Hearts and Minds: Stress, Anxiety, and Depression: Unsung Risk Factors for Cardiovascular Disease

Impact of cardiovascular risk factors on associations between state and trait indices of major depression disorder and objectively assessed physical activity, sleep and circadian rhythmicity within a population based cohort

BACKGROUND

Few studies of the association between accelerometry-assessed physical activity with major depressive disorder (MDD) have considered the influence of both the averages and variability of all three domains of the 24 hour activity cycle including sleep, physical activity, and circadian rhythmicity, the physical health correlates of depression, and the extent to which changes in sleep and physical activity reflect current state versus enduring patterns of MDD in people with depression.

METHODS

The sample includes 2307 participants from a population cohort from Lausanne, Switzerland. Average and variability of daily sleep (SL), physical activity (PA), and circadian rhythmicity (CR) were derived from accelerometry.

RESULTS

Cardiovascular risk factors, particularly cigarette smoking and body mass index (BMI), were significantly associated with both the average and variability of sleep, phyiscal activity and circadian rhythmicity, and with MDD. Lower average and less variable physical activity, as well as more variable circadian rhythmicity were associated with remitted MDD, whereas later sleep midpoint and greater variation of sleep duration variability were associated with depressive states.

LIMITATION

The single geographic setting, cross-sectional nature and two-week assessment period may limit the generalizability of these findings.

CONCLUSION

These results demonstrate the importance of considering both the average and variability of accelerometry-derived phenotypes that may distinguish state from trait manifestations of MDD. Further, the confounding influence of smoking, particularly on state manifestations of MDD, should be considered in studies of accelerometer derived phenotypes, particularly sleep characteristics. Interventions for depression should therefore consider modification of health behaviors such as smoking and overweight, as well as stabilizing the 24-hour rest-activity cycle, rather than treatments that focus solely on the average levels of mood, sleep or physical activity alone.

Network analysis of anxiety and depressive symptoms among patients with cardiovascular disease

BACKGROUND

Patients with cardiovascular disease (CVD) often experience anxiety and depression. However, the central and bridge symptoms of anxiety and depression among patients with CVD remain unclear. Network analysis is a statistical method that can reveal and visualise complex relationships between multiple variables. This study aimed to identify the central and bridge symptoms in the anxiety-depression network, which may provide potential targets for preventing and intervening in anxiety and depression.

METHODS

A total of 1180 patients with CVD were selected from the Psychology and Behavior Investigation of Chinese Residents. The survey was conducted from July 10 to September 15, 2021. Face-to-face electronic questionnaires were distributed to respondents by the investigators. The Generalized Anxiety Disorder 7 (GAD-7) and Patient Health Questionnaire-9 were used to assess anxiety and depressive symptoms among patients with CVD. Network analysis was conducted using R4.02 to identify central and bridge symptoms in the anxiety-depression network.

RESULTS

Among the 1180 patients with CVD included in this study, 673 (57%) were male and 507 (43%) were female. More than half (53.5%) of patients were under 60 years old. The mean GAD-7 score was 4.66 ± 4.38, and 169 (14.3%) patients had anxiety symptoms. The mean PHQ-9 score was 6.29 ± 5.29, and 235 (19.9%) had depressive symptoms. Furthermore, 144 (12.2%) patients people had both anxiety and depressive symptoms. In the network of anxiety and depressive symptoms, "unable to sit still because of anxiety", "feeling afraid that something terrible is about to happen", and "feeling bad or like a failure, or disappointing oneself or family" were the most influential and central symptoms. We also found that "feeling afraid that something terrible is about to happen" and "thoughts of dying or hurting oneself in some way" were pivotal bridge symptoms between anxiety and depression.

CONCLUSIONS

This study provides new insights into the network structure of anxiety and depression in patients with CVD. These identified central and bridge symptoms may be potentially effective targets for preventing anxiety and depression in patients with CVD, and may provide treatment strategies for patients with anxiety and depression.

Associations between subjective and objective well-being and risk of cardiometabolic disease: A prospective cohort study from the UK biobank

BACKGROUND

The distinct and combined impacts of subjective well-being (SWB) and objective well-being (OWB) on cardiometabolic diseases and cardiometabolic multimorbidity remain largely unknown.

METHODS

141,086 participants (mean age 56 years) were included from the UK Biobank study from 2006 to 2010. The SWB included happiness and life satisfaction. The OWB represents the level of satisfaction with objective conditions which was created using latent class analysis. Cardiometabolic diseases comprise diabetes and cardiovascular disease, including coronary heath disease and stroke. The Cox models were used to estimate the hazard ratio (HR) and 95 % confidence intervals (95 % CI) of the individual and combined associations between SWB and OWB with the risk of cardiometabolic diseases.

RESULTS

During a median follow-up of 12 years (1,693,800 person-years), 16,678 new-onset cardiometabolic diseases were reported. In full-adjusted model, the HR (95 % CI) among men with high SWB was 0.93 (0.82-1.05), 0.85 (0.79-0.92) and 0.71 (0.57-0.87), for diabetes, cardiovascular disease, and cardiometabolic multimorbidity, compared to low SWB, respectively. Among women with high SWB, the HR (95 % CI) was 0.71 (0.62-0.81), 0.76 (0.69-0.83) and 0.55 (0.42-0.72) for diabetes, cardiovascular disease and cardiometabolic multimorbidity, respectively. Low OWB increases the cardiometabolic diseases risk by from 16 % to 103 %. Notably, high SWB was associated with lower cardiometabolic diseases risk among individuals with low OWB.

LIMITATIONS

Potential recall bias and residual confounding are the main limitations.

CONCLUSIONS

We found that both high SWB and OWB were significantly associated with a lower risk of cardiometabolic diseases, more evident among women. The association between SWB and cardiometabolic diseases was independent of OWB.

Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation: Endorsed by the American College of Cardiology

The science of cardiac rehabilitation and the secondary prevention of cardiovascular disease has progressed substantially since the most recent American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation update on the core components of cardiac rehabilitation and secondary prevention programs was published in 2007. In addition, the advent of new care models, including virtual and remote delivery of cardiac rehabilitation services, has expanded the ways that cardiac rehabilitation programs can reach patients. In this scientific statement, we update the scientific basis of the core components of patient assessment, nutritional counseling, weight management and body composition, cardiovascular disease and risk factor management, psychosocial management, aerobic exercise training, strength training, and physical activity counseling. In addition, in recognition that high-quality cardiac rehabilitation programs regularly monitor their processes and outcomes and engage in an ongoing process of quality improvement, we introduce a new core component of program quality. High-quality program performance will be essential to improve widely documented low enrollment and adherence rates and reduce health disparities in cardiac rehabilitation access.

Psychologically-enhanced cardiac rehabilitation for psychological and functional improvement in patients with cardiovascular disease: a systematic review with meta-analysis and future research directions

OBJECTIVE

To systematically review the effectiveness of psychologically-enhanced cardiac rehabilitation (CR) in improving psychological and functional outcomes in patients with cardiovascular disease.

DATA SOURCES

A systematic search was performed in PubMed, Scopus, Cochrane Library, Embase, and Web of Science, up to January 31, 2024.

STUDY SELECTION

Two reviewers independently identified randomized clinical trials that evaluated the effectiveness of psychologically-enhanced CR in improving psychological and functional outcomes in patients with cardiovascular disease. The search yielded 1848 results. Finally, data from 14 studies (1531 participants) were included in the review.

DATA EXTRACTION AND DATA SYNTHESIS

Information regarding cardiac rehabilitation phase, duration of the intervention, group characteristics, measured outcomes, and the conclusions drawn by the authors was extracted. The Revised Cochrane risk-of-bias tool for Randomized Trials was used to evaluate the methodological quality.

RESULTS

Pooled results indicate that psychologically-enhanced CR is more effective than specific cardiac training alone in maintaining lower resting blood pressure, with a mean difference of -3.09 (95% CI: -5.18 to -1.00). Furthermore, psychologically-enhanced CR shows superiority in improving patients' quality of life compared to specific cardiac training alone, with a standardized mean difference of 0.15 (95% CI: 0.01 to 0.31). Analyses of depression and anxiety level, exercise tolerance, and blood lipid profile did not show significant differences between the two treatment conditions.

CONCLUSION

Psychologically-enhanced CR shows a positive effect on reducing resting blood pressure and improving the quality of life. However, the supportive methods were of limited effectiveness in addressing the psychological aspects of health.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022304063. CONTRIBUTION OF THE PAPER.

Effect of Citrus aurantium and chamomile aromas on anxiety and vital signs in cardiac care unit patients: A randomized clinical trial

Background and Aim

Complementary therapies, such as aromatherapy, were used to manage acute and chronic symptoms of diseases. Anxiety symptoms and deviations in vital signs are frequently manifest in patients admitted to the cardiac care unit (CCU). This study aimed to evaluate the impact of citrus aurantium and chamomile aromas on anxiety levels and vital signs of patients hospitalized in CCU.

Methods

In this clinical research trial (CRT), a total of 76 hospitalized patients in the CCU were randomly assigned to two groups. The intervention group received aromatherapy using a blend of chamomile and citrus aurantium essences at a ratio of 2:0.5 on an eye pad. They inhaled the aromas from a distance of 10 cm for three nights. Vital signs were recorded every 6 h. Spielberger's anxiety questionnaire was administered before and after the intervention. Data were analyzed using independent t-tests, paired t-tests, Chi-square tests, Fisher's exact tests, and the generalized estimating equation (GEE) approach.

Results

Before the aromatherapy, the mean (SD) scores of state and trait anxiety in the intervention group were 57.9 (11.4) and 50 (12.5) respectively, after the intervention, these scores decreased to 35.3 (8.4) and 38.5 (8.2), and the paired t-test revealed a significant difference between them (p < 0.001). Before the intervention there was no significant difference in the mean scores of state and trait anxiety between the two groups, (p > 0.05), however following the intervention, a significant difference was observed (p < 0.001). Additionally, the intervention resulted in the recovery of patients' heart rate.

Conclusions

The results showed, application of citrus aurantium and chamomile aromas significantly lower anxiety levels and enhance the hemodynamic status of patients in the CCU. It may be suggested as a beneficial nursing intervention for these patients.

Non-Sleep Deep Rest Relaxation and Virtual Reality Therapy for Psychological Outcomes in Patients with Coronary Artery Disease: A Pilot Randomized Controlled Trial

Background: While cardiac rehabilitation (CR) primarily focuses on restoring physical strength, preventing relapse, and reducing rehospitalization rates, psychological interventions play a complementary role by supporting mental health, which is crucial for patients' long-term adherence and overall recovery. The effectiveness of psychological interventions in CR is debated, and while technologies like virtual reality (VR) therapy show promise, they have limitations for patients with coronary artery disease (CAD). Therefore, this study examines non-sleep deep rest (NSDR) relaxation, a novel and easily implementable technique, and compares its impact on depression, anxiety, and stress with VR therapy and standard care. Methods: Forty-five CAD patients undergoing CR in ambulatory conditions were divided into three groups: the NSDR group, which received eight sessions of NSDR relaxation as part of their rehabilitation; the VR group, which received eight sessions of VR therapy as part of their rehabilitation; and the control group, which received standard care including Schultz Autogenic Training (SAT). The outcomes were measured using the Hospital Anxiety and Depression Scale (HADS) and the Perception of Stress Questionnaire (PSQ). Results: Both NSDR relaxation and VR therapy were effective in reducing the HADS total score, anxiety levels, the PSQ general score, and emotional tension. No significant differences were observed between the two treatment approaches. However, SAT was found to be insufficient for effectively improving the mental state of cardiac patients. Conclusions: This study suggests that NSDR relaxation is an effective psychotherapeutic intervention in CR. NSDR and VR therapy showed similar benefits, offering promising alternatives to traditional methods. Integrating these techniques could enhance patient outcomes and adherence in CR. Further research is needed to refine these interventions and optimize their clinical application.

