Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial

CONTEXT

Depression and low perceived social support (LPSS) after myocardial infarction (MI) are associated with higher morbidity and mortality, but little is known about whether this excess risk can be reduced through treatment.

OBJECTIVE

To determine whether mortality and recurrent infarction are reduced by treatment of depression and LPSS with cognitive behavior therapy (CBT), supplemented with a selective serotonin reuptake inhibitor (SSRI) antidepressant when indicated, in patients enrolled within 28 days after MI.

DESIGN, SETTING, AND PATIENTS

Randomized clinical trial conducted from October 1996 to April 2001 in 2481 MI patients (1084 women, 1397 men) enrolled from 8 clinical centers. Major or minor depression was diagnosed by modified Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and severity by the 17-item Hamilton Rating Scale for Depression (HRSD); LPSS was determined by the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Social Support Instrument (ESSI). Random allocation was to usual medical care or CBT-based psychosocial intervention.

INTERVENTION

Cognitive behavior therapy was initiated at a median of 17 days after the index MI for a median of 11 individual sessions throughout 6 months, plus group therapy when feasible, with SSRIs for patients scoring higher than 24 on the HRSD or having a less than 50% reduction in Beck Depression Inventory scores after 5 weeks.

MAIN OUTCOME MEASURES

Composite primary end point of death or recurrent MI; secondary outcomes included change in HRSD (for depression) or ESSI scores (for LPSS) at 6 months.

RESULTS

Improvement in psychosocial outcomes at 6 months favored treatment: mean (SD) change in HRSD score, -10.1 (7.8) in the depression and psychosocial intervention group vs -8.4 (7.7) in the depression and usual care group (P<.001); mean (SD) change in ESSI score, 5.1 (5.9) in the LPSS and psychosocial intervention group vs 3.4 (6.0) in the LPSS and usual care group (P<.001). After an average follow-up of 29 months, there was no significant difference in event-free survival between usual care (75.9%) and psychosocial intervention (75.8%). There were also no differences in survival between the psychosocial intervention and usual care arms in any of the 3 psychosocial risk groups (depression, LPSS, and depression and LPSS patients).

CONCLUSIONS

The intervention did not increase event-free survival. The intervention improved depression and social isolation, although the relative improvement in the psychosocial intervention group compared with the usual care group was less than expected due to substantial improvement in usual care patients.

Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II

BACKGROUND

Weight loss appears to be an effective method for primary prevention of hypertension. However, the long-term effects of weight loss on blood pressure have not been extensively studied.

OBJECTIVE

To present detailed results from the weight loss arm of Trials of Hypertension Prevention (TOHP) II.

DESIGN

Multicenter, randomized dinical trial testing the efficacy of lifestyle interventions for reducing blood pressure over 3 to 4 years. Participants in TOHP II were randomly assigned to one of four groups. This report focuses only on participants assigned to the weight loss (n = 595) and usual care control (n = 596) groups.

PATIENTS

Men and women 30 to 54 years of age who had nonmedicated diastolic blood pressure of 83 to 89 mm Hg and systolic blood pressure less than 140 mm Hg and were 110% to 165% of their ideal body weight at baseline.

INTERVENTION

The weight loss intervention included a 3-year program of group meetings and individual counseling focused on dietary change, physical activity, and social support

MEASUREMENTS

Weight and blood pressure data were collected every 6 months by staff who were blinded to treatment assignment

RESULTS

Mean weight change from baseline in the intervention group was -4.4 kg at 6 months, -2.0 kg at 18 months, and -0.2 kg at 36 months. Mean weight change in the control group at the same time points was 0.1, 0.7, and 1.8 kg. Blood pressure was significantly lower in the intervention group than in the control group at 6, 18, and 36 months. The risk ratio for hypertension in the intervention group was 0.58 (95% CI, 0.36 to 0.94) at 6 months, 0.78 (CI, 0.62 to 1.00) at 18 months, and 0.81 (CI, 0.70 to 0.95) at 36 months. In subgroup analyses, intervention participants who lost at least 4.5 kg at 6 months and maintained this weight reduction for the next 30 months had the greatest reduction in blood pressure and a relative risk for hypertension of 0.35 (CI, 0.20 to 0.59).

