced myocardial ischemia is a recognized phenomenon in patients with coronary heart disease (CHD), but its clinical significance in the contemporary clinical era has not been investigated.

OBJECTIVE

To compare the association of mental stress-induced or conventional stress-induced ischemia with adverse cardiovascular events in patients with CHD.

DESIGN, SETTING, AND PARTICIPANTS

Pooled analysis of 2 prospective cohort studies of patients with stable CHD from a university-based hospital network in Atlanta, Georgia: the Mental Stress Ischemia Prognosis Study (MIPS) and the Myocardial Infarction and Mental Stress Study 2 (MIMS2). Participants were enrolled between June 2011 and March 2016 (last follow-up, February 2020).

EXPOSURES

Provocation of myocardial ischemia with a standardized mental stress test (public speaking task) and with a conventional (exercise or pharmacological) stress test, using single-photon emission computed tomography.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of cardiovascular death or first or recurrent nonfatal myocardial infarction. The secondary end point additionally included hospitalizations for heart failure.

RESULTS

Of the 918 patients in the total sample pool (mean age, 60 years; 34% women), 618 participated in MIPS and 300 in MIMS2. Of those, 147 patients (16%) had mental stress-induced ischemia, 281 (31%) conventional stress ischemia, and 96 (10%) had both. Over a 5-year median follow-up, the primary end point occurred in 156 participants. The pooled event rate was 6.9 per 100 patient-years among patients with and 2.6 per 100 patient-years among patients without mental stress-induced ischemia. The multivariable adjusted hazard ratio (HR) for patients with vs those without mental stress-induced ischemia was 2.5 (95% CI, 1.8-3.5). Compared with patients with no ischemia (event rate, 2.3 per 100 patient-years), patients with mental stress-induced ischemia alone had a significantly increased risk (event rate, 4.8 per 100 patient-years; HR, 2.0; 95% CI, 1.1-3.7) as did patients with both mental stress ischemia and conventional stress ischemia (event rate, 8.1 per 100 patient-years; HR, 3.8; 95% CI, 2.6-5.6). Patients with conventional stress ischemia alone did not have a significantly increased risk (event rate, 3.1 per 100 patient-years; HR, 1.4; 95% CI, 0.9-2.1). Patients with both mental stress ischemia and conventional stress ischemia had an elevated risk compared with patients with conventional stress ischemia alone (HR, 2.7; 95% CI, 1.7-4.3). The secondary end point occurred in 319 participants. The event rate was 12.6 per 100 patient-years for patients with and 5.6 per 100 patient-years for patients without mental stress-induced ischemia (adjusted HR, 2.0; 95% CI, 1.5-2.5).

CONCLUSIONS AND RELEVANCE

Among patients with stable coronary heart disease, the presence of mental stress-induced ischemia, compared with no mental stress-induced ischemia, was significantly associated with an increased risk of cardiovascular death or nonfatal myocardial infarction. Although these findings may provide insights into mechanisms of myocardial ischemia, further research is needed to assess whether testing for mental stress-induced ischemia has clinical value.

An analysis of anxiety and selected aspects of personality in women with ischemic heart disease according to P.T. Costa and R. R. McCrae theory - The role of psychosocial factors in ischemic heart disease

INTRODUCTION

Risk factors for ischemic heart disease (IHD) are very numerous and not fully defined. In addition to classic risk factors, different factors are also distinguished, among them psychological aspects chich have rarely been subject to detailed analyses.

OBJECTIVE

The aim of study was an analysis of the anxiety structure, including the five factors of personality: neuroticism (NEU), extraversion (EXT), openness (OPE), agreeableness (AGR) and conscientiousness (CON), in women with IHD.

MATERIAL AND METHODS

The study involved 140 women aged 37-74 years with IHD confirmed by coronary angiography. Psychological examination was conducted using R.B. Cattell's IPAT Anxiety Scale and P.T. Costa and R.R. McCrae's NEO-FFI Personality Inventory.

RESULTS

The results obtained from the IPAT Anxiety Scale showed that the study group of 140 women with IHD had the correct level of internal integrity (Q3^- ). The dominant factor in the anxiety structure in 88.7% of subjects was neurotic tension (Q4⁺). A lack of sense of safety was indicated by 72.6% of subjects (L⁺), 69.3% experienced a strong tendency to self-blame and experience a sense of guilt (O + ), and over 51.6% of women with IHD expressed decreased emotional stability (C - ). The level of general anxiety was high (GA=7.3). The analysis of the five factors of personality revealed that the dominant factors in the structure of personality of women with IHD were CON in 69.3%, AGR in 46.7% and EXT in 45.2%. NEU and OPE were moderately significant factors.

CONCLUSIONS

Women with IHD are characterised by a high level of anxiety, increased neurotic tension, decreased emotional stability, auto-aggression and a sense of danger and distrust. Women with IHD demonstrate a high level of factors, such as extraversion, agreeableness and conscientiousness.

Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol

BACKGROUND

One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care.

METHODS

eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness.

DISCUSSION

To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Gender-Related Determinants of Adherence to the Mediterranean Diet in Adults with Ischemic Heart Disease

Background: The reasons behind low adherence to the Mediterranean diet (Med-diet) are still not entirely known. We aimed to evaluate the effect of biological (i.e., sex-related) and psycho-socio-cultural (i.e., gender-related) factors on Med-diet adherence. Methods: Baseline Med-diet adherence was measured using a self-administered questionnaire among adults with ischemic heart disease (IHD) from the EVA (Endocrine Vascular Disease Approach) study. A multivariable analysis was performed to estimate the effect of sex- and gender-related factors (i.e., identity, roles, relations, and institutionalized gender) on low adherence. Results: Among 366 participants (66 ± 11 years, 31% women), 81 (22%) adults with low adherence demonstrated higher rates of diabetes, no smoking habit, lower male BSRI (Bem Sex Role Inventory) (median (IQR) 4.8 (4.1 to 5.5) vs. 5.1 (4.5 to 5.6) and p = 0.048), and higher Perceived Stress Scale 10 items (PSS-10) (median (IQR) 19 (11 to 23) vs. 15 (11 to 20) and p = 0.07) scores than those with medium-high adherence. In the multivariable analysis, only active smoking (odds ratio, OR = 2.10, 95% confidence interval, CI 1.14 to 3.85 and p = 0.017), PPS-10 (OR = 1.04, 95% CI 1.00 to 1.08, and p = 0.038) and male BSRI scores (OR = 0.70, 95% CI 0.52 to 0.95, and p = 0.021) were independently associated with low adherence. Conclusions: Male personality traits and perceived stress (i.e., gender identity) were associated with low Med-diet adherence regardless of the sex, age, and comorbidities. Therefore, gender-sensitive interventions should be explored to improve adherence in IHD.

A long-term perspective on cardiovascular job stress research

This review provides perspectives on cardiovascular occupational stress research since the 1960s until now. The author argues for closer links between basic science and clinical follow‐up examinations of patients. In an excellent way urinary excretion of adrenaline and noradrenaline during wake hours mirrors day to day or week to week variations in sympathomedullary activity which could be related to variations in the patient's and cardiovascular and psychosocial situation. Modern methods for following variations over time in heart contractility should also be related to the patients' psychosocial situation. In addition the author argues for more extensive use of the increasing knowledge regarding regeneration and vagal activity in relation to variations in job conditions and development or prevention of cardiovascular disease.