A Quality Improvement Project on Team-Based Care for Depression Screening Before and During the COVID-19 Pandemic in a Specialty Clinic

BACKGROUND

Depression screening is an important first step to identifying patients who might benefit from depression treatment. Merit-based incentive payment system (MIPS) quality measures can yield financial benefits or losses for healthcare systems, including depression screening.

OBJECTIVES

This study aims to (1) develop a team-based care workflow to improve MIPS depression screening in a specialty clinic and (2) modify the workflow to include a virtual nursing and behavioral health resource after the COVID-19 pandemic hit.

METHODS

A quality improvement project, utilizing Lean Six Sigma process improvement methods, was implemented to improve team-based depression screening in a specialty clinic. A multidisciplinary team implemented plan-do-study-act cycles, created educational materials tailored to each role, developed electronic medical record (EMR) tools to alert and assist team members in screening, and ensured the EMR aligned with the MIPS criteria. The percentage of eligible visits where depression screening was performed was analyzed across four study periods: pre-intervention, post-intervention, COVID-19, and recovery. Recovery strategies included developing telehealth workflows, establishing centralized registered nurse triage groups, and using phone-based triage and support resources at virtual visits.

RESULTS

Utilizing team-based strategy and available or newly developed tools, the percentage of eligible visits with completed depression screening was as follows: 1.4% pre-intervention, 58.2% post-intervention, 3.5% COVID-19, and 64.0% recovery. With the COVID-19 pandemic outbreak, initially, improved screening performance declined sharply. Recovery was achieved through the revision of workflows, team members, and support tools.

CONCLUSIONS

A team-based care approach can successfully improve and maintain depression screening in a specialty clinic and was versatile enough to be readapted to virtual visits during the COVID-19 pandemic. In addition to impacting MIPS quality incentives, the depression screening workflows described in this article can be adapted to other uses, including virtual and in-person visits and in other specialty or chronic disease settings.

Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation

The science of cardiac rehabilitation and the secondary prevention of cardiovascular disease has progressed substantially since the most recent American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation update on the core components of cardiac rehabilitation and secondary prevention programs was published in 2007. In addition, the advent of new care models, including virtual and remote delivery of cardiac rehabilitation services, has expanded the ways that cardiac rehabilitation programs can reach patients. In this scientific statement, we update the scientific basis of the core components of patient assessment, nutritional counseling, weight management and body composition, cardiovascular disease and risk factor management, psychosocial management, aerobic exercise training, strength training, and physical activity counseling. In addition, in recognition that high-quality cardiac rehabilitation programs regularly monitor their processes and outcomes and engage in an ongoing process of quality improvement, we introduce a new core component of program quality. High-quality program performance will be essential to improve widely documented low enrollment and adherence rates and reduce health disparities in cardiac rehabilitation access.

Towards an understanding of the biopsychosocial determinants of CVD in SLE: a scoping review

OBJECTIVE

Systemic lupus erythematosus (SLE) is a chronic autoimmune condition with significant physical, mental, psychosocial and economic impacts. A main driver of SLE morbidity and mortality is cardiovascular disease (CVD). Both SLE and CVD exhibit disparities related to gender, race and other social dimensions linked with biological outcomes and health trajectories. However, the biospsychosocial dimensions of CVD in SLE populations remain poorly understood. The objective of this study was to systematically investigate the existing literature around known social factors influencing the development of CVD in SLE.

METHODS

A scoping review protocol was developed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines. The search strategy encompassed three main concepts: SLE, CVD and social factors. Four databases were searched (PubMed, SCOPUS, PsychINFO and CINAHL). 682 studies were identified for screening. Articles were screened in two phases (title/abstract and full text) to determine whether they fulfilled the selection criteria.

RESULTS

Nine studies were included after screening. All were conducted in the USA between 2009 and 2017. Six studies (67%) were cross-sectional and three (33%) were longitudinal. Most employed SLE cohorts (n=7, 78%) and two drew from healthcare databases (n=2; 22%). We identified five main themes encompassing social factors: socioeconomic status and education (n=5; 56%), race and/or ethnicity (n=7; 78%), mental health (n=2; 22%), gender (n=3; 33%) and healthcare quality and/or insurance (n=2; 22%). Overall, low income, fewer years of education, black race and/or ethnicity, depression, male gender, lack of insurance and healthcare fragmentation were all associated with CVD risk factors and outcomes in SLE.

CONCLUSIONS

While several social factors contribute to CVD in SLE populations, considerable gaps remain as many social determinants remain un(der)explored. There is rich opportunity to integrate social theory, advance conceptualisations of race and/or ethnicity and gender, expand investigations of mental health and explore novel geographical contexts. In healthcare policy and practice, identified social factors should be considered for SLE populations during decision-making and treatment, and education resources should be targeted for these groups.

"Close your eyes and relax": the role of hypnosis in reducing anxiety, and its implications for the prevention of cardiovascular diseases

Anxiety is the most common form of mental health disorder, affecting millions of people worldwide. Psychosocial interventions such as mindfulness and cognitive behavioral therapy (CBT) have been suggested as an effective treatment in the management of general anxiety and anxiety disorders, with emerging evidence also suggesting the effectiveness of hypnosis. Moreover, anxiety has shown to be linked to the onset and development of several cardiovascular diseases (CVD), which are the leading cause of global death. In this paper, we review the current literature to examine the role that anxiety has on the onset and development of CVD and summarize the current knowledge on the role that hypnosis and hypnotherapy have in reducing anxiety, also explaining how this can impact the cardiovascular system and the prevention of CVD. Review of the evidence suggests that hypnosis and hypnotherapy are effective in treating anxiety and may positively affect the heart and the cardiovascular system, reducing sympathetic activation and increasing parasympathetic tone, potentially preventing the onset of CVD related to increased sympathetic activation. However, further studies are required to further understand how hypnosis and hypnotherapy affect the cardiovascular system through investigation of the neurophysiological components of the hypnotic state and of the mind-body relationship. Healthcare systems should embed mental health screening in patients at risk of developing CVD as part of the clinical pathway and consider the role that hypnosis and hypnotherapy may play in the management of CVD.

