Adverse events after left ventricular assist device implantation linked to psychosocial risk in women and men

BACKGROUND

Reasons for women's increased probability to experience adverse events (AEs) after left ventricular assist device (LVAD) implantation compared with men's remain uncertain. We explored the role of psychosocial risk in the experience of AEs in women and men.

METHODS

INTERMACS patients receiving a primary continuous-flow LVAD between July 2006 and December 2017, median follow-up 13.6 months, were included (n = 20,123, 21.3% women). Time-to-event was calculated with cumulative incidence functions for 10 types of AEs separately (e.g., infection, device malfunction), each time accounting for the competing outcomes death, heart transplant, and device explant due to recovery. Event-specific Cox proportional hazard models were run with a binary psychosocial risk variable (including substance abuse, psychiatric diagnosis, limited social support, limited cognition, repeated noncompliance), controlled for covariates.

RESULTS

Psychosocial risk was more prevalent in men than in women (21.4% vs 17.5%, p < 0.001). Seven out of 10 AEs were more likely in women than in men (e.g., infection 44.5% vs 39.2%, p < 0.001). The association of psychosocial risk with each AE was either stronger in women than in men (e.g., device malfunction HRadj 1.29, 95% confidence interval (CI) (1.06-1.56) vs HRadj 1.10, 95% CI (0.97-1.25); rehospitalization HRadj 1.15, 95% CI (1.02-1.29) vs HRadj 1.03, 95% CI (0.97-1.10) or similar between sexes.

CONCLUSIONS

Independent of clinical parameters, the presence of psychosocial risk is associated with increases in AEs. This suggests that early modification of psychosocial risk factors may have the potential to lower the risk for AEs in this patient population.

Sex Differences in Recovery and Device Replacement After Left Ventricular Assist Device Implantation as Destination Therapy

Background The relevance of sex and preimplant factors for clinical outcomes among patients with left ventricular assist devices intended for destination therapy is unclear. Methods and Results INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) data (2006-2017) from 6771 men and 1690 women with left ventricular assist devices as destination therapy were analyzed to evaluate the contribution of preimplant clinical, demographic, and clinically judged psychosocial characteristics to time until death, heart transplant, device explant due to recovery, or complication-related device replacement. Associations of sex with time until each competing outcome were evaluated using cumulative incidence functions and event-specific Cox proportional hazards models. Women were younger, more likely to have nonischemic diagnoses, and reported less substance abuse but were more likely to be unmarried, not working for an income, overweight, and depressed than men. After 2 years, women had higher probabilities for recovery (3.7% versus 1.6%, P<0.001) and device replacement (12.1% versus 10%, P=0.019) than men but not for death and transplant (P>0.12). The sex differences remained after controlling for covariates (adjusted hazard ratio [HR_adj] recovery, 1.85; 95% CI, 1.30-2.70; P<0.001; HR_adj device replacement, 1.22; 95% CI, 1.04-1.33; P=0.015). Female-specific diagnoses (eg, postpartum heart failure) contributed to women's enhanced rate of recovery. Demographic and psychosocial factors were unrelated to women's increased event rates. Conclusions In destination therapy, women have higher rates of device replacement and recovery than men. The latter was partly explained by female-specific diagnoses. Standardized assessments of psychosocial characteristics are needed to elucidate their association with sex differences in outcomes.

Gender differences in psychosocial and clinical characteristics in the European Registry for Patients with Mechanical Circulatory Support

BACKGROUND

Not much is known about psychosocial characteristics of men and women receiving continuous flow left ventricular assist devices (CF LVAD).

OBJECTIVE

To investigate gender differences in clinical and psychosocial (demographic, behavioral, psychological) characteristics in CF LVAD recipients.

METHODS

We analyzed European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data (N=2395, 16.8% women; 2011 to 2017) and compared pre-implant characteristics in men and women intended for bridge-to-transplant (BTT) or destination therapy (DT).

RESULTS

Women were underrepresented [DT (n=61): 13.4%; BTT (n=341): 17.6%]. They were more likely to be divorced/separated, widowed, in unstable clinical condition, and non-working (DT only), but less likely to be smokers, to have ischemic cardiomyopathy or diabetes, and younger (BTT only) than men. Missing data were abundant, especially those that reflect psychological characteristics (>87%).