CONCLUSIONS

Clinically significant long-term reductions in blood pressure and reduced risk for hypertension can be achieved with even modest weight loss.

Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial

CONTEXT

Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality.

OBJECTIVE

To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use.

DESIGN AND SETTING

The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states.

PARTICIPANTS

A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis.

INTERVENTION

One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801).

MAIN OUTCOME MEASURES

Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs.

RESULTS

General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly.

CONCLUSIONS

In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

Ischemic, hemodynamic, and neurohormonal responses to mental and exercise stress. Experience from the Psychophysiological Investigations of Myocardial Ischemia Study (PIMI)

BACKGROUND

The pathophysiology of mental stress-induced myocardial ischemia, which occurs at lower heart rates than during physical stress, is not well understood.

METHODS AND RESULTS

The Psychophysiological Investigations of Myocardial Ischemia Study (PIMI) evaluated the physiological and neuroendocrine functioning in unmedicated patients with stable coronary artery disease and exercise-induced ischemia. Hemodynamic and neurohormonal responses to bicycle exercise, public speaking, and the Stroop test were measured by radionuclide ventriculography, ECG, and blood pressure and catecholamine monitoring. With mental stress, there were increases in heart rate, systolic blood pressure, cardiac output, and systemic vascular resistance that were correlated with increases in plasma epinephrine. During exercise, systemic vascular resistance fell, and there was no relationship between the hemodynamic changes and epinephrine levels. The fall in ejection fraction was greater with mental stress than exercise. During mental stress, the changes in ejection fraction were inversely correlated with the changes in systemic vascular resistance. Evidence for myocardial ischemia was present in 92% of patients during bicycle exercise and in 58% of patients during mental stress. Greater increases in plasma epinephrine and norepinephrine occurred with ischemia during exercise, and greater increases in systemic vascular resistance occurred with ischemia during mental stress.

CONCLUSIONS

Mental stress-induced myocardial ischemia is associated with a significant increase in systemic vascular resistance and a relatively minor increase in heart rate and rate-pressure product compared with ischemia induced by exercise. These hemodynamic responses to mental stress can be mediated by the adrenal secretion of epinephrine. The pathophysiological mechanism involved are important in the understanding of the etiology of myocardial ischemia and perhaps in the selection of appropriate anti-ischemic therapy.

Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study

BACKGROUND

Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates.

METHODS AND RESULTS

To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5+/-0.4 years and 5.2+/-0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P=0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36; P=0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P=0.9) and did not predict death even after adjusting for resting ejection fraction (P=0.63), which was similar in both groups (mean, 56.4 versus 59.7; P=0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise.

CONCLUSIONS

In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress-induced ischemia predicts subsequent death.

Increasing the fruit and vegetable consumption of fourth-graders: results from the high 5 project

BACKGROUND

This study evaluated the effects of a school-based dietary intervention program to increase fruit and vegetable consumption among fourth-graders.

METHODS

Twenty-eight elementary schools were randomized to an immediate intervention condition or to a delayed intervention control condition. Measures of diet and psychosocial variables were collected at base line and 1 and 2 years post-baseline. The intervention included classroom, parent, and cafeteria components.

RESULTS

Mean daily consumption of fruit and vegetables was higher for the intervention children compared with controls at Follow-up 1 (X(t) = 3.96, X(c) = 2.28) and at Follow-up 2 (X(t) = 3.20, X(c) = 2.21). Macro- and micronutrient changes favoring the intervention children were also observed at both Follow-up 1 and Follow-up 2. Mean daily consumption of fruit and vegetables was higher for intervention parents compared with controls at Follow-up 1 (X(t) = 4.23,X(c) = 3.94) but not at Follow-up 2.

CONCLUSIONS

Strong effects were found for the High 5 intervention on fruit and vegetable consumption, on macro- and micro-nutrients, and on psychosocial variables. Future work is needed to enhance the intervention effects on parents' consumption and to test the effectiveness of the intervention when delivered by classroom teachers.