The Impact of Anxiety and Depression Symptoms on Cardiovascular Risk Factor Control in Patients Without a History of Atherosclerotic Cardiovascular Disease

Background

Anxiety and depression by affecting lifestyle interfere with preventive actions aimed at eliminating or reducing modifiable risk factors for cardiovascular diseases (CVD).

Purpose

The objective of the study was to assess the impact of anxiety and depression on the achievement of therapeutic goals regarding CVD risk factors in patients without a history of atherosclerotic CVD.

Patients and Methods

The study included 200 patients (median age 52.0 [IQR 43.0-60.5] years). Control of the basic risk factors was assessed: blood pressure, BMI, waist circumference, physical activity, smoking status, LDL cholesterol, triglycerides, and blood glucose. The data analysis included a comparison of the number of controlled risk factors and the percentage of subjects who achieved the therapeutic goal for each of the cardiovascular risk factors. The risk of CVD was assessed with SCORE2 and SCORE2-OP. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). On both subscales (HADS Anxiety and HADS Depression), subjects could achieve normal, borderline, and abnormal scores.

Results

The median number of controlled CVD risk factors was 4.0 (IQR 3.0-5.0), and the median CVD risk assessed with SCORE2 and SCORE2-OP was 3.0% (IQR 1.5-7.0%). Median scores for HADS Anxiety were 3.0 (IQR 2.0-6.0) and for HADS Depression 3.0 (1.0-5.0). Patients with symptoms of anxiety and depression had significantly fewer controlled risk factors (HADS Anxiety p=0.0014; HADS Depression p=0.0304). Among subjects with anxiety and depression, there was a significantly lower percentage of those with a normal waist circumference (HADS Anxiety p=0.0464; HADS Depression p=0.0200) and regular physical activity (HADS Anxiety p=0.0431; HADS Depression p=0.0055). Among subjects with anxiety, there was a significantly lower percentage of those with a normal BMI (p=0.0218) and normal triglyceride concentrations (p=0.0278).

Conclusion

The presence of anxiety and depression may affect the control of CVD risk factors in individuals without a history of atherosclerotic CVD. Assessment of anxiety and depression symptoms should be part of a comprehensive examination of patients with high CVD risk.

Reward system activation improves recovery from acute myocardial infarction

Psychological processes have a crucial role in the recovery from acute myocardial infarction (AMI), yet the underlying mechanisms of these effects remain elusive. Here we demonstrate the impact of the reward system, a brain network associated with motivation and positive expectations, on the clinical outcomes of AMI in mice. Chemogenetic activation of dopaminergic neurons in the reward system improved the remodeling processes and vascularization after AMI, leading to enhanced cardiac performance compared to controls. These effects were mediated through several physiological mechanisms, including alterations in immune activity and reduced adrenergic input to the liver. We further demonstrate an anatomical connection between the reward system and the liver, functionally manifested by altered transcription of complement component 3, which in turn affects vascularization and recovery from AMI. These findings establish a causal connection between a motivational brain network and recovery from AMI, introducing potential therapeutic avenues for intervention.

Knowledge, Attitudes, and Practices Among Elderly CHD Patients Towards Self-Perceived Health Abilities

Objective

This study aimed to assess the knowledge, attitudes and practices (KAP) among elderly coronary heart disease (CHD) patients toward self-perceived health abilities.

Methods

This web-based study was carried out between April 2023 and September 2023 at Guang'anmen Hospital, China Academy of Chinese Medical Sciences. A self-developed questionnaire was utilized to collect demographic information from elderly CHD patients, and evaluate their KAP towards self-perceived health abilities.

Results

A total of 568 valid questionnaires were collected. Among the participants, the average age was 65.97±5.50 years, and 298 (52.46%) were female, and the mean scores for knowledge, attitudes, and practices were 6.34±2.29 (possible range: 0-9), 35.24±4.99 (possible range: 9-45), and 27.79±10.09 (possible range: 9-45), respectively. The structural equation model demonstrated that elderly CHD patients' knowledge directly affects attitudes and practices, with path coefficient of 0.93 (P<0.001) and 0.39 (P=0.033), respectively. Moreover, attitudes play an intermediary role between knowledge and practice with path coefficient of 0.75 (P<0.001). Furthermore, residence directly affects knowledge with path coefficient of 0.67 (P<0.001), cardiac function directly affects knowledge with path coefficient of -0.97 (P<0.001) and history of interventional therapy directly affects practice with path coefficient of 4.23 (P<0.001).

Conclusion

Elderly CHD patients demonstrated sufficient knowledge, positive attitudes, and proactive practices towards self-perceived health abilities. However, educational programs and behavior modification are recommended, particularly for elderly with lower age and education, living in rural areas, lacking interventional therapy, obese, or taking multiple CHD medications.

The effects of Solution-Focused Brief Therapy on self-care and mental health among older adults at risk of coronary heart disease: A randomized controlled trial

This study tested the effectiveness of a nursing program developed based on Solution-Focused Brief Therapy (SFBT) in improving self-care skills and mental health among community-dwelling older adults at risk for coronary heart disease (CHD). A total of 120 older adults were randomly assigned to either an SFBT group or a control group. Participants' self-care ability, depressive symptoms, and anxiety at baseline and post-intervention were assessed using the Self-care Ability Scale for the Elderly (SASE), Self-Rating Depression Scale (SDS), and Self-Rating Anxiety Scale (SAS), respectively. The t-test, Mann-Whitney U, and chi-square tests were conducted for group comparisons. After 6 months of intervention, the intervention group had significantly higher self-concept, self-skills, self-care awareness, and health knowledge scores than the baseline and the control group (all P-values < 0.05). The intervention group had significantly lower depression and anxiety scores than the baseline and the control group (all P-values < 0.05). SFBT is effective in improving older adults' self-care and mental health and may be widely applied among older adults to prevent CHD and promote well-being in the future.