CONCLUSION

Gender differences were noted, some specific to device strategy. Improved collection of psychosocial characteristics is warranted to elucidate their relationship to future prognosis.

Modulation of startle and heart rate responses by fear of physical activity in patients with heart failure and in healthy adults

Fear of physical activity (FoPA) has been suggested as a barrier to physical activity in patients with heart failure and might be associated with low adherence to exercise regimen despite medical guideline recommendations. The present study examined physiological indicators of FoPA by assessing startle modulation (via EMG at the orbicularis oculi muscle) and heart rate responses (derived from ECG) after affective priming with lexical stimuli of positive, neutral, and negative valence, as well as words related to physical activity as potentially phobic cues. After screening for FoPA in patients with heart failure and healthy adults, twenty participants each were assigned to one of three subsamples: a healthy control group and two cardiac patient groups scoring either low or high on FoPA. The high-FoPA group showed startle potentiation and more pronounced heart rate acceleration (than did controls) in the phobic prime condition, indicating defensive response mobilization. Among the patients, higher FoPA accounted for 30% of the startle potentiation by phobic priming, whereas general anxiety, depression, and disease severity were no significant predictors of startle modulation. These findings suggest that FoPA in patients with heart failure is associated with defensive responses on a physiological level that might be indicative of avoidance behavior, thereby contributing to low adherence to exercise regimen. Thus, FoPA presents a significant target for psychological interventions to foster physical activity in cardiac patients.

Fear of Physical Activity, Anxiety, and Depression

Abstract. Background: Physical activity (PA) is recommended by heart failure treatment guidelines. Adherence to exercise prescriptions is low and not much is known about everyday PA in this patient group. Aims: This study describes objectively assessed everyday PA/sedentary behavior in men and women with chronic heart failure and examines associations of potential barriers for engaging in PA, namely fear of physical activity (FoPA), general anxiety, and depression, with indicators of PA and sedentary behavior. Method: In 61 outpatients with heart failure (67.5 ± 10.7 years of age) the impact of FoPA, trait anxiety, and depression on 6-day accelerometer measures was evaluated using linear regression models. Results: Sedentary behavior was prevalent in men and women alike, with lying down and sitting/standing as predominant activity classes during daytime. Men had higher PA energy expenditure (726 vs. 585 kcal/d, Cohen’s effect size d = 0.74) and walked up/down more often (0.21% vs. 0.12% of total PA, d = 0.56) than women. FoPA did not differ between sexes. FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates (β-values between −0.26 and −0.44, p-values < 0.024). Limitations: The self-selected sample included few women. Medical data were assessed via self-reports. Conclusion: FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates. These preliminary findings highlight FoPA as a barrier to everyday PA in patients with heart failure.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Role of Depression and Social Isolation at Time of Waitlisting for Survival 8 Years After Heart Transplantation

Background

We evaluated depression and social isolation assessed at time of waitlisting as predictors of survival in heart transplant (HTx) recipients.

Methods and Results

Between 2005 and 2006, 318 adult HTx candidates were enrolled in the Waiting for a New Heart Study, and 164 received transplantation. Patients were followed until February 2013. Psychosocial characteristics were assessed by questionnaires. Eurotransplant provided medical data at waitlisting, transplantation dates, and donor characteristics; hospitals reported medical data at HTx and date of death after HTx. During a median follow‐up of 70 months (<1–93 months post‐HTx), 56 (38%) of 148 transplanted patients with complete data died. Depression scores were unrelated to social isolation, and neither correlated with disease severity. Higher depression scores increased the risk of dying (hazard ratio=1.07, 95% confidence interval, 1.01, 1.15, P=0.032), which was moderated by social isolation scores (significant interaction term; hazard ratio = 0.985, 95% confidence interval, 0.973, 0.998; P=0.022). These findings were maintained in multivariate models controlling for covariates (P values 0.020–0.039). Actuarial 1‐year/5‐year survival was best for patients with low depression who were not socially isolated at waitlisting (86% after 1 year, 79% after 5 years). Survival of those who were either depressed, or socially isolated or both, was lower, especially 5 years posttransplant (56%, 60%, and 62%, respectively).

Conclusions

Low depression in conjunction with social integration at time of waitlisting is related to enhanced chances for survival after HTx. Both factors should be considered for inclusion in standardized assessments and interventions for HTx candidates.