Cardiovascular reactivity to video game predicts subsequent blood pressure increases in young men: The CARDIA study

OBJECTIVE

This study was undertaken to determine the relationship between heightened reactivity of blood pressure (BP) during stress and 5-year changes in blood pressure and hypertensive status, using the CARDIA study.

METHOD

A total of 3364 participants (910 white men, 909 white women, 678 black men, and 867 black women), initially 20 to 32 years old and normotensive, were included. Cardiovascular reactivity to psychological stressors (video game and star-tracing tasks for 3 minutes, cold pressor test for 1 minute) was measured in 1987-1988. We then examined reactivity as a predictor of significant BP change (> or = 8 mm Hg, thought to represent a clinically significant increase) over the next 5 years. Logistic regression models were used to control for potential covariates. Significant BP change and the development of hypertension (BP greater than 140/90 or taking medication for hypertension) over the 5-year follow-up were examined in separate analyses.

RESULTS

Increased systolic blood pressure (SBP) reactivity to the video game was associated with a significant 5-year SBP increase among the entire cohort, independent of resting SBP (p < .0001). Subsequent analyses showed that this relationship held for men but not for women. Reactivity to the star-tracing task or the cold pressor test did not predict significant BP change. Among black men only, new hypertensives (N = 36) had greater diastolic blood pressure (DBP) reactivity to the video game (p = .01).

CONCLUSIONS

Although BP reactivity to all physical and mental stressors used in this study did not consistently predict 5-year change in BP in this young cohort, the results indicate that reactivity to a video game stressor predicts 5-year change in BP and early hypertension among young adult men. These findings are consistent with other studies showing the usefulness of stressors producing a primarily beta-adrenergic response in predicting BP change and hypertension. The results may be limited by the shortened initial rest and recovery periods used in the CARDIA protocol.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions

BACKGROUND

Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS

Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS

Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS

Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Psychosocial treatment within sex by ethnicity subgroups in the Enhancing Recovery in Coronary Heart Disease clinical trial

OBJECTIVE

Intervening in depression and/or low perceived social support within 28 days after myocardial infarction (MI) in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial did not increase event-free survival. The purpose of the present investigation was to conduct post hoc analyses on sex and ethnic minority subgroups to assess whether any treatment subgroup is at reduced or increased risk of greater morbidity/mortality.

METHODS

The 2481 patients with MI (973 white men, 424 minority men, 674 white women, 410 minority women) who had major or minor depression and/or low perceived social support were randomly allocated to usual medical care or cognitive behavior therapy. Total mortality or recurrent nonfatal MI (ENRICHD primary endpoint) and cardiac mortality or recurrent nonfatal MI (secondary endpoint) were analyzed as composite endpoints by group for time to first event using Cox proportional hazards regression.

RESULTS

There was a trend in the direction of treatment efficacy for white men for the primary endpoint (hazard ratio [HR], 0.80; 95% confidence interval, 0.61-1.05; p =.10) and a significant (p <.006, Bonferroni corrected) effect for the secondary endpoint (HR, 0.63; 95% CI, 0.46-0.87; p =.004). In contrast, the HRs for each of the other three subgroups were nonsignificant. The magnitude of differences in treatment effects between white men and the other subgroups remained significant for the secondary endpoint (p =.04) after adjustment for age, education, living alone, antidepressant use, comorbidity score, cardiac catheterization, ejection fraction, history of hypertension, and major depression.

CONCLUSIONS

White men, but not other subgroups, may have benefited from the ENRICHD intervention, suggesting that future studies need to attend to issues of treatment design and delivery that may have prevented benefit among sex and ethnic subgroups other than white men.

Body image among men and women in a biracial cohort: the CARDIA Study

OBJECTIVE

To examine body image in a population-based, biracial cohort.

METHOD

Body image measures were obtained on 1,837 men (45% Black) and 1,895 women (51% Black) in the CARDIA study. Subscales of the Multidimensional Body Self-Relations Questionnaire (Appearance Evaluation and Appearance Orientation) and a measure of body size dissatisfaction were obtained.