Preventive Cardiology 2024: State of Problem Perspectives of Development

This article presents the current relevance of preventive cardiology, substantiates the increasing importance of the prevention of cardiovascular diseases (CVD) to reduce mortality and the burden of CVD, including in the era of widespread use of modern high-tech methods and effective drug therapy for treating CVD in clinical practice. The article also addresses effectiveness of secondary prevention of CVD and approaches to its improvement. Particular attention is paid to the high importance of introducing into practice comprehensive programs for secondary prevention of CVD and cardiac rehabilitation. The principles of organizing such programs and their most important components are presented in detail.

Exploratory analysis of the effectiveness of virtual reality in cardiovascular rehabilitation

Virtual reality therapy has been shown to be effective in coping with psychological disorders accompanied by cardiovascular disease. Age appears to be a factor that can affect the effectiveness of psychological therapy in a virtual environment. Therefore, the aim of the study was to explore whether there are age-related differences in the effectiveness of reducing levels of depression and anxiety during a virtual reality psychological intervention implemented for rehabilitation. The study included 25 younger (< 65 years) and 25 older (65 +) patients with cardiovascular disease who participated in virtual reality therapy to cope with anxiety and depression. The Hospital Anxiety and Depression Scale was used to assess anxiety and depressive disorders before and after intervention. Significant reductions in anxiety and depression scores after intervention were observed in both age-matched groups, and no significant differences were found between the younger and older participants. Further evaluation of patient age as a predictor of the effectiveness of psychological intervention in virtual reality did not show a significant effect of age on effectiveness in reducing anxiety and depressive disorders. The results obtained suggest that older patients benefit similarly to younger patients from psychological intervention in a virtual environment. Furthermore, age does not appear to be considered a predictor of effectiveness in reducing the level of anxiety and depression in patients with cardiovascular disease using virtual reality therapy.

The importance, consequences and treatment of psychosocial risk factors in heart disease: less conversation, more action!

Psychosocial factors play a significant role in the incidence and prognosis of cardiovascular disease with a rapidly increasing body of knowledge, as acknowledged by their inclusion in the European Society of Cardiology cardiovascular prevention guideline since 2012. Nevertheless, psychosocial risk is not consistently assessed, acknowledged and treated in daily clinical practice. Therefore, adopting a multidimensional approach that encompasses biological, psychological, and social factors is crucial for understanding the dynamic nature of cardiovascular health and disease, delivering patient-centred care, and developing effective interventions to ultimately enhance health and satisfaction with contemporary medicine and care. The current review summarises the state-of-the-art evidence for screening and treating psychological risk factors in coronary heart disease, heart failure, and atrial fibrillation in the context of cardiac rehabilitation, along with accompanying recommendations. The limited adoption of routine screening, despite longstanding recommendations, highlights the importance of prioritising the implementation and expansion of routine screening in primary and secondary prevention. To advance psychosocial treatment, a standardised and personalised approach including comprehensive education, physical exercise, and psychosocial support with a focus on patient-reported outcomes is crucial. Treating heart and mind together has the potential to decrease psychosocial risk while enhancing the prognosis and quality of life, therefore delivering true patient-centred care.

Inflammation, atherosclerosis and hypertension: the impact of depression and stress on their complex relationship

This future perspective analyzes the complex relationship between inflammation and atherosclerosis and arterial hypertension. The involvement of inflammation in atherosclerosis has led to research therapies that target inflammation to prevent or treat cardiovascular disease. This aspect has recently been included in the treatment management of residual cardiovascular risk. The recent pandemic has exacerbated cardiovascular risk both through an increase in unhealthy lifestyle behaviors and through the reduction of cardiovascular screening. What actions to take? Primary prevention campaigns for healthy subjects with specific attention to young people.

Better together: Relationship quality and mental health among cardiac patients and spouses

Reductions in marital relationship quality are pervasive post-cardiac event. It is not yet understood how relationship quality is linked to mental health outcomes in couples where one member has established cardiovascular disease (CVD) and the interdependence within dyads is seldom measured. This research is required as psychological distress has been independently linked to CVD incidence, morbidity, and mortality. This study assessed associations of relationship quality with depression and anxiety among patients with CVD and their spouses. Participants completed questionnaires measuring four dimensions of relationship quality and mental health. Data were analyzed using an Actor-Partner Interdependence Model with hierarchical moderation analyses. 181 dyads (N = 362 participants) comprised the study sample. Most patients had coronary artery disease (66.3%) and 25.9% were female. Patients reported higher relationship satisfaction and fewer anxiety symptoms than did spouses. Patients and spouses with high dyadic consensus and affectional expression reported fewer mental health symptoms, but only when the other partner also perceived high levels of consensus and affectional expression in the relationship. Patients and spouses with low dyadic cohesion reported worse mental health symptoms (actor effects), but those effects were no longer significant when both the patient and the spouse appraised the relationship as having high levels of dyadic cohesion. Taken together, relationship quality is linked to mental health symptoms in patients with CVD and their spouses. Longitudinal and experimental studies are now warranted to further substantiate the cross-sectional findings of this study.

Associations of Health-Related Quality of Life and Sleep Disturbance With Cardiovascular Disease Risk in Postmenopausal Breast Cancer Survivors

BACKGROUND

Breast cancer (BC) survivors are at an increased risk of long-term cardiovascular disease (CVD), often attributed to cancer treatment. However, cancer treatment may also negatively impact health-related quality of life (HRQoL), a risk factor of CVD in the general population.

OBJECTIVE

We examined whether sleep disturbance, and physical or mental HRQoL were associated with CVD risk in BC survivors.

METHODS

We conducted a longitudinal analysis in the Women's Health Initiative of postmenopausal women given a diagnosis of invasive BC during follow-up through 2010 with no history of CVD before BC. The primary outcome was incident CVD, defined as physician-adjudicated coronary heart disease or stroke, after BC. Physical and mental HRQoL, measured by the Short-Form 36 Physical and Mental Component Summary scores, and sleep disturbance, measured by the Women's Health Initiative Insomnia Rating Scale, were recorded post BC. Time-dependent Cox proportional hazards models were used starting at BC diagnosis until 2010 or censoring and adjusted for relevant confounders.