Smoking Status at Time of Listing for a Heart Transplant Predicts Mortality on the Waiting List

Objective:

We examined the association of smoking status at time of listing with waitlist mortality among heart transplant (HTx) candidates.

Participants and Design:

Data were analyzed from 316 participants (aged 53 ± 11; 18% female) of the Waiting for a New Heart Study, a prospective observational study of patients newly listed for HTx at 17 hospitals.

Results:

During the study period (April 2005 to March 2010), 14% of those who never smoked died, 18% among former smokers died, and almost half (42%) died among those who reported smoking at time of wait listing. Multivariate Cox regression models controlling for age, sex, and disease severity revealed smoking at time of listing was associated with significantly higher risk of mortality compared to never smoking (hazard ratio [HR] = 3.43; P = .03). The relationship between smoking and mortality risk appeared to follow a dose-dependent pattern: adjusted HRs were 1.80 for those who quit ≤1 year ago, 1.25 for those who quit >1 to 10 years ago, and 0.90 for those quit >10 years ago, compared to never smokers. Smoking at time of listing may increase risk of mortality during the waiting period, indicating the need for improved strategies to achieve smoking cessation as early as possible in the course of HTx.

Who makes use of Internet-delivered health information? The role of gender role self-concept in young men and women

This study examined the contribution of gender role self-concept (expressiveness and instrumentality) on active interest in and use of Internet-delivered health information among young men and women. Four hundred and twenty university students reported health behaviours and perceived personal vulnerability regarding five diseases. We analysed active interest in receiving health-related information concerning these diseases (providing email address to receive a link to health-related websites) and actual use of provided websites two weeks afterwards. Usage of health-related information via the Internet was objectively assessed by recording log-ins on the website and obtaining individual click counts. In both sexes, higher expressiveness was independently associated with being more likely to show active interest in health-related information. Additionally, expressiveness was positively associated with website use in men independent of age, personal vulnerability and reported health behaviours. Thus, an expressive self-concept facilitates the use of health-related information, especially among men.

Cardiac threat appraisal and depression after first myocardial infarction

The present study investigated cardiac threat appraisal and its association with depression after first myocardial infarction (MI). A semi-structured interview allowing for DSM-IV-axis I diagnoses was administered to 36 patients after first MI. Patients completed self-reports 5–15 days after the MI (time 1), 6–8 weeks later (time 2), and again 6 months later (time 3). Assessments at time 1 included indices of cardiac threat appraisal, locus of control, coping, and depression while at time 2 and time 3 only measures of depression were obtained. Cardiac threat appraisal was significantly correlated with depression at time 1, but was unrelated to depression scores at time 2 and time 3. Furthermore, there was a significant inverse association between cardiac threat appraisal and the subscales “search for affiliation” and “threat minimization” of the coping questionnaire. Additionally, “search for affiliation” correlated negatively with depression scores at time 1 and time 3, and “threat minimization” negatively with depression scores at time 1 and time 2. These results suggest a significant association between cardiac threat appraisal and depressive symptoms shortly after MI. Practical implications for treatment are discussed.

Patients' sex and emotional support as predictors of death and clinical deterioration in the waiting for a new heart study: results from the 1-year follow-up

CONTEXT

Little is known about the role of patient's sex and emotional support in the prognosis of heart transplant candidates.

OBJECTIVE

To examine patient's sex and emotional support as predictors of outcomes in the Waiting for a New Heart Study.

DESIGN, SETTING, AND PARTICIPANTS

The Waiting for a New Heart Study is a prospective observational study of 318 patients (18% female) newly added to the waiting list for a heart transplant. Demographic, medical, psychosocial characteristics (including social support [ENRICHD Social Support Index; high vs. low support]) were assessed at the time of wait-listing. Main Outcomes-Time until death/delisting due to deteriorated tealth, considering competing outcomes (e.g., transplantation) during the first 12 months after wait-listing were analyzed via cause-specific Cox proportional hazard models.