Stress and Inflammation in Coronary Artery Disease: A Review Psychoneuroendocrineimmunology-Based

Recent findings have deeply changed the current view of coronary heart disease, going beyond the simplistic model of atherosclerosis as a passive process involving cholesterol build-up in the subintimal space of the arteries until their final occlusion and/or thrombosis and instead focusing on the key roles of inflammation and the immune system in plaque formation and destabilization. Chronic inflammation is a typical hallmark of cardiac disease, worsening outcomes irrespective of serum cholesterol levels. Low-grade chronic inflammation correlates with higher incidence of several non-cardiac diseases, including depression, and chronic depression is now listed among the most important cardiovascular risk factors for poor prognosis among patients with myocardial infarction. In this review, we include recent evidence describing the immune and endocrine properties of the heart and their critical roles in acute ischaemic damage and in post-infarct myocardial remodeling. The importance of the central and autonomic regulation of cardiac functions, namely, the neuro-cardiac axis, is extensively explained, highlighting the roles of acute and chronic stress, circadian rhythms, emotions and the social environment in triggering acute cardiac events and worsening heart function and metabolism in chronic cardiovascular diseases. We have also included specific sections related to stress-induced myocardial ischaemia measurements and stress cardiomyopathy. The complex network of reciprocal interconnections between the heart and the main biological systems we have presented in this paper provides a new vision of cardiovascular science based on psychoneuroendocrineimmunology.

[Clinical-Epidemiological Program of Studying Psychosocial Risk Factors in Cardiological Practice in Patients With Arterial Hypertension and Ischemic Heart Disease: First Results of a Multicenter Study in Russia]

BACKGROUND

More than 10 years passed since conduction of the first clinical-epidemiological study of prevalence of psychosocial risk factors (PSRF) in patients with arterial hypertension (AH) an/or ischemic heart disease in Russian Federation.

PURPOSE

to assess current prevalence of PSRF in patients with AH/CHD and their relationship with traditional risk factors.

MATERIALS AND METHODS

Patients with verified AH and/or CHD aged ≥55 years were included into this cross-sectional study in 30 cities of Russia representing 7 federal districts according to the following procedure. In each city we selected 2-5 federal clinics - providers of primary medical care; in each of these clinics we at random invited 2-5 physicians to take part in this study. Each of these physicians for 1-2 days included 10 consecutive patients with AH and/or CHD. Information collected from patients comprised social demographic and clinical characteristics, risk factors, adherence to therapy; Hospital Anxiety and Depression Scale (HADS) was applied for detection of symptoms of anxiety and depression. Obtained information was used for analysis of prevalence of cardiovascular risk factors and their association with symptoms of depression and anxiety in a framework of Pearson linear and Kendall rank correlation analysis.

RESULTS

Symptoms of anxiety of various severity (HADS-A≥7) were detected in 42.2% of patients with AH and/or CHD, in 25.5% they were clinically significant (HADS-A≥11). Symptoms of depression of various severity (HADS-D ≥7) were detected in 42.5% of patients with AH and/or CHD, in 16.3% they were clinically significant (HADS-D≥11). We also observed several significant associations of symptoms of depression and anxiety with traditional cardiovascular risk factors: low level of physical activity, elevated systolic and diastolic arterial pressure, level of total cholesterol, abdominal obesity; some unhealthy nutritional habits.

CONCLUSIONS

Prevalence of symptoms of anxiety and depression was found to be high among ambulatory patients with AH and/or CHD. However, in this study it was lower compared with that reported by previous studies in Russia.

Chest Pain and Mental Stress-Induced Myocardial Ischemia: Sex Differences

BACKGROUND

Mental stress-induced myocardial ischemia is a frequent phenomenon in patients with coronary artery disease. Women with coronary artery disease tend to have more mental stress-induced myocardial ischemia and more chest pain/anginal symptoms than men, but whether the association between mental stress-induced myocardial ischemia and angina burden differs in women and men is unknown.

METHODS

This was a cross-sectional study with experimental manipulation of 950 individuals with stable coronary artery disease. Chest pain/angina frequency in the previous 4 weeks was assessed with the Seattle Angina Questionnaire's angina-frequency subscale. Mental stress-induced myocardial ischemia was assessed with myocardial perfusion imaging during mental stress (standardized public speaking task). Presence of mental stress-induced myocardial ischemia was based on expert readers and established criteria. A conventional (exercise or pharmacologic) stress test was used as a control condition.

RESULTS

Overall, 338 individuals (37%) reported angina; 112 (12%) developed mental stress-induced myocardial ischemia, and 256 (29%) developed conventional stress ischemia. Women who reported angina had almost double the probability to develop mental stress-induced myocardial ischemia (19% vs 10%, adjusted prevalence rate ratio, 1.90; 95% confidence interval, 1.04-3.46), whereas there was no such difference in men (11% vs 11%, adjusted prevalence rate ratio, 1.09; 95% confidence interval, 0.66-1.82). No association was found between angina symptoms and conventional stress ischemia for women or men. Results for ischemia as a continuous variable were similar.

CONCLUSIONS

In women, but not in men, anginal symptoms may be a marker of vulnerability toward ischemia induced by psychologic stress. These results highlight the psychosocial origins of angina in women and may have important implications for the management and prognosis of women with angina.

Moral Distress at the End of a Life: When Family and Clinicians Do Not Agree on Implantable Cardioverter-Defibrillator Deactivation

A 63-year-old man with end-stage ischemic cardiomyopathy presented with incessant ventricular tachycardia. He had been hospitalized multiple times in the past year for severe heart failure. As he approached end of life and was regularly receiving defibrillator shocks, his care team recommended deactivation of his implantable cardioverter-defibrillator. However, his family did not wish to allow deactivation, reporting a religious obligation to prolong his life, regardless of the risk of suffering. The patient was unable to adequately participate in the decision-making process. An implantable cardioverter-defibrillator can serve to avoid sudden death but may lead to a prolonged death from heart failure. This possibility forces the examination of values regarding prolongation of life, sometimes producing disagreement among stakeholders. Although ethical consensus holds that defibrillator deactivation is legal and ethical, disagreements about life prolongation may complicate decision making. The ethical, technical, and medical complexity involved in this case speaks to the need for clear, prospective communication involving the patient, the patient's family, and members of the care team.

[The comparative analysis of the influence of the supervised exercise training and home-based exercise training on the psychological status of the following coronary artery bypass grafting]

This article was designed to report the results of the comparative analysis of the influence of the home-based exercise training (HBT) and the supervised exercise training in the form of the controlled training (CVT) under conditions of outpatient rehabilitative treatment on the patients' quality of life (QoL) and psychological status (including manifestations of anxiety and depression) following coronary artery bypass grafting (CABG).

AIM

The objective of the present study was to evaluate the consequences of the application of different programs of physical rehabilitation under the outpatient conditions on the psychoemotional status and quality of life of the patients who had undergone coronary artery bypass grafting.

MATERIALS AND METHODS

A total of 114 male patients suffering from coronary artery disease (CAD) who had undergone CABG were available for the examination. All the patients were allocated to three groups. Group 1 was comprised of the patients (n=36) treated with the use of the supervised cycling training (SCT) while group 2 consisted of the patients who had to perform home-based walking training (HBWT) (n=36). The group of comparison included 42 patients. The psychophysiological assessment was carried out based on the Beck Depression Inventory (BDI) and the Spielberger-Hanin Personal and Reactive Anxiety Scale. The quality of life (QoL) was assessed with the use of the SF-36 questionnaire. All the patients were examined prior to surgery, 1.4 months and 1 year after CABG.