RESULTS

In 2884 BC survivors, 157 developed CVD during a median follow-up of 9.5 years. After adjustment, higher Physical Component Summary scores were significantly associated with a lower risk of CVD (hazard ratio, 0.90 [95% confidence interval, 0.81-0.99]; per 5-point increment in Physical Component Summary). No associations with CVD were found for Mental Component Summary or Insomnia Rating Scale.

CONCLUSION

In BC survivors, poor physical HRQoL is a significant predictor of CVD.

IMPLICATIONS FOR PRACTICE

Our findings highlight the importance for nurses to assess and promote physical HRQoL as part of a holistic approach to mitigating the risk of CVD in BC survivors.

The effect of mobile-based logotherapy on depression, suicidal ideation, and hopelessness in patients with major depressive disorder: a mixed-methods study

Major depressive disorder is one of the most common psychiatric disorders in the world. It is essential to study and use effective, available, and affordable psychotherapy methods along with drug therapy to manage the symptoms of this disease. Therefore, the current study aimed to determine the effect of mobile phone-based logotherapy on depression, suicidal ideation, and hopelessness in patients with major depressive disorder by using a mixed-methods approach. In the first phase of this mixed-methods study, 70 patients completed the quantitative phase (control group = 35, intervention group = 35). The intervention group received an 8-week mobile-based logotherapy program via WhatsApp (one 180-min module per week) combined with sertraline, while the control group received just sertraline plus education about pharmacotherapy. Data was collected before, immediately after the intervention, and 3 months later using the Beck depression inventory short form items (BDI-13), the Beck hopelessness scale (BHS), and the Beck scale for suicide ideation (BSSI). Then, a qualitative study on the intervention group was conducted to explain the findings of the quantitative phase. The repeated measure MANOVA revealed a significant interaction effect of time and group on the set of dependent variables (F(6,63) = 25.218, P < 0.001). Qualitative analysis confirmed the efficacy of sertraline plus mobile-based logotherapy on depression, suicidal ideation, and hopelessness in the intervention group. Three key themes extracted from the participants' experiences of mobile-based logotherapy were "efficient instruction", "user-friendly intervention" and "constructive change". Mobile-based logotherapy through WhatsApp was an effective psychotherapy method for decreasing depression, hopelessness, and suicidal ideation in patients with major depressive disorder. It is suggested that educational, institutional, and technological infrastructure for providing and using mobile-based logotheapy for patients with major depressive disorder be considered in the mental health care system.

A cross-sectional study of the relationship between depression status, health care coverage, and sexual orientation

Health care coverage is an important factor in receipt of behavioral healthcare. This study uses data from the New York City Community Health Survey to examine how sexual minority status impacts the relationship between depression status and having health care coverage. Approximately 10% of the sample (n = 9571; 47% 45+ years old; 35% White Non-Hispanic; 7% sexual minority) reported probable depression and low health care coverage. Compared to heterosexual participants, a greater proportion of sexual minority participants had low health care coverage (17% vs. 9%) and probable depression (19% vs. 9%). Logistic regression examining the association between probable depression status and health care coverage showed that those with probable depression have odds of low health care coverage that are were 3.08 times those who did not have probable depression; this relationship was not modified by sexual orientation. Continued research to understand the interplay of health care coverage, mental health, and sexual orientation is needed.

Sexual Satisfaction and Quality of Life in Cardiovascular Patients: The Mediating Role of Anxiety

BACKGROUND

Cardiovascular diseases represent one of the most important problems for public health. Research indicates that elderly patients consider sexual satisfaction as a fundamental aspect of their quality of life and a better sexual function is related to higher general wellbeing.

OBJECTIVE

The main objective of this study was to investigate the mediating role of anxiety and depression in the relationship between quality of life and sexual satisfaction in cardiovascular (CVD) patients.

METHODS

The sample comprised 128 adult patients, males and females, hospitalized in a Cardiology Rehabilitation clinical center. To collect data, the following were used: a demographic information sheet, the left ventricular ejection fraction (EF) to evaluate cardiac function, cardiovascular diagnosis type, the HADS scale to evaluate anxiety and depression states, a test for sexual satisfaction evaluation (SAS) and the SF-36 survey to measure quality of life.

RESULTS

The results indicated that only SF-36 physical health is indirectly related to SAS through its relationship with anxiety.

CONCLUSION

A mediating model was proposed to explore the underlying association between sexual satisfaction and quality of life. We recommend investigating perceived general health and sexuality as clinical indicators for therapeutic decisions and risk evaluation for the management of cardiovascular diseases.

Effect of a Nurse-Led Intervention on Knowledge of the Modifiable Risk Behaviors of Cardiovascular Disease: A Randomized Controlled Trial

INTRODUCTION

Cardiovascular disease (CVD) has disproportionately burdened the low- and middle-income countries where awareness and detection rates remain very low. Interventions directed to promote the community's awareness of CVD may help reduce the public's exposure to behavioral risk factors. However, the effectiveness of interventions implemented through a nurse on knowledge of the modifiable behavioral risk factors and preventive measures of CVD has not been determined in Kenya.

OBJECTIVE

To establish the effect of a nurse-led intervention on knowledge of the modifiable risk behaviors of CVD in adults with metabolic syndrome (MetS) attending a mission-based hospital in Kenya.

METHODS

A two-armed parallel-group randomized controlled trial design was conducted among 352 adults aged 18-64 years with MetS. The participants were recruited from a faith-based hospital in Nairobi, Kenya and randomly allocated to either a nurse-led lifestyle intervention or a control group. The intervention group received a comprehensive health education intervention using the World Health Organization (WHO) guideline recommendations for CVD control and prevention. Individuals in the control group were exposed to the usual CVD care according to hospital protocol. The duration of the intervention was 12 months. The primary outcome measure was a change in levels of knowledge on the modifiable risk factors and preventive measures of CVD. Outcome measures were assessed at baseline and at 15 months postintervention. Pre- and postintervention difference in the level of knowledge between the two groups was determined using the chi-square test of independence.