RESULTS

Blacks were more invested in appearance than Whites and women were more invested than men. Women were more dissatisfied with size and overall appearance than men, and White men were more dissatisfied with appearance than Black men. Black and White women were similarly dissatisfied with size and appearance. However, after adjustment for age, body mass index, and education, Black women were more satisfied with both dimensions than White women. Obesity was strongly associated with body dissatisfaction across all gender-ethnicity groups.

DISCUSSION

Significant differences in body image were apparent by gender and ethnicity, and different patterns were evident depending on the dimension considered.

Alcohol intake and blood pressure in young adults: the CARDIA Study

Associations between self-reported average daily alcohol intake and blood pressure were assessed in 5031 black and white men and women ages 18-30 from the Coronary Artery Risk Development in Young Adults Study (CARDIA). In general, intake was positively but weakly related to both systolic and diastolic blood pressure. Associations with systolic pressure were generally stronger than those with diastolic pressure. With average daily alcohol intake categorized as none, 0.1-9.9 ml, 10.0-19.9 ml, 20.0-29.9 ml, and 30.0+ ml, mean systolic pressure, adjusted for age, body mass index, education, smoking, and physical activity, increased progressively with increasing intake in black and white men and in white women. Mean diastolic pressure increased progressively with increasing intake only in white men and women, but was highest for those averaging 30.0+ ml per day in black women as well as white men and women. Mean pressures were also compared for those averaging 75.0+ ml per day (men) or 50.0+ ml per day (women) vs those reporting no intake. Differences in adjusted mean pressures for white men were 3.2 mmHg (95% confidence limits (CL) -0.3, 6.8) for systolic pressure and 1.7 mmHg (-1.6, 5.0) for diastolic pressure. In black men differences were 4.4 mmHg (1.4, 7.4) and 3.4 mmHg (0.6, 6.3), respectively. Differences in white women were 1.4 mmHg (-2.5, 5.3) for systolic pressure and 0.9 mmHg (-2.7, 4.5) for diastolic pressure and for black women, -0.2 mmHg (-4.3, 3.8) and 1.9 mmHg (-1.9, 5.8). Separate analyses in smokers and nonsmokers of the associations between alcohol intake and blood pressure suggested that associations may differ by smoking status in some sex-race groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The Depression Interview and Structured Hamilton (DISH): rationale, development, characteristics, and clinical validity

OBJECTIVE

The Depression Interview and Structured Hamilton (DISH) is a semistructured interview developed for the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study, a multicenter clinical trial of treatment for depression and low perceived social support after acute myocardial infarction. The DISH is designed to diagnose depression in medically ill patients and to assess its severity on an embedded version of Williams' Structured Interview Guide for the Hamilton Depression scale (SIGH-D). This article describes the development and characteristics of the DISH and presents a validity study and data on its use in ENRICHD.

METHODS

In the validity study, the DISH and the Structured Clinical Interview for DSM-IV (SCID) were administered in randomized order to 57 patients. Trained interviewers administered the DISH, and clinicians administered the SCID. In ENRICHD, trained research nurses administered the DISH and recorded a diagnosis. Clinicians reviewed 42% of the interviews and recorded their own diagnosis. The Beck Depression Inventory (BDI) was administered in both studies.

RESULTS

In the validity study, the SCID diagnosis agreed with the DISH on 88% of the interviews (weighted kappa = 0.86). In ENRICHD, the clinicians agreed with 93% of the research nurses' diagnoses. The BDI and the Hamilton depression scores derived from the DISH in the two studies correlated 0.76 (p < .0001) in the validity study and 0.64 (p < .0001) in ENRICHD.

CONCLUSIONS

These findings support the validity of the DISH as a semistructured interview to assess depression in medically ill patients. The DISH is efficient in yielding both a DSM-IV depression diagnosis and a 17-item Hamilton depression score.