RESULTS

By 12 months, 32 men (12%) and 10 women (17%) had died/deteriorated. Medical risk was comparable across sexes. More men than women reported low emotional support (20.4% vs. 8.6%) and being a past or current smoker (80.4% vs. 56.9%). More women than men had low vocational level (93.1% vs. 69.6%; all P values < .05). With medical risk and other confounding variables controlled for, female sex significantly increased risk of death/deterioration (hazard ratio, 2.30; 95% confidence interval, 1.04-5.12; P = .04); low emotional support further tended to increase the risk for this outcome (P = .07). As none of the 5 women with low emotional support had reached this end point, analyses were performed in the male sample and revealed that men with low emotional support were more than twice as likely to die/deteriorate than were men with high support (hazard ratio, 2.23; 95% confidence interval, 1.04-4.82; P = .04).

CONCLUSION

Women had worse survival while awaiting a heart transplant than men had, independent of confounding variables. Even though emotional support may be an important buffer for men, protective factors for women warrant further investigation with larger samples and/or longer follow-ups.

Patients' Sex and Emotional Support as Predictors of Death and Clinical Deterioration in the Waiting for a New Heart Study: Results from the 1-Year Follow-up

Context

Little is known about the role of patient's sex and emotional support in the prognosis of heart transplant candidates.

Objective

To examine patient's sex and emotional support as predictors of outcomes in the Waiting for a New Heart Study.

Design, Setting, and Participants

The Waiting for a New Heart Study is a prospective observational study of 318 patients (18% female) newly added to the waiting list for a heart transplant. Demographic, medical, psychosocial characteristics (including social support [ENRICHD Social Support Index; high vs low support]) were assessed at the time of wait-listing.

Main Outcomes

Time until death/delisting due to deteriorated health, considering competing outcomes (eg, transplantation) during the first 12 months after wait-listing were analyzed via cause-specific Cox proportional hazard models. Results—By 12 months, 32 men (12%) and 10 women (17%) had died/deteriorated. Medical risk was comparable across sexes. More men than women reported low emotional support (20.4% vs 8.6%) and being a past or current smoker (80.4% vs 56.9%). More women than men had low vocational level (93.1% vs 69.6%; all P values < .05). With medical risk and other confounding variables controlled for, female sex significantly increased risk of death/deterioration (hazard ratio, 2.30; 95% confidence interval, 1.04–5.12; P = .04); low emotional support further tended to increase the risk for this outcome ( P = .07). As none of the 5 women with low emotional support had reached this end point, analyses were performed in the male sample and revealed that men with low emotional support were more than twice as likely to die/deteriorate than were men with high support (hazard ratio, 2.23; 95% confidence interval, 1.04–4.82; P = .04).

Conclusion

Women had worse survival while awaiting a heart transplant than men had, independent of confounding variables. Even though emotional support may be an important buffer for men, protective factors for women warrant further investigation with larger samples and/or longer follow-ups.

Eine deutsche Adaptation des ENRICHD Social Support Inventory (ESSI)

Zusammenfassung. Zur Erfassung der wahrgenommenen emotionalen sozialen Unterstützung bei kardialen Patienten wird das ESSI-D (ENRICHD Social Support Inventory – Deutsch), eine deutsche Adaptation des englischen ESSI, vorgestellt. Mit einer Stichprobe von N = 1597 Patienten (22.7% Frauen), die sich einer Bypass-Operation unterzogen, wurden die psychometrischen Eigenschaften des ESSI-D überprüft. Cronbachs Alpha der Gesamtskala lag bei α = .89. Eine konfirmatorische Faktorenanalyse bestätigte die einfaktorielle Struktur der Skala. Korrelationen mit unterschiedlichen Kriteriumsvariablen wie Partnerstatus, soziale Funktionsfähigkeit, körperliche Funktion und Depressivität lieferten Hinweise für eine zufriedenstellende Konstruktvalidität. Das ESSI-D erweist sich für diese Patientengruppe als ein ökonomisches Instrument zur Erfassung der emotionalen sozialen Unterstützung mit guten psychometrischen Eigenschaften.

Social isolation and depression predict 12-month outcomes in the "waiting for a new heart study"

BACKGROUND

Identification of modifiable psychosocial characteristics related to survival of heart transplant (HTx) candidates is needed to prevent clinical deterioration and improve prognosis.

METHODS

A multi-site, prospective study was conducted with 318 HTx candidates (18% female, 82% male; 53 +/- 11 years of age) newly listed at 17 hospitals in Germany and Austria. Baseline demographic and psychosocial characteristics were assessed by questionnaires. Indicators of disease severity (Heart Failure Survival Score, creatinine, cardiac index) and 12-month outcomes (death, high-urgency HTx, elective HTx, de-listing due to deterioration or improvement) were provided by Eurotransplant.

