Can lifestyle modification improve neurocognition? Rationale and design of the ENLIGHTEN clinical trial

BACKGROUND

Risk factors for cardiovascular disease (CVD) not only increase the risk for clinical CVD events, but also are associated with a cascade of neurophysiologic and neuroanatomic changes that increase the risk of cognitive impairment and dementia. Although epidemiological studies have shown that exercise and diet are associated with lower CVD risk and reduced incidence of dementia, no randomized controlled trial (RCT) has examined the independent effects of exercise and diet on neurocognitive function among individuals at risk for dementia. The ENLIGHTEN trial is a RCT of patients with CVD risk factors who also are characterized by subjective cognitive complaints and objective evidence of neurocognitive impairment without dementia (CIND) STUDY DESIGN: A 2 by 2 design will examine the independent and combined effects of diet and exercise on neurocognition. 160 participants diagnosed with CIND will be randomly assigned to 6 months of aerobic exercise, the DASH diet, or a combination of both exercise and diet; a (control) group will receive health education but otherwise will maintain their usual dietary and activity habits. Participants will complete comprehensive assessments of neurocognitive functioning along with biomarkers of CVD risk including measures of blood pressure, glucose, endothelial function, and arterial stiffness.

CONCLUSION

The ENLIGHTEN trial will (a) evaluate the effectiveness of aerobic exercise and the DASH diet in improving neurocognitive functioning in CIND patients with CVD risk factors; (b) examine possible mechanisms by which exercise and diet improve neurocognition; and (c) consider potential moderators of treatment, including subclinical CVD.

Multi-scale heart rate dynamics detected by phase-rectified signal averaging predicts mortality after acute myocardial infarction

AIMS

Acceleration and deceleration capacity (AC and DC) for beat-to-beat short-term heart rate dynamics are powerful predictors of mortality after acute myocardial infarction (AMI). We examined if AC and DC for minute-order long-term heart rate dynamics also have independent predictive value.

METHODS AND RESULTS

We studied 24-hr Holter electrcardiograms in 708 post-AMI patients who were followed up for up to 30 months thereafter. Acceleration capacity and DC was calculated with the time scales of T (window size defining heart rate) and s (wavelet scale) from 1 to 500 s and compared their prognostic values with conventional measures (AC(conv) and DC(conv)) that were calculated with (T,s) = [1,2 (beat)]. During the follow-up, 47 patients died. Both increased AC(conv) and decreased DC(conv) predicted mortality (C statistic, 0.792 and 0.797). Concordantly, sharp peaks of C statistics were observed at (T,s) = [2,7 (sec)] for both increased AC and decreased DC (0.762 and 0.768), but there were larger peaks of C statistics at around [30,60 (sec)] for both (0.783 and 0.796). The C statistic was greater for DC than AC at (30,60) (P = 0.0012). Deceleration capacity at (30,60) was a significant predictor even after adjusted for AC(conv) (P = 0.020) and DC(conv) (P = 0.028), but the predictive power of AC at (30,60) was no longer significant.

CONCLUSION

A decrease in DC for minute-order long-term heart rate dynamics is a strong predictor for post-AMI mortality and the predictive power is independent of AC(conv) and DC(conv) for beat-to-beat short-term heart rate dynamics.

Determinants and consequences of adherence to the dietary approaches to stop hypertension diet in African-American and white adults with high blood pressure: results from the ENCORE trial

BACKGROUND

Although the Dietary Approaches to Stop Hypertension (DASH) diet is an accepted nonpharmacologic treatment for hypertension, little is known about what patient characteristics affect dietary adherence and what level of adherence is needed to reduce blood pressure (BP).

OBJECTIVE

Our aim was to determine what factors predict dietary adherence and the extent to which dietary adherence is necessary to produce clinically meaningful BP reductions.

DESIGN

Ancillary study of the ENCORE (Exercise and Nutrition Interventions for Cardiovascular Health) trial--a 16-week randomized clinical trial of diet and exercise.

PARTICIPANTS/SETTING

Participants included 144 sedentary, overweight, or obese adults (body mass index 25 to 39.9) with high BP (systolic 130 to 159 mm Hg and/or diastolic 85 to 99 mm Hg).

INTERVENTION

Patients were randomized to one of three groups: DASH diet alone, DASH diet plus weight management, and Usual Diet Controls.