Sufficient conditions for effective treatment of substance abusing homeless persons

Treatment efficacy for homeless substance abusers (primarily crack cocaine) was studied in a randomized control design with subjects (n = 176) assigned to usual care (UC) or an enhanced day treatment program plus abstinent contingent work therapy and housing (EC). Subjects met DSM-III-R criteria for Substance Use Disorder and McKinny Act criteria for homelessness. UC involved weekly individual and group counseling. EC involved a day treatment program consisting of daily attendance, transportation, lunch, manualized psychoeducational groups, and individual counseling. A total of 131 (74.4%) subjects (62 UC and 69 EC) were treated and followed. UC subjects attended 28.5% and EC attended 48.4% of expected treatment during the first 2 months. After 2 months, EC subjects experienced up to 4 months of abstinent contingent work therapy (44.9% of EC subjects) and housing (37.7% of EC subjects), with day treatment available two afternoons per week. Longitudinal Wei-Lachin analyses of medians (reported alcohol use, days homeless and employed) and proportions (cocaine toxicologies) were conducted across 2-, 6-, and 12-month follow-up points. EC had 36% fewer positive cocaine toxicologies at 2-months and 18% fewer at 6-months than UC with regression toward baseline at 12-months. EC had 8 days fewer days of reported alcohol use in the past 30 days, 52 fewer days homeless in the past 60 days, and 10 more days employed in the past 30 days from baseline to the 12-months. UC showed no changes except a temporary increase in employment at 6-months. This is one of the first demonstrations that homeless cocaine abusers can be retained and effectively treated.

Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial

CONTEXT

Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth.

OBJECTIVE

To evaluate dissemination strategies aimed at increasing appropriate use of this therapy.

DESIGN AND SETTING

Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13).

SUBJECTS

Obstetricians and their preterm delivery cases at participating hospitals.

INTERVENTION

Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback.

MAIN OUTCOME MEASURE

Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122).

RESULTS

Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways.

CONCLUSION

An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

Weight gain with breast cancer adjuvant treatment

Available information suggests that individuals with breast cancer gain weight during adjuvant treatment and that this weight gain may be associated with poor prognosis. Exploration of the factors which affect weight gain may aid in developing weight control interventions for these patients. To determine the factors which are associated with weight gain, 32 women undergoing adjuvant chemotherapy were followed over 2 years from the beginning of adjuvant treatment. Measures of psychologic functioning and self-reports of exercise levels and eating were assessed every 2 months during the course of treatment. Sixty-nine percent of the women gained weight over treatment, resulting in a significant weight gain for the group as a whole. Weight gain was correlated positively with several psychologic measures but not with assessed biologic measures. A multiple-regression equation using psychologic/behavioural measures of emotional discharge, logical analysis, affective regulation, interpersonal sensitivity, average number of symptoms, and obsessive compulsiveness accounted for 58% of the variance in overall weight gain. At 2 years of follow-up, 27 women had gained weight for an average of 6.03 kg. The coping style of logical analysis emerged as a significant predictor of disease recurrence, accounting for 28% of the variance in weight gain at 2 years. The results are discussed in terms of identification of women likely to gain weight during adjuvant treatment, directions for future research, and development of interventions to control weight gain.

Parental recognition of overweight in school-age children

OBJECTIVE

Examine the accuracy of parental weight perceptions of overweight children before and after the implementation of childhood obesity legislation that included BMI screening and feedback.

METHODS AND PROCEDURES

Statewide telephone surveys of parents of overweight (BMI > or = 85th percentile) Arkansas public school children before (n = 1,551; 15% African American) and after (n = 2,508; 15% African American) policy implementation were examined for correspondence between parental perception of child's weight and objective classification.

RESULTS

Most (60%) parents of overweight children underestimated weight at baseline. Parents of younger children were significantly more likely to underestimate (65%) than parents of adolescents (51%). Overweight parents were not more likely to underestimate, nor was inaccuracy associated with parental education or socioeconomic status. African-American parents were twice as likely to underestimate as whites. One year after BMI screening and feedback was implemented, the accuracy of classification of overweight children improved (53% underestimation). African-American parents had significantly greater improvements than white parents (P < 0.0001).

DISCUSSION

Parental recognition of childhood overweight may be improved with BMI screening and feedback, and African-American parents may specifically benefit. Nonetheless, underestimation of overweight is common and may have implications for public health interventions.