RESULTS

The study has demonstrated the most pronounced improvement in the quality of life of the patients following the 3-month supervised cycling training after CABG that was manifested as the decrease of anxiety and depression. The minimal changes in the psychological and emotional status were documented in the absence of any exercise training integrated into the postoperative rehabilitation program. Only the moderate improvement of QoL was observed in the patients treated with the application of the 3-month home-based walking training program after CABG. The positive effects of the three-month exercise training were evened out within 1 year after its initiation.

DISCUSSION

It has been shown that the effectiveness of HBT is somewhat lower than that of CVT in terms of the influence on the psychoemotional status of the patients following CABG. This finding is at variance with the results reported by the foreign authors and should provide a basis for the enhancement of the effectiveness of the post-CABG rehabilitation programs to be implemented under conditions of the medical facilities, their principal objective being the education of the patients in safe and efficient methods for the pots-surgical self-rehabilitation with the emphasis placed on the measures intended for the improvement of the approaches to monitoring the compliance of the patients with the prescribed recommendations and for increasing their motivation to observe as long as possible the advices given by the health care professionals.

CONCLUSION

The home-based walking training of moderate intensity provides a safe, easy to perform, and readily available tool for a large number of patients who underwent coronary artery bypass grafting even though it is somewhat less effective than the supervised cycling training. The effects of both rehabilitation modalities are rather short-term.

Quality of life as predictor for the development of cardiac ischemia in high-risk asymptomatic diabetic patients

BACKGROUND

Ischemia induced by psychological stress and depression is a common phenomenon in stable coronary artery disease (CAD). We evaluated the quality of life (QoL) of diabetic patients screened for CAD and assessed the prognostic value of mental and physical QoL scores to predict the development of new cardiac ischemia.

METHODS

Prospective multicentre outcome study. The study comprised 400 asymptomatic diabetic patients without history or symptoms of CAD. They underwent myocardial perfusion single-photon emission computed tomography (MPS) and assessment of QoL by two questionnaires: Hospital Depression and Anxiety Scale (HADS-D and HADS-A) and Medical Outcomes Study Short Form 36 (SF-36) at baseline and after 2 years. Patients with normal MPS received usual care; those with abnormal MPS received medical or combined invasive and medical management.

RESULTS

Only mental QoL scores but not physical QoL scores or traditional cardiovascular risk factors were predictive of new ischemia (n = 11/306) during follow-up. The prognostic value for new ischemia as quantified by the area under the receiver operating characteristics curve (AUC) amounted to 0.784 (95% confidence interval (CI) 0.654-0.914, P = 0.002) for HADS-D and to 0.737 (95% CI 0.580-0.893, P = 0.011) for HADS-A. This finding was confirmed by SF-36 mental sum score (AUC 0.688, 95% CI 0.539-0.836, P = 0.036), but not SF-36 physical sum score. QoL scores did not change after 2 years in patients with ischemia at baseline.

CONCLUSIONS

QoL scores assessing mental health, particularly depression and anxiety, predicted the development of new cardiac ischemia in asymptomatic diabetic patients. The study is limited by a small number of events (new ischemia) and so the results should be considered hypothesis generating rather than conclusive.

Myocardial ischemia/reperfusion impairs neurogenesis and hippocampal-dependent learning and memory

The incidence of cognitive impairment in cardiovascular disease (CVD) patients has increased, adversely impacting quality of life and imposing a significant economic burden. Brain imaging of CVD patients has detected changes in the hippocampus, a brain region critical for normal learning and memory. However, it is not clear whether adverse cardiac events or other associated co-morbidities impair cognition. Here, using a murine model of acute myocardial ischemia/reperfusion (I/R), where the coronary artery was occluded for 30min followed by reperfusion, we tested the hypothesis that acute myocardial infarction triggers impairment in cognitive function. Two months following cardiac I/R, behavioral assessments specific for hippocampal cognitive function were performed. Mice subjected to cardiac I/R performed worse in the fear-conditioning paradigm as well as the object location memory behavioral test compared to sham-operated mice. Reactive gliosis was apparent in the hippocampal subregions CA1, CA3, and dentate gyrus 72h post-cardiac I/R as compared with sham, which was sustained two months post-cardiac I/R. Consistent with the inflammatory response, the abundance of doublecortin positive newborn neurons was decreased in the dentate gyrus 72h and 2months post-cardiac I/R as compared with sham. Therefore, we conclude that following acute myocardial infarction, rapid inflammatory responses negatively affect neurogenesis, which may underlie long-term changes in learning and memory.

Associations between positive emotional well-being and stress-induced myocardial ischemia: Well-being scores predict exercise-induced ischemia

OBJECTIVE

Depressive symptoms have been associated with myocardial ischemia induced by mental (MSIMI) and exercise (ESIMI) stress in clinically stable ischemic heart disease (IHD) patients, but the association between positive emotions and inducible ischemia is less well characterized. The objective of this study was to examine the associations between ratings of well-being and stress-induced ischemia.

METHODS

Subjects were adult patients with documented IHD underwent mental and exercise stress testing for the Responses of Myocardial Ischemia to Escitalopram Treatment (REMIT) trial. The General Well-Being Schedule (GWBS), with higher scores reflecting greater subjective well-being, and the Center for Epidemiologic Studies Depression Scale (CES-D) were obtained from the REMIT participants. Echocardiography was used to measure ischemic responses to mental stress and Bruce protocol treadmill exercise testing. Data were analyzed using logistic regression adjusting for age, sex, resting left-ventricular ejection fraction (LVEF), and resting wall motion score index, as well as health-related behaviors.

RESULTS

GWBS scores were obtained for 210 individuals, with MSIMI present in 92 (43.8%) and ESIMI present in 64 (30.5%). There was a significant inverse correlation between GWBS-PE (Positive Emotion subscale) scores and probability of ESIMI (OR=0.55 (95%CI 0.36-0.83), p=0.005). This association persisted after additional control for CESD subscales measuring negative and positive emotions and for variables reflecting health-related behaviors. A similar inverse correlation between GWBS-PE and MSIMI was observed, but did not reach statistical significance (OR=0.81 (95%CI 0.54-1.20), p=0.28).

CONCLUSION

This is, to our knowledge, the first study demonstrating that greater levels of self-reported positive emotions are associated with a lower likelihood of ESIMI among patients with known IHD. Our results highlight the important interface functions of the central nervous and cardiovascular systems and underscore areas for future investigation.

Gender-specific issues in cardiac rehabilitation: do women with ischaemic heart disease need specially tailored programmes?