MAIN OUTCOMES MEASURES

Our primary outcomes were a composite index of adherence to the DASH diet and clinic BP.

STATISTICAL ANALYSES PERFORMED

General linear models were used to compare treatment groups on post-treatment adherence to the DASH diet. Linear regression was used to examine potential predictors of post-treatment DASH adherence. Analysis of covariance was used to examine the relation of adherence to the DASH diet and BP.

RESULTS

Participants in the DASH diet plus weight management (16.1 systolic BP [SBP]; 95% CI 13.0 to 19.2 mm Hg and 9.9 diastolic BP [DBP]; 95% CI 8.1 to 11.6 mm Hg) and DASH diet alone (11.2 SBP; 95% CI 8.1 to 14.3 mm Hg and 7.5 DBP; 95% CI 5.8 to 9.3 mm Hg) groups showed significant reductions in BP in comparison with Usual Diet Controls participants (3.4 SBP; 95% CI 0.4 to 6.4 mm Hg and DBP 3.8; 95% CI 2.2 to 5.5 mm Hg). Greater post-treatment consumption of DASH foods was noted in both the DASH diet alone (mean = 6.20; 95% CI 5.83 to 6.57) and DASH diet plus weight management groups (mean = 6.23; 95% CI 5.88 to 6.59) compared with Usual Diet Controls (mean = 3.66; 95% CI 3.30 to 4.01; P<0.0001), and greater adherence to the DASH diet was associated with larger reductions in clinic SBP and DBP (P ≤ 0.01). Only ethnicity predicted dietary adherence, with African Americans less adherent to the DASH diet compared with whites (4.68; 95% CI 4.34 to 5.03 vs 5.83; 95% CI 5.50 to 6.11; P<0.001).

CONCLUSIONS

Greater adherence to the DASH diet was associated with larger BP reductions independent of weight loss. African Americans were less likely to be adherent to the DASH dietary eating plan compared with whites, suggesting that culturally sensitive dietary strategies might be needed to improve adherence to the DASH diet.

Relation between volume of exercise and clinical outcomes in patients with heart failure

OBJECTIVES

This study determined whether greater volumes of exercise were associated with greater reductions in clinical events.

BACKGROUND

The HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial showed that among patients with heart failure (HF), regular exercise confers a modest reduction in the adjusted risk for all-cause mortality or hospitalization.

METHODS

Patients randomized to the exercise training arm of HF-ACTION who were event-free at 3 months after randomization were included (n = 959). Median follow-up was 28.2 months. Clinical endpoints were all-cause mortality or hospitalization and cardiovascular mortality or HF hospitalization.

RESULTS

A reverse J-shaped association was observed between exercise volume and adjusted clinical risk. On the basis of Cox regression, exercise volume was not a significant linear predictor but was a logarithmic predictor (p = 0.03) for all-cause mortality or hospitalization. For cardiovascular mortality or HF hospitalization, exercise volume was a significant (p = 0.001) linear and logarithmic predictor. Moderate exercise volumes of 3 to <5 metabolic equivalent (MET)-h and 5 to <7 MET-h per week were associated with reductions in subsequent risk that exceeded 30%. Exercise volume was positively associated with the change in peak oxygen uptake at 3 months (r = 0.10; p = 0.005).

CONCLUSIONS

In patients with chronic systolic HF, volume of exercise is associated with the risk for clinical events, with only moderate levels (3 to 7 MET-h per week) of exercise needed to observe a clinical benefit. Although further study is warranted to confirm the relationship between volume of exercise completed and clinical events, our findings support the use of regular exercise in the management of these patients.

Effects of exercise training on depressive symptoms in patients with chronic heart failure: the HF-ACTION randomized trial

CONTEXT

Depression is common in patients with cardiac disease, especially in patients with heart failure, and is associated with increased risk of adverse health outcomes. Some evidence suggests that aerobic exercise may reduce depressive symptoms, but to our knowledge the effects of exercise on depression in patients with heart failure have not been evaluated.

OBJECTIVE

To determine whether exercise training will result in greater improvements in depressive symptoms compared with usual care among patients with heart failure.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, randomized controlled trial involving 2322 stable patients treated for heart failure at 82 medical clinical centers in the United States, Canada, and France. Patients who had a left ventricular ejection fraction of 35% or lower, had New York Heart Association class I to IV heart failure, and had completed the Beck Depression Inventory II (BDI-II) score were randomized (1:1) between April 2003 and February 2007. Depressive scores ranged from 0 to 59; scores of 14 or higher are considered clinically significant.