Diagnoses, symptoms, and attribution of symptoms among black and white inpatients admitted for coronary heart disease

OBJECTIVES

This study examined health care-seeking behaviors to elucidate factors that contribute to differences in patterns of coronary heart disease between African Americans and Whites. The prevalence of diagnosed coronary heart disease, patients' perceptions of symptoms and attribution of symptoms, and predictors of painful symptoms and attribution of cardiac symptoms were examined.

METHODS

The study involved 2416 patients admitted with diagnoses of coronary artery disease, ischemic heart disease, or myocardial infarction or to rule out myocardial infarction. Structured interview questions were used to obtain demographic information, symptoms precipitating admission, and patients' attribution of their symptoms. Discharge diagnoses were obtained from hospital records.

RESULTS

Acute myocardial infarction, unstable angina, nonacute ischemic heart disease, and atherosclerosis were more frequent in White patients. For Blacks, the odds of reporting painful symptoms were only 64% of the odds found for Whites when other factors were controlled, and the odds of attributing symptoms to cardiac origins were almost 50% lower for Blacks than for Whites.

CONCLUSIONS

The tendency of Blacks to report fewer painful symptoms and to attribute their symptoms to noncardiac origins may contribute to differences in care-seeking and in medical management of heart disease in Blacks.

Adherence in the training levels comparison trial

In the Training Levels Comparison Trial, 197 male coronary heart disease patients were randomized to low or high intensity training with target heart rates, which corresponded to 50% and 85% of the VO2max achieved on the previous exercise test, respectively. Patients were to exercise at their assigned intensity level at three 1-h long supervised sessions per week for 2 yr. This paper reports on two components of adherence: attendance at exercise sessions and achievement of heart rates in the target range. During the first year of training, the average percent of exercise sessions attended (mean +/- SE) for the low intensity group (64.0 +/- 2.5%) was significantly higher than for the high intensity group (55.5% +/- 2.7%). At the end of 1 yr of training, 54% and 37% of the low and high intensity patients, respectively, achieved heart rates within 5 beats.min-1 of their target heart rates. Although the low intensity program was preferable to achieve maximum attendance, attenders on the high intensity program achieved higher heart rates. These results suggest that to maximize the achieved heart rate, it would be optimal to motivate a cardiac rehabilitation patient to train at the high intensity level for a prolonged period of time.

Sodium reduction for hypertension prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II

Sodium reduction is efficacious for primary prevention of hypertension, but the feasibility of achieving this effect is unclear. The objective of the paper is detailed analyses of adherence to and effects of the sodium reduction intervention among overweight adults in the Trials of Hypertension Prevention, Phase II. Sodium reduction (comprehensive education and counselling about how to reduce sodium intake) was tested vs no dietary intervention (usual care) for 36-48 months. A total of 956 white and 203 black adults, ages 30-54 years, with diastolic blood pressure 83-89 mmHg, systolic blood pressure (SBP) <140 mmHg, and body weight 110-165% of gender-specific standard weight were included in the study. At 36 months, urinary sodium excretion was 40.4 mmol/24 h (24.4%) lower in sodium reduction compared to usual care participants (P<0.0001), but only 21% of sodium reduction participants achieved the targeted level of sodium excretion below 80 mmol/24 h. Adherence was positively related to attendance at face-to-face contacts. Net decreases in SBP at 6, 18, and 36 months of 2.9 (P<0.001), 2.0 (P<0.001), and 1.3 (P=0.02) mmHg in sodium reduction vs usual care were associated with an overall 18% lower incidence of hypertension (P=0.048); were relatively unchanged by adjustment for ethnicity, gender, age, and baseline blood pressure, BMI, and sodium excretion; and were observed in both black and white men and women. From these beneficial but modest results with highly motivated and extensively counselled individuals, sodium reduction sufficient to favourably influence the population blood pressure distribution will be difficult to achieve without food supply changes.

Rapid early action for coronary treatment: rationale, design, and baseline characteristics. REACT Research Group

OBJECTIVE

Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay.

METHODS

Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed.

RESULTS

Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86).