Ischaemic heart disease (IHD) has changed from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s. Most clinical studies during the past three decades have been conducted with men. Cardiac rehabilitation programmes were also developed with special regard to improving the rate of return to work in middle-aged men. The rehabilitation needs of older patients and women in particular have been largely neglected. The aim of this review is briefly to outline our present knowledge on gender issues in cardiac rehabilitation, and to specify barriers with regard to physical activities especially in (older) women. Coping with a cardiac event, women tend to minimize or play down the impact of their health situation and avoid burdening their social contacts. After a first cardiac event, women report greater psychological distress and lower self-efficacy and self-esteem. In addition, older age, lower exercise levels and reduced functional capacity or co-morbid conditions such as osteoporosis and urinary incontinence are barriers to physical activities in women with IHD. Recent studies on psychosocial intervention revealed less favourable results in women compared with men. These findings have not yet been well explained. This emphasizes our current lack of knowledge about the processes and determinants of successful psychosocial interventions in men and women with IHD. A large (European) trial on gender-specific coping styles, needs, and preferences of older women, and the effects of psychosocial intervention is proposed.

Intrusion and Confusion—The Impact of Medication and Health Professionals after Acute Myocardial Infarction

Background: Secondary prevention is important in preventing new cardiovascular events after acute myocardial infarction (AMI).

Aim: To explore patients' experiences of secondary prevention after a first AMI.

Methods: A qualitative approach with hermeneutical analysis of in depth interviews was used.

Results: Twenty patients (12 men and 8 women, aged 34–79 years) were interviewed. None of the patients was previously treated for cardiovascular disease except one that had a history of angina pectoris. Two main themes emerged from the analysis. 1) Impact of medication: patients interpreted bodily sensations as a consequence of being medicated rather than as a result of their heart attack. The medication led to feelings of being intruded upon but also to positive feelings of security. 2) Impact of health professionals: communication with health professionals resulted in confusion about both treatment and the severity of the coronary disease. Patients expressed a need of being reassured by their physician regarding their physical status.

Conclusions: Health professionals need to consider the impact of pharmacological treatment on patients' life, at least in patients who suffer from a first AMI. The point of departure in secondary preventive work must be patients' beliefs about their condition and the treatment they receive. Nurses and physicians must be aware of the information each patient has been given, and from this starting point, they have to be in concordance with one another. From the patients' perspective it is deemed necessary for the physicians to discuss the disease and the consequences it may have, both in the near future and in the long run, as soon as possible.

The impact of health-related quality of life on the incidence of ischaemic heart disease and stroke; a cohort study in an Iranian population

OBJECTIVE

The aim of study was to evaluate the impact of health-related quality of life (QoL) on the occurrence of ischaemic heart disease (IHD) and stroke using a validated questionnaire.

METHODS

We followed the 3,283 subjects, aged ≥ 35 years and without history of cardiovascular events (CVE) over four years from 2007 to 2011 from the Isfahan cohort study. The World Health Organization QoL questionnaire (WHOQOL-BREF), which contains four separate domains, was used to assess QoL. Incidence rates of IHD and stroke were recorded during follow-up. Socioeconomic demographic data including marital state, educational level, occupation, income and place of living and metabolic risk factors such as diabetes mellitus (DM), hypertension (HTN), dyslipidaemia, body mass index and smoking were also recorded.

RESULTS

More IHD (42%) and stroke (57%) patients were illiterate; while the educational status was significantly different only in the IHD group (P = 0.000). Differences in income and occupation were notable in patients with stroke and IHD, respectively, compared to subjects without them (P < 0.050). DM and HTN were significantly higher in IHD and stroke patients in comparison with subjects without CVE (P = 0.000). Two-way multivariate analyses of covariance test after age, educational status and metabolic risk factors adjustment showed that subjects with stroke had a significantly higher score in all QoL domains in comparison with individuals without stroke (P < 0.050). There was no significant association between QoL domains and IHD incidence (P > 0.050).

CONCLUSION

This study indicates that there is no association between QoL and IHD incidence although there was a significant relationship between higher QoL and incidence of stroke.

Psychosocial predictors of long-term mortality among women with suspected myocardial ischemia: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation

This paper evaluated long-term associations between psychosocial factors and premature mortality among women with suspected coronary artery disease (CAD). We tracked total mortality events over a median 9.3 years in a cohort of 517 women [baseline mean age = 58.3 (11.4) years]. Baseline evaluations included coronary angiography, psychosocial testing, and CAD risk factors. Measures included the Spielberger Trait Anxiety Scale, Beck Depression Inventory, self-rated health, and Social Network Index. Cox regression analysis was used to assess relationships. Covariates included age, CAD risk factors, and CAD severity. BDI scores (HR 1.09, 95 % CI 1.02-1.15), STAI scores (HR .86, 95 % CI .78-.93), and very good self-rated health (relative to the poor self-rated health group; HR .33, 95 % CI .12-.96) each independently predicted time to mortality outcomes in the combined model. SNI scores (HR .91, 95 % CI .81-1.06) and other self-rated health categories (i.e., fair, good, and excellent categories) were not significant mortality predictors after adjusting for other psychosocial factors. These results reinforce and extend prior psychosocial research in CAD populations.

Effect of Health Literacy on Quality of Life amongst Patients with Ischaemic Heart Disease in Australian General Practice

Background

Appropriate understanding of health information by patients with cardiovascular disease (CVD) is fundamental for better management of risk factors and improved morbidity, which can also benefit their quality of life.

Objectives

To assess the relationship between health literacy and health-related quality of life (HRQoL) in patients with ischaemic heart disease (IHD), and to investigate the role of sociodemographic and clinical variables as possible confounders.

Methods

Cross-sectional study of patients with IHD recruited from a stratified sample of general practices in two Australian states (Queensland and South Australia) between 2007 and 2009. Health literacy was measured using a validated questionnaire and classified as inadequate, marginal, or adequate. Physical and mental components of HRQoL were assessed using the Medical Outcomes Study Short Form (SF12) questionnaire. Analyses were adjusted for confounders (sociodemographic variables, clinical history of IHD, number of CVD comorbidities, and CVD risk factors) using multiple linear regression.

Results

A total sample of 587 patients with IHD (mean age 72.0±8.4 years) was evaluated: 76.8% males, 84.2% retired or pensioner, and 51.4% with up to secondary educational level. Health literacy showed a mean of 39.6±6.7 points, with 14.3% (95%CI 11.8–17.3) classified as inadequate. Scores of the physical component of HRQoL were 39.6 (95%CI 37.1–42.1), 42.1 (95%CI 40.8–43.3) and 44.8 (95%CI 43.3–46.2) for inadequate, marginal, and adequate health literacy, respectively (p-value for trend = 0.001). This association persisted after adjustment for confounders. Health literacy was not associated with the mental component of HRQoL (p-value = 0.482). Advanced age, lower educational level, disadvantaged socioeconomic position, and a larger number of CVD comorbidities adversely affected both, health literacy and HRQoL.

Conclusion

Inadequate health literacy is a contributing factor to poor physical functioning in patients with IHD. Increasing health literacy may improve HRQoL and reduce the impact of IHD among patients with this chronic CVD.

Resilience in Patients with Ischemic Heart Disease

BACKGROUND

Resilience is a psychosocial factor associated with clinical outcomes in chronic diseases. The relationship between this protective factor and certain diseases, such heart diseases, is still under-explored.

OBJECTIVE

The present study sought to investigate the frequency of resilience in individuals with ischemic heart disease.

METHOD

This was a cross-sectional study with 133 patients of both genders, aged between 35 and 65 years, treated at Rio Grande do Sul Cardiology Institute - Cardiology University Foundation, with a diagnosis of ischemic heart disease during the study period. Sixty-seven patients had a history of acute myocardial infarction. The individuals were interviewed and evaluated by the Wagnild & Young resilience scale and a sociodemographic questionnaire.