INTERVENTIONS

Participants were randomized either to supervised aerobic exercise (goal of 90 min/wk for months 1-3 followed by home exercise with a goal of ≥120 min/wk for months 4-12) or to education and usual guideline-based heart failure care.

MAIN OUTCOME MEASURES

Composite of death or hospitalization due to any cause and scores on the BDI-II at months 3 and 12.

RESULTS

Over a median follow-up period of 30 months, 789 patients (68%) died or were hospitalized in the usual care group compared with 759 (66%) in the aerobic exercise group (hazard ratio [HR], 0.89; 95% CI, 0.81 to 0.99; P = .03). The median BDI-II score at study entry was 8, with 28% of the sample having BDI-II scores of 14 or higher. Compared with usual care, aerobic exercise resulted in lower mean BDI-II scores at 3 months (aerobic exercise, 8.95; 95% CI, 8.61 to 9.29 vs usual care, 9.70; 95% CI, 9.34 to 10.06; difference, -0.76; 95% CI,-1.22 to -0.29; P = .002) and at 12 months (aerobic exercise, 8.86; 95% CI, 8.67 to 9.24 vs usual care, 9.54; 95% CI, 9.15 to 9.92; difference, -0.68; 95% CI, -1.20 to -0.16; P = .01).

CONCLUSIONS

Compared with guideline-based usual care, exercise training resulted in a modest reduction in depressive symptoms, although the clinical significance of this improvement is unknown.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00047437.

Exercise and pharmacological treatment of depressive symptoms in patients with coronary heart disease: results from the UPBEAT (Understanding the Prognostic Benefits of Exercise and Antidepressant Therapy) study

OBJECTIVES

The aim of this study was to assess the efficacy of exercise and antidepressant medication in reducing depressive symptoms and improving cardiovascular biomarkers in depressed patients with coronary heart disease.

BACKGROUND

Although there is good evidence that clinical depression is associated with poor prognosis, optimal therapeutic strategies are currently not well defined.

METHODS

One hundred one outpatients with coronary heart disease and elevated depressive symptoms underwent assessment of depression, including a psychiatric interview and the Hamilton Rating Scale for Depression. Participants were randomized to 4 months of aerobic exercise (3 times/week), sertraline (50-200 mg/day), or placebo. Additional assessments of cardiovascular biomarkers included measures of heart rate variability, endothelial function, baroreflex sensitivity, inflammation, and platelet function.

RESULTS

After 16 weeks, all groups showed improvement on Hamilton Rating Scale for Depression scores. Participants in both the aerobic exercise (mean -7.5; 95% confidence interval: -9.8 to -5.0) and sertraline (mean -6.1; 95% confidence interval: -8.4 to -3.9) groups achieved larger reductions in depressive symptoms compared with those receiving placebo (mean -4.5; 95% confidence interval: -7.6 to -1.5; p = 0.034); exercise and sertraline were equally effective at reducing depressive symptoms (p = 0.607). Exercise and medication tended to result in greater improvements in heart rate variability compared with placebo (p = 0.052); exercise tended to result in greater improvements in heart rate variability compared with sertraline (p = 0.093).

CONCLUSIONS

Both exercise and sertraline resulted in greater reductions in depressive symptoms compared to placebo in patients with coronary heart disease. Evidence that active treatments may also improve cardiovascular biomarkers suggests that they may have a beneficial effect on clinical outcomes as well as on quality of life. (Exercise to Treat Depression in Individuals With Coronary Heart Disease; NCT00302068).

Is Exercise a Viable Treatment for Depression?

Depression is a common disorder that is associated with compromised quality of life, increased health care costs, and greater risk for a variety of medical conditions, particularly coronary heart disease. This review examines methods for assessing depression and discusses current treatment approaches. Traditional treatments include psychotherapy and antidepressant medications, but such treatments are not effective for all patients and alternative approaches have recently received increased attention, especially the use of aerobic exercise. This review examines evidence that exercise is effective in improving depressive symptoms among patients with major depression and offers practical suggestions for helping patients initiate and maintain exercise in their daily lives.