RESULTS

By 12 months, 33 patients died, 83 received an urgent HTx, 30 underwent an elective HTx, and 9 were de-listed due to clinical deterioration and 17 due to improvement. All measures of disease severity predicted outcomes. Controlling for disease severity, the number of social contacts contributed significantly to outcomes, favoring those who improved. Comparing socially isolated patients (<4 social contacts/month) who also had depression scores in the clinical range (high psychosocial risk group; n = 37) to those with >10 social contacts/month without depression (low psychosocial risk group; n = 47) revealed significant differences in the distribution of outcome frequencies (chi-square = 11.2, df = 4, p < 0.04). The high psychosocial risk group was more likely to have died/deteriorated and less likely to have improved than the low psychosocial risk group.

CONCLUSIONS

Regardless of disease severity, socially isolated HTx candidates who are also depressed may be at increased risk for clinical deterioration and mortality, indicating a need for psychosocial intervention.

Psychosocial and behavioural factors in heart transplant candidates – an overview

Mortality among heart transplant (HTX) candidates remains high. This review of the literature shows that psychosocial characteristics like depression, social isolation and coping strategies contribute to morbidity and mortality in heart failure (HF) patients, and may also be relevant to the prognosis of HTX candidates. Based on the research to date, physical activity favourably affects subjective and objective parameters not only in HF patients, but also in HTX candidates. Depression is prevalent among HTX candidates, especially in ischaemic patients, and seems to be related to earlier transplantation. Findings on the effects of depression on pretransplant mortality are conflicting. Not much is known concerning social isolation, coping, nutrition, or weight loss in this patient group. Identification of modifiable psychosocial and behavioural variables related to clinical status in this patient group is clearly needed and will aid the development of behavioural interventions to supplement medical therapies.

Psychosoziale Aspekte und Gesundheitsverhalten bei Herzinsuffizienz

Zusammenfassung. Für die steigende Zahl von Patienten mit Herzinsuffizienz stehen verschiedene medizinische Behandlungsansätze zur Verfügung, darunter als letzte Option die Herztransplantation (HTX). Ergänzende psychosoziale und behaviorale Interventionen erscheinen aus verschiedenen Gründen auch für Patienten auf der HTX-Warteliste sinnvoll. Unser Literaturüberblick zeigt, dass bekannte psychosoziale koronare Risikofaktoren wie Depressivität und soziale Isolation auch bei Herzinsuffizienz Morbidität und Mortalität erhöhen. Körperliche Aktivität wirkt sich dagegen günstig auf subjektive und objektive Parameter aus. Diese Faktoren stellen erste Ansatzpunkte für verhaltensorientierte Interventionen dar. Welche Rolle andere koronare Risikofaktoren (z.B. Feindseligkeit, Ärger, Ernährung und Gewichtsreduktion) spielen, ist bislang ungeklärt. Ausblickend werden einige viel versprechende Forschungsansätze skizziert.

Bericht über die deutsche Adaptation der State-Trait Depression Scales (STDS)

Zusammenfassung. Die neu entwickelte deutsche Version der State-Trait Depression Scales (STDS) stellt ein Instrument dar, mit dessen Hilfe in erster Linie depressives Erleben bei gesunden Probandinnen und Probanden der Forschung zugänglich gemacht werden soll. Anhand der Daten von fünf nicht-klinischen Stichproben wurden verschiedene Analysen durchgeführt, um die Güte der Skalen zu prüfen. Die interne Struktur wurde mittels konfirmatorischer Faktorenanalysen untersucht. Daneben wurden die psychometrischen Eigenschaften der Items und Skalen bestimmt. Um die externe Validität der Skalen zu prüfen, wurden die Zusammenhänge zwischen den STDS und anderen Depressionsinstrumenten sowie weiteren State- und Traitskalen analysiert. An einer weiteren Stichprobe durchgeführte Latent-State-Trait-Analysen belegten die den Skalen zugrunde liegende State-Trait-Konzeption. Darüber hinaus wurde in einem Experiment mit kontrollierter Induktion von Erfolg und Mißerfolg die Sensitivität der State-Skala sowie das Zusammenwirken von State- und Trait-Depression untersucht.