RESULTS

Eighty-one percent of patients were classified as resilient according to the scale.

CONCLUSION

In the sample studied, resilience was identified in high proportion among patients with ischemic heart disease.

Do urban and rural residents living in Poland differ in their ways of coping with chronic diseases?

OBJECTIVE

Chronic disease is a critical life event which demands significant psychological adjustment. Coping strategies and resources such as sense of coherence, self-efficacy, etc. remain factors affecting stress response.

PATIENTS AND METHODS

The examined group included patients with ischemic heart disease (n = 134), type 1 diabetes mellitus (n = 109) or rheumatoid arthritis (n = 92). 159 patients came from urban area whereas 176 came from rural setting. All patients filled up inventories of life satisfaction, severity of depression, coping strategies, self-efficacy, social support and sense of coherence.

RESULTS

The analysis showed that patients from rural areas had higher levels of well-being, i.e., were characterized by lower severity of depression. The predictors of satisfaction with life included two types of resources i.e. self-efficacy, social support and two coping strategies i.e. turning to religion and self-distraction (R2 = 0.39; F = 26.87**). Life satisfaction was determined by social support, sense of coherence and positive reappraisal (R2 = 0.36; F = 29.11**).

CONCLUSIONS

Rural/urban differences in the use of coping strategies may be associated with environmental or lifestyle differences. Patients with IHD, T1D or RA in Polish rural areas are high risk for depression so they may need help in finding systematic contact with specialists of healthcare.

[Quality of Life of Patients With Ischemic Heart Disease and Pronounced Dysfunction of Left Ventricular Myocardium With Medical and Surgical Treatments]

We assessed quality of life in 80 patients with ischemic heart disease and pronounced dysfunction of left ventricular myocardium. Forty patients underwent coronary bypass surgery and 40 patients received only medical therapy. Duration of follow-up was 7 years. Baseline quality of life was low in both groups. Degree of its lowering was positively related to functional class of angina and heart failure and negatively - to exercise tolerance. Incessant drug treatment was associated with moderate improvement of quality of life both in groups of patients subjected and not subjected to surgery.

Ischemic heart disease in women: a focus on risk factors

Heart disease remains a major contributor to morbidity and mortality in women in the United States and worldwide. This review highlights known and emerging risk factors for ischemic heart disease (IHD) in women. Traditional Framingham risk factors such as hypertension, hyperlipidemia, diabetes, smoking, as well as lifestyle habits such as unhealthy diet and sedentary lifestyle are all modifiable. Health care providers should be aware of emerging cardiac risk factors in women such as adverse pregnancy outcomes, systemic autoimmune disorders, obstructive sleep apnea, and radiation-induced heart disease; psychosocial factors such as mental stress, depression, anxiety, low socioeconomic status, and work and marital stress play an important role in IHD in women. Appropriate recognition and management of an array of risk factors is imperative given the growing burden of IHD and need to deliver cost-effective, quality care for women.

[Clinical intervention research on mental stress-induced myocardial ischemia]

OBJECTIVE

To observe the impact of Xinkeshu on top of standard medication on psychological stress-related emotional and biophysiological parameters in patients with mental stress-induced myocardial ischemia (MSIMI).

METHODS

A randomized controlled clinical trial was conducted on 40 patients with MSIMI and patients were randomized into treatment group (n = 21) and control group (n = 19) by random number table method. Patients in the treatment group received Xinkeshu (12 capsules/d) on top of standard therapy, and the control group received placebo on top of standard therapy. Serum homocysteine (Hcy), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) were compared between the groups at baseline and after 8 weeks therapy.

RESULTS

(1) Baseline data were similar between the 2 groups (all P > 0.05). (2) After 8 weeks, LVFS was significantly increased (from (34.62 ± 5.76)% to (35.90 ± 4.99) %, P = 0.027) and serum Hcy (from (18.08 ± 1.81) µmol/L to (16.06 ± 10.10) µmol/L), PHQ-9 (from 8.14 ± 3.98 to 6.28 ± 2.87) and GAD-7 (from 9.52 ± 4.98 to 6.48 ± 3.84) were significantly reduced in treatment group (all P < 0.05) compared to baseline. In the control group, only GAD-7 was significantly reduced (from 8.89 ± 5.06 to 6.74 ± 4.80, P = 0.003) after 8 weeks therapy compared to baseline (P < 0.05) while other parameters remained unchanged (all P > 0.05).

CONCLUSION

Xinkeshu on the top of standard therapy can improve the emotional state and left ventricular systolic function in patients with MSIMI.

[Anxiety and polymorphism Val66Met of BDNF gene--predictors of depression severity in ischemic heart disease]

In a framework of search for early predictors of depression in patients with ischemic heart disease (IHD) we studied effect of molecular-genetic factors (polymorphism of brain-derived neirotrophic factor--BDNF), personality traits (anxiety, neuroticism), IHD severity, and psychosocial stressors on manifestations of depression in men with verified diagnosis of IHD. Severity of depression was assessed by Hamilton Depression Rating Scale 21-item (HAMD 21), anxiety and neuroticism were evaluated by the Spielberger State-Trait Anxiety Inventory and "Big Five" questionnaire, respectively. It wa shown that personal anxiety and ValVal genotype of BDNF gene appeared to be predictors of moderate and severe depression.

[Features of oxygen utilization by the body of patients with arterial hypertension in the days of magnetic storms depending on the psychosomatic status and treatment options]

During magnetic storms the observed increase in γ-background environment and the reduction of the rate of oxygen utilization by the tissues, but the increase in the number of angina attacks per day to magnetic storms the choleric, in the days of magnetic storms in sanguine, for 3-4 days at a phlegmatic, and 4-5 days in the melancholic especially in groups high anxiety phlegmatic and melancholic. Last-risk group severe arterial hypertension and ischemic heart disease. Antihypertensive therapy based on the blockade of the features of the psychosomatic status, significantly reduced the number of attacks and brought the values of the utilization of oxygen and coefficient of oxygen utilization bu the tissues of all the days to those in healthy individual relevant anxiety and temperament.

Effects of moderate aerobic exercise training on hemorheological and laboratory parameters in ischemic heart disease patients

BACKGROUND AND DESIGN

In this study we set out to determine the effects of long-term physical training on hemorheological, laboratory parameters, exercise tolerability, psychological factors in cardiac patients participating in an ambulatory rehabilitation program.

METHODS

Before physical training, patients were examined by echocardiography, tested on treadmill by the Bruce protocol, and blood was drawn for laboratory tests. The enrolled 79 ischemic heart disease patients joined a 24-week cardiac rehabilitation training program. Blood was drawn to measure hematocrit (Hct), plasma and whole blood viscosity (PV, WBV), red blood cell (RBC) aggregation and deformability. Hemorheological, clinical chemistry and psychological measurements were repeated 12 and 24 weeks later, and a treadmill test was performed at the end of the program.

RESULTS

After 12 weeks Hct, PV, WBV and RBC aggregation were significantly decreased, RBC deformability exhibited a significant increase (p<0.05). Laboratory parameters (triglyceride, uric acid, hsCRP and fibrinogen) were significantly decreased (p<0.05). After 24 weeks the significant results were still observed. By the end of the study, IL-6 and TNF-α levels displayed decreasing trends (p<0.06). There was a significant improvement in MET (p<0.001), and the BMI decrease was also significant (p<0.05). The vital exhaustion parameters measured on the fatigue impact scale indicated a significant improvement in two areas of the daily activities (p<0.05).