Polygenic risk, rapid childhood growth, and the development of obesity: evidence from a 4-decade longitudinal study

OBJECTIVE

To test how genomic loci identified in genome-wide association studies influence the development of obesity.

DESIGN

A 38-year prospective longitudinal study of a representative birth cohort.

SETTING

The Dunedin Multidisciplinary Health and Development Study, Dunedin, New Zealand.

PARTICIPANTS

One thousand thirty-seven male and female study members.

MAIN EXPOSURES

We assessed genetic risk with a multilocus genetic risk score. The genetic risk score was composed of single-nucleotide polymorphisms identified in genome-wide association studies of obesity-related phenotypes. We assessed family history from parent body mass index data collected when study members were 11 years of age.

MAIN OUTCOME MEASURES

Body mass index growth curves, developmental phenotypes of obesity, and adult obesity outcomes were defined from anthropometric assessments at birth and at 12 subsequent in-person interviews through 38 years of age.

RESULTS

Individuals with higher genetic risk scores were more likely to be chronically obese in adulthood. Genetic risk first manifested as rapid growth during early childhood. Genetic risk was unrelated to birth weight. After birth, children at higher genetic risk gained weight more rapidly and reached adiposity rebound earlier and at a higher body mass index. In turn, these developmental phenotypes predicted adult obesity, mediating about half the genetic effect on adult obesity risk. Genetic associations with growth and obesity risk were independent of family history, indicating that the genetic risk score could provide novel information to clinicians.

CONCLUSIONS

Genetic variation linked with obesity risk operates, in part, through accelerating growth in the early childhood years after birth. Etiological research and prevention strategies should target early childhood to address the obesity epidemic.

Pain coping skills training and lifestyle behavioral weight management in patients with knee osteoarthritis: a randomized controlled study

Overweight and obese patients with osteoarthritis (OA) experience more OA pain and disability than patients who are not overweight. This study examined the long-term efficacy of a combined pain coping skills training (PCST) and lifestyle behavioral weight management (BWM) intervention in overweight and obese OA patients. Patients (n=232) were randomized to a 6-month program of: 1) PCST+BWM; 2) PCST-only; 3) BWM-only; or 4) standard care control. Assessments of pain, physical disability (Arthritis Impact Measurement Scales [AIMS] physical disability, stiffness, activity, and gait), psychological disability (AIMS psychological disability, pain catastrophizing, arthritis self-efficacy, weight self-efficacy), and body weight were collected at 4 time points (pretreatment, posttreatment, and 6 months and 12 months after the completion of treatment). Patients randomized to PCST+BWM demonstrated significantly better treatment outcomes (average of all 3 posttreatment values) in terms of pain, physical disability, stiffness, activity, weight self-efficacy, and weight when compared to the other 3 conditions (Ps<0.05). PCST+BWM also did significantly better than at least one of the other conditions (ie, PCST-only, BWM-only, or standard care) in terms of psychological disability, pain catastrophizing, and arthritis self-efficacy. Interventions teaching overweight and obese OA patients pain coping skills and weight management simultaneously may provide the more comprehensive long-term benefits.

The effect of job strain on nighttime blood pressure dipping among men and women with high blood pressure

OBJECTIVES

Blunted nighttime blood pressure dipping is an established cardiovascular risk factor. This study examined the effect of job strain on nighttime blood pressure dipping among men and women with high blood pressure.

METHODS

The sample consisted of 122 blue- and white collar workers (men=72, women=50). The Job Content Questionnaire was used to measure job psychological demands, job control, and social support. The ratio of job demands to job control was used to assess job strain. Nighttime blood pressure dipping was evaluated from 24-hour ambulatory blood pressure monitoring performed on three workdays.

RESULTS

Men with high job strain had a 5.4 mm Hg higher sleep systolic blood pressure (P=0.03) and 3.5 mm Hg higher sleep pulse pressure (P=0.02) compared to men with low job strain. Men with high job strain had a smaller fall in systolic blood pressure and pulse pressure from awake to sleep state than those with low job strain (P<0.05). Hierarchical analyses showed that job strain was an independent determinant of systolic blood pressure dipping (P=0.03) among men after adjusting for ethnicity, body mass index, anxiety and depression symptoms, current smoking status, and alcohol consumption. Further exploratory analyses indicated that job control was the salient component of job strain associated with blood pressure dipping (P=0.03).