CONCLUSIONS

REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Sex differences in chest pain in patients with documented coronary artery disease and exercise-induced ischemia: Results from the PIMI study

BACKGROUND

Sex differences in the pathophysiologic course of coronary artery disease (CAD) are widely recognized, yet accurate diagnosis of coronary artery disease in women remains challenging.

METHODS

To determine sex differences in the clinical manifestation of CAD, we studied chest pain reported during daily activities, exercise, and mental stress in 170 men and 26 women. All patients had documented CAD (>50% narrowing in at least 1 major coronary artery or prior myocardial infarction) and all had 1-mm ST-segment depression on treadmill exercise. We collected psychologic test results, serum samples (potassium, epinephrine, norepinephrine, cortisol, b-endorphin, and glucose), and cardiac function, sensory threshold, and autonomic function data at specified times before, during, or after exercise and mental stress tests to assess measures of depression, anxiety, and neurohormonal and thermal pain perception.

RESULTS

Women reported chest pain more often than men during daily activities (P =.04) and during laboratory mental stressors (P =.01) but not during exercise. Men had lower scores than women on measures of depression, trait anxiety, harm avoidance, and reward dependence (P <.05 for all). Women had significantly lower plasma b-endorphin levels at rest (4.2 +/- 3.9 vs 5.0 +/- 2.5 pmol/L for men, P =.005) and at maximal mental stress (6.4 +/- 5.1 vs 7.4 +/- 3.5 pmol/L for men, P <.01). A higher proportion of women than men had marked pain sensitivity to graded heat stimuli applied to skin (hot pain threshold <41 degrees C, 33% vs 10%, P =.001).

CONCLUSIONS

Our results reflect sex differences in the affective and discriminative aspects of pain perception and may help explain sex-related differences in clinical presentations.

Adverse effect of pregnancy on high density lipoprotein (HDL) cholesterol in young adult women. The CARDIA Study. Coronary Artery Risk Development in Young Adults

The authors analyzed data from the Coronary Artery Risk Development in Young Adults (CARDIA) Study in order to examine associations between parity and lipoproteins. Of 2,787 women recruited in 1985-1986, 2,534 (91%) returned in 1987-1988 and 2,393 (86%) returned in 1990-1991 for repeat evaluations. Two-year change (1987-1988 to 1985-1986) in high density lipoprotein (HDL) cholesterol was significantly different among the parity groups. HDL cholesterol decreased in women who had their first pregnancy of at least 28 weeks duration during follow-up (mean +/- standard error, -3.5 +/- 1.2 mg/dl), and this change was significantly different from the increase in women parous at baseline who had no further pregnancies (2.5 +/- 0.3 mg/dl) and in nullipara (2.4 +/- 0.3 mg/dl). There was a nonsignificant trend for a greater decrease in HDL2 cholesterol fraction in the primipara compared with the other groups. The HDL cholesterol decrease remained significant after controlling for race, age, education, oral contraceptive use, and changes in body mass index, waist-hip ratio, physical activity, smoking status, and alcohol intake. Change in HDL cholesterol was also significantly different among the parity groups in analyses of pregnancies that occurred during the subsequent 3 years of follow-up. There were no differences for change in LDL cholesterol or triglycerides. Potential mechanisms for a detrimental effect of pregnancy on HDL cholesterol include hormonal, body composition, or life-style/behavioral changes.

The Women's Health Trial Feasibility Study in Minority Populations: design and baseline descriptions

The Women's Health Trial: Feasibility Study in Minority Populations (WHT:FSMP), a randomized trial of 2208 women, was conducted to investigate three questions. First, can women from minority and low-socioeconomic-status populations be recruited in numbers sufficient to evaluate a dietary intervention designed to lower fat intake. Second, the efficacy of a low fat, increased fruit/vegetable/ grain product intervention for reducing fat consumption. Third, will participation in the intervention lower plasma cholesterol and estradiol levels relative to the controls. The baseline results showed that an adequate number of minority and low SES women could be recruited to test the study hypotheses. A diverse study population of postmenopausal women consuming a high fat diet was recruited: 28% of participants were Black, 16% were Hispanic, 11% had less than a high school level of education, and 15.5% had household incomes of < $15,000.