CONCLUSIONS

Regular physical training improved the exercise tolerability of patients with ischemic heart disease. Previous publications have demonstrated that decreases in Hct and PV may reduce cardiovascular risk, while a decrease in RBC aggregation and an increase in deformability improve the capillary flow. Positive changes in laboratory parameters and body weight may indicate better oxidative and inflammatory circumstances and an improved metabolic state. The psychological findings point to an improvement in the quality of life.

Non-attendance and drop-out in cardiac rehabilitation among patients with ischaemic heart disease

INTRODUCTION

Previous studies have shown drop-out from cardiac rehabilitation (CR) to have prognostic influence on morbidity and mortality among patients with ischaemic heart disease (IHD). We aimed to identify and clarify patients' reasons for non-attendance and drop-out from CR.

MATERIAL AND METHODS

A total of 872 consecutive patients with acute myocardial infarction and/or after percutaneous coronary intervention or coronary artery bypass surgery were asked by conventional mail to fill in a self-completion questionnaire on their choice of post-hospital CR and their reasons for drop-out or for non-attendance.

RESULTS

Age, employment and marital status had a statistically significant influence on the overall course of CR. Younger age, affiliation with the labour market and living alone were related to a higher drop-out from CR in univariate analysis. We found no evidence of a gender difference among the patients who withdrew. Lack of time was stated as the prevailing reason for non-attendance and withdrawal from CR programmes among employed patients and in people aged 65 years or younger. Patients above 75 years of age asked for additional differentiation of exercise levels; currently two levels are offered. Or they found CR meaningless given their physical condition or their overall life situation.

CONCLUSION

In patients with IHD, age, marital status and employment status play a role in the patient's attendance or drop out from CR. Different physical conditions, lack of time, too great a distance from residence to hospital, transport problems and lack of understanding of the benefits of CR explain why patients refuse to participate in or drop-out from CR.

FUNDING

supported by grant from The Danish Ministry of Health.

TRIAL REGISTRATION

not relevant.

[Informed consent for patients undergoing surgery for ischemic cardiomyopathy]

The prognosis of patients with ischemic cardiomyopathy after medical treatment remains poor, despite advances in various therapeutic strategies. In addition to the poorer prognosis, they face higher operative risk, and complex, unestablished operative procedures should be addressed when obtaining preoperative informed consent from patients with ischemic cardiomyopathy. Although the established indications for revascularization in patients with ischemic heart failure pertain to those with angina and significant coronary artery disease, the management of patients with ischemic heart failure without angina is a challenge because of the lack of evidence in this population. The possibility of combining myocardial revascularization with surgical ventricular reconstruction (SVR) to reverse left ventricular remodeling or with mitral valve plasty to repair the incompetence of mitral valve coaptation has been examined in many trials, although little difference in the long-term outcomes between the simple revascularization and the combined procedure groups have been observed. The therapeutic guidelines for patients with ischemic cardiomyopathy state that choosing to add SVR and/or mitral surgery to revascularization should be based on a precise, careful evaluation and should be performed only by surgeons with a high level of surgical expertise.

[Temperament and character traits measured by temperament and character inventory (TCI) by Cloninger in patients with ischemic heart disease]

Ischemic heart disease (IHD) is one of the main causes of death and disability worldwide. This situation stimulates research of its ethiopathogenesis. The role of psychosocial factors like depression, stress is underlined. Also personality traits play an important role in this process. The aim of study was to assess temperament and character traits in a group of patients with IHD.

MATERIAL AND METHODS

Temperament and Character Inventory (TCI) was used to determine temperament and character dimensions. Temperament traits: harm avoidance (HA), reward dependence (RD), novelty seeking (NS), persistence (P), character traits: cooperativeness (C), self-directedness (SD), self-transcendence (ST). Each of these traits has a varying number of subscales. The dimensions are determined from a 240-item questionnaire.

RESULTS

Patients with IHD obtained higher scores in HA dimension of the TCI questionnaire. The study group achieved lower score in a subscale of NS called extravagance (NS3), and higher score of C dimension called compassion (C4).

CONCLUSION

The intensity of temperament and character traits are different in a group of patients with IHD in comparison with the control group especially in dimensions of HA, NS3 and C4. Variables that differentiated the study group were also sex, age and years of education.

Depression, dietary habits, and cardiovascular events among women with suspected myocardial ischemia

BACKGROUND

Dietary habits and depression are associated with cardiovascular disease risk. Patients with depression often report poor eating habits, and dietary factors may help explain commonly observed associations between depression and cardiovascular disease.

METHODS

From 1996 to 2000, 936 women were enrolled in the Women's Ischemia Syndrome Evaluation at 4 US academic medical centers at the time of clinically indicated coronary angiography and then assessed (median follow-up, 5.9 years) for adverse outcomes (cardiovascular disease death, heart failure, myocardial infarction, stroke). Participants completed a protocol including coronary angiography (coronary artery disease severity) and depression assessments (Beck Depression Inventory scores, antidepressant use, and depression treatment history). A subset of 201 women (mean age, 58.5 years; standard deviation, 11.4) further completed the Food Frequency Questionnaire for Adults (1998 Block). We extracted daily fiber intake and daily servings of fruit and vegetables as measures of dietary habits.

RESULTS

In separate Cox regression models adjusted for age, smoking, and coronary artery disease severity, Beck Depression Inventory scores (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.01-1.10), antidepressant use (HR, 2.4; 95% CI, 1.01-5.9), and a history of treatment for depression (HR, 2.4; 95% CI, 1.1-5.3) were adversely associated with time to cardiovascular disease outcomes. Fiber intake (HR, 0.87; 95% CI, 0.78-0.97) and fruit and vegetable consumption (HR, 0.36; 95% CI, 0.19-0.70) were associated with a decreased time to cardiovascular disease event risk. In models including dietary habits and depression, fiber intake and fruit and vegetable consumption remained associated with time to cardiovascular disease outcomes, whereas depression relationships were reduced by 10% to 20% and nonsignificant.

CONCLUSIONS

Among women with suspected myocardial ischemia, we observed consistent relationships among depression, dietary habits, and time to cardiovascular disease events. Dietary habits partly explained these relationships. These results suggest that dietary habits should be included in future efforts to identify mechanisms linking depression to cardiovascular disease.

The effect of daily self-measurement of pressure pain sensitivity followed by acupressure on depression and quality of life versus treatment as usual in ischemic heart disease: a randomized clinical trial

BACKGROUND

Depressive symptoms and reduced quality of life (QOL) are parts of the chronic stress syndrome and predictive of adverse outcome in patients with ischemic heart disease (IHD). Chronic stress is associated with increased sensitivity for pain, which can be measured by algometry as Pressure Pain Sensitivity (PPS) on the sternum.

AIM

To evaluate if stress focus by self-measurement of PPS, followed by stress reducing actions including acupressure, can decrease depressive symptoms and increase psychological well-being in people with stable IHD.

DESIGN

Observer blinded randomized clinical trial over 3 months of either intervention or treatment as usual (TAU).

STATISTICAL ANALYSIS

Intention to treat.