RESULTS

The knowledge level of CVD risk factors and preventive measures was very low in both groups at baseline without significant difference. A significant improvement in the level of knowledge on CVD risk factors (78.2% vs. 30.4%, p < .001) and preventive measures (74.4% vs. 29.0%, p < .001) was observed in the intervention group relative to the control at the end-line.

CONCLUSIONS

The nurse-led lifestyle intervention significantly improved participants' level of knowledge on CVD risk factors and preventive measures. It is highly recommended that nurses incorporate routine health education interventions for patients with cardio-metabolic abnormalities.

Sex and Gender Determinants of Vascular Disease in the Global Context

Globally, vascular diseases are a leading cause of morbidity and mortality. Many of the most significant risk factors for vascular disease have a gendered dimension, and sex differences in vascular diseases incidence are apparent, worldwide. In this narrative review, we provide a contemporary picture of sex- and gender-related determinants of vascular disease. We illustrate key factors underlying sex-specific risk stratification, consider similarities and sex differences in vascular disease risk and outcomes with comparisons of data from the global North (ie, developed high-income countries in the Northern hemisphere and Australia) and the global South (ie, regions outside Europe and North America), and explore the relationship between country-level gendered inequities in vascular disease risk and the United Nation's gender inequality index. Review findings suggest that the rising incidence of vascular disease in women is partly explained by an increase in the prevalence of traditional risk factors linked to gender-related determinants such as shifting roles and relations related to the double burden of employment and caregiving responsibilities, lower educational attainment, lower socioeconomic status, and higher psychosocial stress. Social isolation partly explained the higher incidence of vascular disease in men. These patterns were apparent across the global North and South. Study findings emphasize the necessity of taking into account sex differences and gender-related factors in the determination of the vascular disease risk profiles and management strategies. As we move toward the era of precision medicine, future research is needed that identifies, validates, and measures gender-related determinants and risk factors in the global South.

Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease

Cardiovascular disease (CVD), the leading cause of death among US adults, is more prevalent in menopausal females compared with age-matched males. Vasomotor symptoms of menopause (VMS; hot flashes/flushes and night sweats) are common among females undergoing menopausal transition and have been associated with elevated blood pressure (BP) and increased CVD risk. Autonomic dysregulation of BP has been posited as a contributing factor to the elevated CVD risk in menopausal females with VMS. This review includes 1) a brief overview of the relationship between VMS and CVD, 2) mechanisms of hot flushes and their potential impact on short- and long-term BP regulation, and 3) how the disruption of autonomic function associated with VMS might provide a mechanistic pathway to CVD development. Finally, this review will highlight knowledge gaps and future directions toward better understanding of hot flush physiology and VMS contributions to CVD.

Does Mental Distress Predict Cardiac Surgical Outcome?

BACKGROUND

 Mental distress is suspected to influence the morbidity of cardiac patients. Evaluating mental distress in cardiac patients is rare and the impact on surgical outcome is still not certified.

METHODS

 In 94 cardiac surgical patients, mental distress was assessed by the Patient Health Questionnaire-4 (PHQ-4). We defined length of stay in hospital and on intensive care unit as well as time of mechanical ventilation as outcomes on surgery. Age, physical activity, diabetes, overweight, PHQ-4, and an inflammation marker were tested for their predictive value on outcomes.

RESULTS

 Reportedly prevalence of generalized anxiety was 16.0% and depression rate was 13.8%. Length of stay in hospital was 13 ± 8 days, time of mechanical ventilation was 10 (0-1,207) hours, and length of stay on intensive care unit was 3 ± 6 days. Length of stay in hospital was significantly predicted by age (p = 0.048), low physical activity (p = 0.029), and high C-reactive protein (CRP; p = 0.031). Furthermore, CRP was the only significant predictor of time of mechanical ventilation and length of stay on intensive care unit.

CONCLUSION

 Outcome was not predicted by mental distress. However, inflammation marker CRP was predictive for outcome, potentially caused by higher cardiovascular risk profile. Additionally, depression was referred to be associated with inflammation. Probably, the small sample and the timing of assessment were responsible for the missing relation between mental distress and outcome. We presume a relation with low physical activity and depression. Nevertheless, further randomized studies are needed to pay more attention on patients' distress to intervene preoperatively to improve postoperative outcome.

Effectiveness of Mindfulness and Positive Strengthening mHealth Interventions for the Promotion of Subjective Emotional Wellbeing and Management of Self-Efficacy for Chronic Cardiac Diseases

Intervention in health prevention and treatment via mobile phones is becoming a key element on health promotion. Testing the efficacy of these mobile health (mHealth) psychological interventions for cardiovascular health is necessary as it is a chronic pathology, and it can influence the affective and cognitive states of patients. This research aimed to analyze the effectiveness of two brief psychological interventions-mindfulness and positive strengthening-to promote subjective emotional wellbeing and disease management self-efficacy using mHealth. This was a three-arm intervention and feasibility study, with a pre-post design and three follow-up measures with 105 patients (93 completed all phases) with cardiovascular diseases. Group 1 and 2 received the mindfulness or strengthening intervention, and Group 3 was the control group. The positive-negative affect and management self-efficacy for chronic and cardiovascular diseases were analyzed over time, while anxiety and depression levels were assessed at the beginning of the study. The results showed that mindfulness and positive strengthening interventions both had a positive effect on participants' affective state and management self-efficacy for the disease in comparison with the control group over time, even after controlling for baseline anxiety and depression levels. Positive strengthening seems to be more effective for improving cardiac self-efficacy, while mindfulness practice was significantly more effective at reducing negative affect at the first face-to-face evaluation.

Cardiovascular disease, self-care and emotional regulation processes in adult patients: balancing unmet needs and quality of life

BACKGROUND

Cardiovascular disease is a chronic non-communicable illness that causes more than half of all deaths across Europe. Unhealthy lifestyle, inadequate adherence to medical prescriptions, themselves associated with psycho-emotional disorders are considered risk factors for reduced quality of life as well physical condition.