CONCLUSIONS

High job strain is associated with a blunting of the normal diurnal variation in blood pressure and pulse pressure, which may contribute to the relationship between job strain and cardiovascular disease.

Sex differences in the endothelial function of untreated hypertension

Vascular endothelial dysfunction is associated with increased risk for adverse cardiovascular (CV) events. However, less is known about sex differences in the endothelial function of untreated hypertensive individuals. The purpose of this study was to assess endothelial function in women and men with untreated hypertension. Ninety participants (35 women, 55 men), aged 40 to 60 years (mean age, 46.1±8.2 years), with untreated stage 1 hypertension (systolic blood pressure 140-159 mm Hg and/or diastolic blood pressure 90-99 mm Hg) underwent brachial artery endothelial-dependent flow-mediated dilation and endothelial-independent glyceryl trinitrate dilation. Women had a smaller flow-mediated dilation response than men (adjusted mean±standard error of the mean [SEM]; 1.8±0.6% vs 3.9±0.4%, P=.036), adjusting for baseline arterial diameter (P=.004), age (P=.596), ethnicity (P=.496), log shear stress ratio (P<.001), body mass index (P=.009), 24-hour diastolic blood pressure (P=.169), high-density lipoprotein (P=.225), log creatinine (P=.927), and log physical activity (P=.682). Glyceryl trinitrate dilation did not differ by sex in adjusted models. Women between the ages of 40 and 60 years with untreated stage 1 hypertension exhibited a greater impairment of endothelial function compared with their male counterparts. These findings raise the possibility that female sex may impart a greater risk of CV events in patients with untreated stage 1 hypertension potentially due to poorer endothelial function.

Ethnic differences in the effects of the DASH diet on nocturnal blood pressure dipping in individuals with high blood pressure

BACKGROUND

Ethnic differences in nocturnal blood pressure (BP) dipping may contribute to the increased risk for adverse cardiovascular events noted in African Americans (AAs). The DASH (Dietary Approaches to Stop Hypertension) diet has been shown to be efficacious in lowering clinic and ambulatory BP; however, the effect of the DASH diet on BP dipping is unclear.

METHODS

One hundred and eighteen men and women with high clinic BP (systolic BP (SBP) 130-159; diastolic BP 85-99) and above ideal body weight were randomized to a DASH diet intervention or to a usual diet control (UC) condition. Measures of 24-h ambulatory BP were obtained at baseline and at the end of the 4-month intervention period.

RESULTS

At baseline, AAs (n = 43) displayed blunted nocturnal SBP dipping compared to Caucasians (CAs; n = 75) and were more likely to be categorized as nondippers (<10% nocturnal decline in SBP, AAs: 51% vs. CAs: 27%). AAs randomized to the DASH diet intervention showed a significant improvement in SBP dipping postintervention compared to AAs in the UC condition (P = 0.04), whereas there was no appreciable change in SBP dipping in CAs (P = 0.72). Following the intervention, ethnic differences in SBP dipping were no longer statistically significant (nondipper status: AAs: 44% vs. CAs: 32%; P = 0.19).

CONCLUSIONS

Our study provides preliminary evidence suggesting that in overweight men and women with high BP, AAs may be especially likely to benefit from augmented SBP dipping associated with consumption of the DASH diet.

Increased non-gaussianity of heart rate variability predicts cardiac mortality after an acute myocardial infarction