METHODS

Two hundred and thirteen participants with IHD were included: 106 to active treatment and 107 to TAU. Drop-out: 20 and 12, respectively. The active intervention included self-measurement of PPS twice daily followed by acupressure as mandatory action, aiming at a reduction in PPS. Primary endpoint: change in depressive symptoms as measured by Major depression inventory (MDI). Other endpoints: changes in PPS, Well-being (WHO-5) and mental and physical QOL (SF-36).

RESULTS

At 3 months PPS decreased 28%, to 58, in active and 11%, to 72, in TAU, p<0.001. MDI decreased 22%, to 6.5, in active group vs. 12%, to 8.3 in TAU, p = 0.040. WHO-5 increased to 71.0 and 64.8, active group and TAU, p = 0.015. SF-36 mental score sum increased to 55.3 and 53.3, active and TAU, p = 0.08.

CONCLUSIONS

PPS measurements followed by acupressure reduce PPS, depressive symptoms and increase QOL in patients with stable IHD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01513824.

Factors associated with anxiety and depression among type 2 diabetes outpatients in Malaysia: a descriptive cross-sectional single-centre study

OBJECTIVE

To determine the prevalence and factors associated with anxiety and depression among type 2 diabetes outpatients in Malaysia.

DESIGN

Descriptive, cross-sectional single-centre study with universal sampling of all patients with type 2 diabetes.

SETTING

Endocrinology clinic of medical outpatient department in a Malaysian public hospital.

PARTICIPANTS

All 169 patients with type 2 diabetes (men, n=99; women, n=70) aged between 18 and 90 years who acquired follow-up treatment from the endocrinology clinic in the month of September 2013.

MAIN OUTCOME MEASURES

The validated Hospital Anxiety and Depression Scale (HADS), sociodemographic characteristics and clinical health information from patient records.

RESULTS

Of the total 169 patients surveyed, anxiety and depression were found in 53 (31.4%) and 68 (40.3%), respectively. In multivariate analysis, age, ethnicity and ischaemic heart disease were significantly associated with anxiety, while age, ethnicity and monthly household income were significantly associated with depression.

CONCLUSIONS

Sociodemographics and clinical health factors were important correlates of anxiety and depression among patients with diabetes. Integrated psychological and medical care to boost self-determination and confidence in the management of diabetes would catalyse optimal health outcomes among patients with diabetes.

[Evaluation of the clinical, psychological and socio-environmental factors, affecting disability of elderly people undergoing surgical myocardial revascularization]

Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization are considered in the article. The authors demonstrate that for each level of the problem there are their own significant factors. Besides, the most essential correlations between investigated factors are marked out. The results obtained will enable to determine more correctly clinical-and-labor prognosis for patients with ischemic heart disease and develop their efficient rehabilitation programs. It is demonstrated that elderly patients have some features of vital activity restriction which are necessary to take into account while medical social expertise and rehabilitation program development.

[Psychoemotional status and "adaptation diseases" at patients with the peptic ulcer in Ural Federal Territory]

RESEARCH OBJECTIVE

To study the psycho-emotional status and prevalence of the coronary heart disease (CHD) and the idiopathic hypertensia (IH) at patients with the peptic ulcer of a stomach (PUS) and at patients with a peptic ulcer of a duodenum is (YaB DPK).

MATERIALS AND METHODS

Examination of 226 patients with an exacerbation of a peptic ulcer was conducted. Patients were distributed in 3 groups of observation depending on localization of ulcerative process. At all surveyed questioning was carried out, data on heriditary burdeness, smoking, alcohol intake, existence of somatopathies were specified, clinic-morphological implications of a peptic ulcer were studied.

RESULTS

Feeling of alarm was present at 109 (48.2%) patients with a peptic ulcer, from them at 92 (40.7%) the subclinical level of alarm is noted, and at 17 (7.5%) clinically expressed form is taped. At 39.3% of the examined patients the depression is defined, from them two thirds of patients had the subclinical level of a depression, and 13 people suffered from clinically expressed depression form. Communication of recurrence with a stress was noted at 86.0% of patients, professionally caused stress--at 44.4%. In our research at the time of the beginning of a disease prevalence of an ischemic heart disease among patients with an ulcer of a duodenum (DPK) made 18.2%. In group of patients with the combined localization of ulcerative defect in a stomach and in DPK which already had an ischemic heart disease before emergence of the second ulcerative defect there were 26.6% that statistically significantly doesn't differ. However that by the time of emergence of the combined lesion this category of patients made already 73.4% is indicative. In case of DPK ulcer prevalence of an ischemic heart disease increased from the moment of the beginning of a disease until carrying out research twice (to 36.4%), but patients with the combined ultserozny lesion nevertheless distinguished both larger initial prevalence of an ischemic heart disease, and more expressed its gain. At the time of the beginning of a disease of GB met in a group of persons with the isolated ulcerative defect authentically more often (36.4% against 18.7% in group of patients with the combined localization of an ulcer). At the time of carrying out research prevalence of GB among patients with DPK ulcer (47.7%) whereas in group of the combined lesion of a stomach and DPK of GB without ischemic heart disease there was only every fourth patient remained significant by 2,7 times (DI 1.2-6.3). The combination of associated diseases of an ischemic heart disease and GB at patients with the advent of an ulcer at the same time in a stomach and DPK practically always met at the persons abusing alcohol and tobacco smoking that in general enlarges risk of development of an ulcer of the second localization by 7,6 times

CONCLUSION

At the peptic ulcer (PU) of any localization the previous stress conducting quite often to formation of alarm and a depression conducts to also education a stress--the induced conditions, for example, of an arterial hypertonia, and later--to an ischemic heart disease. As specific to every second patient with the combined form of a peptic ulcer of a stomach and a duodenum it is possible to consider a polisintropiya from such the comorbidity diseases as coronary heart disease and an idiopathic hypertensia. The combination of these associated diseases to alcohol intake and tobacco smoking progressively enlarges risk of development of a peptic ulcer of the combined localization by 7,6 times in comparison with the isolated duodenum canker.

RESEARCH OBJECTIVE

To define influence of the comorbidity diseases and risk.

[Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization]

Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization are considered. It is demonstrated that each level of the problem in consideration has its own significant factors. Besides, the most essential correlations between investigated factors are marked out. The results obtained would allow determining clinical-and-labor prognosis for patients with ischemic heart disease more correctly and develop the efficient programs aimed at their rehabilitation.

Does coronary artery bypass grafting improve quality of life in elderly patients?

Traditional outcome measures such as long-term mortality may be of less value than symptomatic improvement in elderly patients undergoing coronary artery bypass grafting (CABG). In this systematic review, we analyse health-related quality of life (HRQOL) as a marker of outcome after CABG. We aimed to assess the role of HRQOL tools in making recommendations for elderly patients undergoing surgery, where symptomatic and quality-of-life improvement may often be the key indications for intervention. Twenty-three studies, encompassing 4793 patients were included. Overall, elderly patients underwent CABG at reasonably low risk. Our findings, therefore, support the conclusion that performing CABG in the elderly may be associated with significant improvements in HRQOL. In order to overcome previous methodological limitations, future work must clearly define and stringently follow-up this elderly population, to develop a more robust, sensitive and specialty-specific HRQOL tool.