Non-Gaussianity index (λ) is a new index of heart rate variability (HRV) that characterizes increased probability of the large heart rate deviations from its trend. A previous study has reported that increased λ is an independent mortality predictor among patients with chronic heart failure. The present study examined predictive value of λ in patients after acute myocardial infarction (AMI). Among 670 post-AMI patients, we performed 24-h Holter monitoring to assess λ and other HRV predictors, including SD of normal-to-normal interval, very-low frequency power, scaling exponent α(1) of detrended fluctuation analysis, deceleration capacity, and heart rate turbulence (HRT). At baseline, λ was not correlated substantially with other HRV indices (|r| < 0.4 with either indices) and was decreased in patients taking β-blockers (P = 0.04). During a median follow-up period of 25 months, 45 (6.7%) patients died (32 cardiac and 13 non-cardiac) and 39 recurrent non-fatal AMI occurred among survivors. While all of these HRV indices but λ were significant predictors of both cardiac and non-cardiac deaths, increased λ predicted exclusively cardiac death (RR [95% CI], 1.6 [1.3-2.0] per 1 SD increment, P < 0.0001). The predictive power of increased λ was significant even after adjustments for clinical risk factors, such as age, diabetes, left ventricular function, renal function, prior AMI, heart failure, and stroke, Killip class, and treatment ([95% CI], 1.4 [1.1-2.0] per 1 SD increment, P = 0.01). The prognostic power of increased λfor cardiac death was also independent of all other HRV indices and the combination of increased λ and abnormal HRT provided the best predictive model for cardiac death. Neither λ nor other HRV indices was an independent predictor of AMI recurrence. Among post-AMI patients, increased λ is associated exclusively with increased cardiac mortality risk and its predictive power is independent of clinical risk factors and of other HRV predictors.

Blood pressure dipping: ethnicity, sleep quality, and sympathetic nervous system activity

BACKGROUND

Blunted blood pressure (BP) dipping is an established predictor of adverse cardiovascular outcomes. Although blunted BP dipping is more common in African Americans than whites, the factors contributing to this ethnic difference are not well understood. This study examined the relationships of BP dipping to ethnicity, body mass index (BMI), sleep quality, and fall in sympathetic nervous system (SNS) activity during the sleep-period.

METHODS

On three occasions, 128 participants with untreated high clinic BP (130-159/85-99 mm Hg) underwent assessments of 24-h ambulatory BP (ABP), sleep quality, (evaluated by sleep interview, self-report, actigraphy) and sleep-period fall in sympathetic activity (measured by waking/sleep urinary catecholamine excretion).

RESULTS

Compared to whites (n = 72), African Americans (n = 56) exhibited higher sleep-period systolic (SBP) (P = 0.01) and diastolic BP (DBP) (P < 0.001), blunted SBP dipping (P = 0.01), greater BMI (P = 0.049), and poorer sleep quality (P = 0.02). SBP dipping was correlated with BMI (r = -0.32, P < 0.001), sleep quality (r = 0.30, P < 0.001), and sleep-period fall in sympathetic activity (r = 0.30, P < 0.001). Multiple regression analyses indicated that these three factors were independent determinants of sleep-period SBP dipping; ethnic differences in dipping were attenuated when controlling for these factors.

CONCLUSIONS

Blunted BP dipping was related to higher BMI, poorer sleep quality, and a lesser decline in sleep-period SNS activity. Although African-American ethnicity also was associated with blunted dipping compared to whites in unadjusted analyses, this ethnic difference was diminished when BMI, sleep quality, and sympathetic activity were taken into account.

[Psychiatric and behavioral aspects of cardiovascular disease: epidemiology, mechanisms, and treatment]

Psychosocial and behavioral factors, including mood (depression, anxiety, anger, and stress), personality (Type A, Type D, and hostility), and social support, are associated with both the development and progression of cardiovascular disease. "Negative" emotions have been associated with increased rates of cardiovascular death and recurrent cardiac events, although the mechanisms responsible for this association remain unclear. A number of pathophysiological mechanisms have been proposed to explain these relationships, including hypothalamic-pituitary-adrenal axis dysregulation, platelet activation, and inflammation. Behavioral factors also have been implicated, such as nonadherence to prescribed medical therapies and physical inactivity. Several randomized trials of patients with cardiovascular disease have examined the impact of pharmacologic and behavioral treatments on hard cardiovascular disease events as well as on cardiovascular disease biomarkers of risk. Although psychological treatments generally have been shown to improve quality of life and psychological functioning among cardiac patients, the benefit of psychological interventions with respect to improving clinical outcomes has not been conclusively demonstrated.