[Autonomic nervous system unbalance in patients with ischemic heart disease and depression]

It is set that in 26.9% patients with coronary desease there are the depressed disorders. The easy degree of depression was observed in 61.1% persons, maskable depression--in 27.8% persons, middle degree of depression--in 11.1% persons. For such patients the decline of heart rhythm variability, increase of sympathetic tone, violation of day's rhythm of vegetative nervous system, prevalence of humoral influence on a heart rhythm were revealed.

Effect of escitalopram on mental stress-induced myocardial ischemia: results of the REMIT trial

IMPORTANCE

Mental stress can induce myocardial ischemia and also has been implicated in triggering cardiac events. However, pharmacological interventions aimed at reducing mental stress-induced myocardial ischemia (MSIMI) have not been well studied.

OBJECTIVE

To examine the effects of 6 weeks of escitalopram treatment vs placebo on MSIMI and other psychological stress-related biophysiological and emotional parameters.

DESIGN, SETTING, AND PARTICIPANTS

The REMIT (Responses of Mental Stress Induced Myocardial Ischemia to Escitalopram Treatment) study, a randomized, double-blind, placebo-controlled trial of patients with clinically stable coronary heart disease and laboratory-diagnosed MSIMI. Enrollment occurred from July 24, 2007, through August 24, 2011, at a tertiary medical center.

INTERVENTIONS

Eligible participants were randomized 1:1 to receive escitalopram (dose began at 5 mg/d, with titration to 20 mg/d in 3 weeks) or placebo over 6 weeks.

MAIN OUTCOMES AND MEASURES

Occurrence of MSIMI, defined as development or worsening of regional wall motion abnormality; left ventricular ejection fraction reduction of 8% or more; and/or horizontal or down-sloping ST-segment depression of 1 mm or more in 2 or more leads, lasting for 3 or more consecutive beats, during 1 or more of 3 mental stressor tasks.

RESULTS

Of 127 participants randomized to receive escitalopram (n = 64) or placebo (n = 63), 112 (88.2%) completed end point assessments (n = 56 in each group). At the end of 6 weeks, more patients taking escitalopram (34.2% [95% CI, 25.4%-43.0%]) had absence of MSIMI during the 3 mental stressor tasks compared with patients taking placebo (17.5% [95% CI, 10.4%-24.5%]), based on the unadjusted multiple imputation model for intention-to-treat analysis. A significant difference favoring escitalopram was observed (odds ratio, 2.62 [95% CI, 1.06-6.44]). Rates of exercise-induced ischemia were slightly lower at 6 weeks in the escitalopram group (45.8% [95% CI, 36.6%-55.0%]) than in patients receiving placebo (52.5% [95% CI, 43.3%-61.8%]), but this difference was not statistically significant (adjusted odds ratio; 1.24 [95% CI, 0.60-2.58]; P = .56).

CONCLUSIONS AND RELEVANCE

Among patients with stable coronary heart disease and baseline MSIMI, 6 weeks of escitalopram, compared with placebo, resulted in a lower rate of MSIMI. There was no statistically significant difference in exercise-induced ischemia. Replication of these results in multicenter settings and investigations of other medications for reducing MSIMI are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00574847.

Clinical and socio-demographic predictors of postoperative vital exhaustion in patients after cardiac surgery

BACKGROUND

Vital exhaustion, a psychological state characterized by extreme fatigue, is an independent predictor of future cardiac events. However, the attributes of vital exhaustion following coronary artery bypass (CABG) surgery are poorly understood.

OBJECTIVE

The study objective was to assess correlates of vital exhaustion following CABG surgery.

METHODS

In a descriptive, exploratory study, 42 patients who had CABG surgery were evaluated for exhaustion 4-8 weeks post-hospital discharge. Demographic and clinical data were obtained from self-report and medical chart review.

RESULTS

Of the total sample (mean age 67.9 ± 12.5, 90% male, 70% Caucasian, 3.12 ± 1.3 grafts), approximately 41% reported exhaustion. When compared to their exhausted post-CABG counterpart, non-exhausted post-CABG patients had a significantly higher frequency of preoperative insulin use. Exhausted patients were significantly more likely to have higher left ventricular ejection fraction ([LVEF], OR: 1.07, p = 0.04), and elevated hemoglobin (OR: 2.98, p = 0.03) and eosinophils (OR: 1.02, p = 0.02) than those who were not exhausted.

CONCLUSION

Clinicians should evaluate all patients for exhaustion post-CABG surgery; patients with elevated LVEF, hemoglobin, and eosinophil levels warrant increased scrutiny.

Health ramifications of the Gush Katif evacuation

BACKGROUND

Following the 2005 evacuation of Gush Katif, a community of Jewish settlements located in the greater Gaza Strip, many evacuees reported a deterioration in their health status.

OBJECTIVES

To determine if and to what degree the evacuation of Gush Katif caused a worsening in the health status of the evacuees.

METHODS

In this retrospective cohort study we assessed the medical records of 2962 evacuees for changes in prevalence of diabetes, hypertension and ischemic heart disease in the period beginning 1 year before and ending 5 years after the evacuation. The findings were compared to those for the general israeli population. A questionnaire was distributed to 64 individuals to assess lifestyle and social change.

RESULTS

An increase in diabetes and hypertension was found in men aged 45-64. The prevalence of diabetes mellitus in the 45-54 male group rose from 8.7% in 2004 to 12.6% in 2007 to 18.7% in 2010; in the 55-64 age group it rose from 24.6% in 2004 to 29.9% in 2007 to 32.9% in 2010. Hypertension in 45-64 year old men rose from 27.1% in 2004 to 35.12% in 2010. The increases in diabetes were significant and higher than those in the general population. The increases in hypertension were of similar magnitude. The prevalence of heart disease did not change and is similar to that in the general population. The questionnaire sample showed an increase in depression and overweight.

CONCLUSIONS

The Gush Katif evacuation appears to be associated with increased morbidity of chronic disease. This may be attributed to any of several mechanisms, with unemployment, depression, inactivity and overweight playing significant roles. Preventive medical interventions and measures should be employed to screen and treat this population which underwent a major stressful event and as a result seem at greater risk than their peers.

Psychosocial distress as a risk factor of ischemic heart disease mortality

BACKGROUND

Ischemic heart disease (IHD) is the leading cause of morbidity and mortality in the industrialized world. Recent research evidence suggests that psychosocial distress has been implicated as both a precursor to IHD and a significant risk factor for death in those with established IHD. According to WHO, psychosocial distress will be the most harmful risk factor for the development of IHD in the near future. Some experts have underlined the importance of the psychosocial distress of economic and political reforms as the main reason for the IHD mortality crisis in Russia in the 1990s. The aim of the present study was to estimate the effect of psychosocial distress on IHD mortality rate in Russia.

SUBJECTS AND METHODS

Trends in age-adjusted, sex-specific suicide (as an integral indicator for psychosocial distress) and IHD mortality rate in Russia from 1965 to 2005 were analyzed employing a distributed lags analysis in order to assess the bivariate relationship between the two time series.

RESULTS

Time series analysis indicates the presence of a statistically significant association between the two time series for males at lags 0 and females at lags 0 and 1.

CONCLUSIONS

These findings suggest that the Russian IHD mortality crisis is most likely to have been precipitated by the psychosocial distress imposed by rapid societal transformation. The experience of Russia should serve as an example of how societal-level change can influence the health of a population.