[Psychiatric and behavioral aspects of cardiovascular disease: epidemiology, mechanisms, and treatment]

Psychosocial and behavioral factors, including mood (depression, anxiety, anger, and stress), personality (Type A, Type D, and hostility), and social support, are associated with both the development and progression of cardiovascular disease. "Negative" emotions have been associated with increased rates of cardiovascular death and recurrent cardiac events, although the mechanisms responsible for this association remain unclear. A number of pathophysiological mechanisms have been proposed to explain these relationships, including hypothalamic-pituitary-adrenal axis dysregulation, platelet activation, and inflammation. Behavioral factors also have been implicated, such as nonadherence to prescribed medical therapies and physical inactivity. Several randomized trials of patients with cardiovascular disease have examined the impact of pharmacologic and behavioral treatments on hard cardiovascular disease events as well as on cardiovascular disease biomarkers of risk. Although psychological treatments generally have been shown to improve quality of life and psychological functioning among cardiac patients, the benefit of psychological interventions with respect to improving clinical outcomes has not been conclusively demonstrated.

New frontiers in cardiovascular behavioral medicine: comparative effectiveness of exercise and medication in treating depression

Exercise, considered a mainstay of cardiac rehabilitation, has been shown to reduce cardiac risk factors such as hyperlipidemia and hypertension. Growing evidence also suggests that exercise has beneficial effects on mental health, which is relevant for cardiac patients because of the prognostic significance of depression in patients with coronary heart disease (CHD). Depression has been associated with increased mortality and nonfatal cardiac events in patients with CHD; it is also associated with worse outcomes in patients who undergo coronary artery bypass graft surgery and those who have heart failure. The standard therapy for depression is pharmacologic treatment, often with second-generation antidepressants such as selective serotonin reuptake inhibitors. Despite their widespread use, antidepressants have only modest effects on depression for many patients compared with placebo controls. Exercise therapy, already an established component of cardiac rehabilitation, has potential efficacy as a treatment for depression in cardiac disease patients. Randomized controlled trials are needed to determine the clinical effects of exercise in this population and to compare the effects of exercise with those of antidepressants.

Association of cortisol and the metabolic syndrome in Korean men and women

Obesity and the metabolic syndrome are closely related and have become increasingly prevalent in Korea. The cardiovascular disease (CVD) risk factors comprising the metabolic syndrome have previously been associated with increased hypothalamic-pituitary-adrenal axis (HPAA) activity, but the associations have not been extensively examined in non-Caucasian populations. The aim of the present study was to investigate the relationships between cortisol, adiposity and the metabolic syndrome in a Korean population. A total of 1,881 adults participated in the study between January 2001 and February 2008. Sociodemographic data were assessed by questionnaires. Body composition, clinic blood pressures as well as metabolic variables including glucose, insulin, and lipid profile were assessed and analyzed in relation to cortisol levels. Mean age of the participants was 58.7 ± 10.8 yr. Higher levels of cortisol was associated with elevated blood pressure, fasting glucose and total cholesterol in men, and between cortisol and systolic blood pressure, fasting glucose and total cholesterol in women. There was an increased risk for the metabolic syndrome associated with higher cortisol levels in both men (P < 0.001) and women (P = 0.040) adjusting for age and body mass index. Higher cortisol levels are associated with several CVD risk factors and the metabolic syndrome, independent of overall of adiposity level, in Korean men and women.

The DASH diet and insulin sensitivity

Lifestyle modifications, including adoption of the Dietary Approaches to Stop Hypertension (DASH) dietary pattern, weight loss in individuals who are overweight or obese, and physical activity, are effective in the prevention and treatment of hypertension. A healthy lifestyle may also have beneficial effects on metabolic abnormalities, such as insulin resistance, that are associated with high blood pressure. This review examines the independent and combined effects of the DASH diet and weight loss plus exercise on blood pressure and insulin sensitivity, with a focus on recently published results from the ENCORE study. Our data suggest that the DASH eating plan alone lowers blood pressure in overweight individuals with higher than optimal blood pressure, but significant improvements in insulin sensitivity are observed only when the DASH diet is implemented as part of a more comprehensive lifestyle modification program that includes exercise and weight loss.

Stress and coping in caregivers of patients awaiting solid organ transplantation

Caregivers for patients undergoing solid organ transplantation play an essential role in the process of transplantation. However, little is known about stress and coping among these caregivers. Six hundred and twenty-one primary caregivers of potential candidates for lung (n = 317), liver (n = 147), heart (n = 115), and/or kidney (n = 42) transplantation completed a psychometric test battery at the time of the candidate's initial pre-transplant psychosocial evaluation. Caregivers were generally well adjusted, with only 17% exhibiting clinical symptoms of depression (Beck Depression Inventory-II score >13) and 13% reporting clinical levels of anxiety (State Trait Anxiety Inventory score >48). Greater caregiver burden and negative coping styles were associated with higher levels of depression. Greater objective burden and avoidant coping were associated with higher levels of anxiety. Caregivers evidenced a high degree of socially desirable (i.e., defensive) responding, which may reflect a deliberate effort to minimize fears or worries so as to not jeopardize patients' listing status.

Worsening depressive symptoms are associated with adverse clinical outcomes in patients with heart failure

OBJECTIVES

The purpose of this study was to assess the impact of changes in symptoms of depression over a 1-year period on subsequent clinical outcomes in heart failure (HF) patients.

BACKGROUND

Emerging evidence shows that clinical depression, which is prevalent among patients with HF, is associated with a poor prognosis. However, it is uncertain how changes in depression symptoms over time may relate to clinical outcomes.

METHODS

One-hundred forty-seven HF outpatients with ejection fraction of less than 40% were assessed for depressive symptoms using the Beck Depression Inventory (BDI) at baseline and again 1 year later. Cox proportional hazards regression analyses, controlling for established risk factors, were used to evaluate how changes in depressive symptoms were related to a combined primary end point of death or cardiovascular hospitalization over a median follow-up period of 5 years (with a range of 4 to 7 years and no losses to follow-up).

RESULTS

The 1-year change in symptoms of depression, as indicated by higher BDI scores over a 1-year interval (1-point BDI change hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02 to 1.12, p = 0.007), was associated with death or cardiovascular hospitalization after controlling for baseline depression (baseline BDI HR: 1.1, 95% CI: 1.06 to 1.14, p < 0.001) and established risk factors, including HF cause, age, ejection fraction, plasma N-terminal pro-B-type natriuretic peptide level, and prior hospitalizations.

CONCLUSIONS

Worsening symptoms of depression are associated with a poorer prognosis in HF patients. Routine assessment of symptoms of depression in HF patients may help to guide appropriate medical management of these patients who are at increased risk for adverse clinical outcomes.

Coping effectively with heart failure (COPE-HF): design and rationale of a telephone-based coping skills intervention

BACKGROUND

Coping Effectively with Heart Failure (COPE-HF) is an ongoing randomized clinical trial funded by the National Institutes of Health to evaluate if a coping skills training (CST) intervention will result in improved health status and quality of life as well as reduced mortality and hospitalizations compared with a heart failure education (HFE) intervention.

METHODS AND RESULTS

Two hundred heart failure (HF) patients recruited from the Duke University Medical Center and the University of North Carolina Hospital system will be randomized to a CST intervention (16 weekly 30-minute telephone counseling sessions including motivational interviewing and individually tailored cognitive behavioral therapy) or to an HFE intervention (16 weekly 30-minute telephone sessions including education and symptom monitoring). Primary outcomes will include postintervention effects on HF biomarkers (B-type natriuretic peptide, ejection fraction) and quality of life, as well as long-term clinical outcomes (hospitalizations and death). Secondary analyses will include an evaluation of treatment effects across subpopulations, and potential mechanisms by which CST may improve clinical outcomes.

CONCLUSIONS

COPE-HF is a proof-of-concept study that should provide important insights into the health benefits of a CST intervention designed to enhance HF self-management, improve health behaviors, and reduce psychologic distress.

Association of vascular health and neurocognitive performance in overweight adults with high blood pressure

The relationship between vascular health--including flow-mediated dilation (FMD) and intima medial thickness (IMT)--and neurocognitive performance was examined in a sample of 124 sedentary, middle-aged adults with high blood pressure (systolic blood pressure, SBP, 130-159 mmHg or diastolic blood pressure, DBP, 85-99 mmHg) who were overweight or obese (body mass index 25.0-39.99 kg/m²). Patients completed a neuropsychological test battery, including measures of executive function and psychomotor speed, and measures of IMT and FMD were obtained. Hierarchical multiple regression analyses were used to investigate the association between vascular measures and neurocognitive performance after controlling for demographic factors and cerebrovascular risk factors. Higher levels of FMD predicted better executive function (b = 0.90, p = .045). Greater IMT tended to be associated with slower psychomotor speed (b = -0.82, p = .084), with the effect attenuated after controlling for FMD. Impaired FMD is associated with worse neurocognitive functioning among overweight adults with high blood pressure.