OBJECTIVE

Aim of our study was to understand predictive factors for disease management by evaluating psychological aspects, self-care processes and emotional regilati0on in CVD outpatients.

METHODS

An observational study was conducted. Sixty-one patients, age 18-75 years (M 56.4 ± sd 12.0), diagnosed with CVD participated in the study. The psychological battery was administered during clinical follow-up oriented to detect emotional and psychological dimensions as well adaptive behavioral and quality of life by standardized questionnaire/scales.

RESULTS

Finding showed that emotional dysregulation might influence QoL, particularly significant effect of awareness (β= 0.022; SE = 1.826; p < 0.002), goals (β = - 0.54; SE = 1.48; p < 0.001) and clarity (β = - 0.211; SE = 2.087; p < 0.003). The results also suggest that the mediated effect accounted for awareness index was 18.7% (R² = 0.187) of the variance; goals index 62.8% (R² = 0.628) of the variance and, then significant mediated effect of clarity was 58.8% (R² = 0.588) of the variance. This evidence suggests that the relationship between triggers and QoL is mediated by emotional dysregulation indexes.

CONCLUSION

In clinical practice psychological screening can be an effective tool for detecting predictive factors in the management of the CVD patient's health and adherence to medical treatment: the screening of predictive psychological factors for allowing a good clinical condition management and a self-care empowerment aimed at increasing psychological well-being and the Quality of Life by planning adequate integrated and multidisciplinary support.

Biology, Bias, or Both? The Contribution of Sex and Gender to the Disparity in Cardiovascular Outcomes Between Women and Men

Purpose of Review

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity worldwide for both men and women. However, CVD is understudied, underdiagnosed, and undertreated in women. This bias has resulted in women being disproportionately affected by CVD when compared to men. The aim of this narrative review is to explore the contribution of sex and gender on CVD outcomes in men and women and offer recommendations for researchers and clinicians.

Recent Findings

Evidence demonstrates that there are sex differences (e.g., menopause and pregnancy complications) and gender differences (e.g., socialization of gender) that contribute to the inequality in risk, presentation, and treatment of CVD in women.

Summary

To start addressing the CVD issues that disproportionately impact women, it is essential that these sex and gender differences are addressed through educating health care professionals on gender bias; offering patient-centered care and programs tailored to women’s needs; and conducting inclusive health research.

Stress and cardiovascular risk burden after the pandemic: current status and future prospects

INTRODUCTION

The recent COVID-19 pandemic has induced an increase in anxiety, stress, and depression in the world population, prompting a reevaluation of these well-known risk factors on cardiovascular burden.

AREAS COVERED

This short report analyzes the impact of the pandemic on stress and depression, highlighting how the phenomenon has particularly affected women and highlights the strategies that can be undertaken after the pandemic to reduce stress and depression. We have analyzed the pandemic because it has completely changed the scenario of cardiovascular risk factors with an important increase in socio-economic stressors.

EXPERT OPINION

It is still difficult to assess the damage produced on cardiovascular risk just as it is almost impossible to predict how the overwhelming and important increase in Long-Covid Syndromes will impact the population. Strong action is needed to support critical situations and to implement social campaigns aimed at restoring healthy lifestyles. Physical activity can be an easy and inexpensive tool to help cope with stress and depression.

Type and effectiveness of community-based interventions in improving knowledge related to cardiovascular diseases and risk factors: A systematic review

Background: Despite an improvement in the healthcare system, cardiovascular diseases (CVDs) remain the leading cause of morbidity and mortality worldwide. Improving knowledge is a key for behavioral change towards prevention of CVDs. However, up-to-date evidence is limited on the effect of interventions on CVD knowledge. Thus this study aimed to synthesize comprehensive evidence on the type and effectiveness of community-based interventions (CBIs) to improve knowledge related to CVDs. Methods: We performed a systematic review of studies that tested the effectiveness of CBIs in improving CVD knowledge. International databases including MEDLINE, EMBASE, CINAHL, PSYCINFO and Cochrane register of controlled studies were searched for studies published between January 2000 and December 2019. The Cochrane risk of bias tools were used to assess the methodological quality of included studies. Since CVD knowledge was measured using various tools, results were synthesized narratively and reported in line with the reporting guideline for Synthesis Without Meta-analysis (SWiM). The review protocol is registered in the PROSPERO database (CRD42019119885). Results: 7 randomized and 9 non-randomized controlled trials involving 34,845 participants were included. Most of the interventions targeted the general population and majorities delivered the intervention to groups of individuals. Likewise, most of the interventions employed various intervention components including health education using different strategies. Overall, most studies showed that CBIs significantly improved knowledge related to CVDs. Conclusion: Community-based CVD preventive interventions are effective in improving knowledge related to CVD and risk factors. Measures to scale up CBIs are recommended to improve an individual's level of CVD knowledge, which potentially helps to counter the growing burden of CVDs.

Let It Beat: How Lifestyle and Psychosocial Factors Affect the Risk of Sudden Cardiac Death-A 10-Year Follow-Up Study

(1) Background: The aim of this study was to evaluate the lifestyle and occurrence of psychosocial factors in patients with a high risk of sudden cardiac death (SCD) and to explore their effect on the occurrence of the adequate therapy of an Implantable Cardioverter Defibrillator (ICD). (2) Methods: In this retro-prospective single-centre study, a group of patients aged 18-65 years old, who underwent the first ICD implantation for primary (PP) or secondary (SP) prevention between 2010-2014, was studied. The control group consisted of pair-matched (age ± 5 years, gender) respondents without a high risk of SCD. Information was obtained using a self-reported questionnaire and hospital electronic health records. The adequacy of ICD therapy was evaluated regularly until 31 January 2020. Multivariate logistic regression models were employed to assess the risk of SCD. (3) Results: A family history of SCD, coronary artery disease, diabetes mellitus and depression significantly aggravated the odds of being at a high risk of SCD. The occurrence of an appropriate ICD therapy was significantly associated with being in the SP group, BMI, education level and TV/PC screen time. (4) Conclusions: Lifestyle and psychosocial factors have been confirmed to affect the risk of SCD. Early identification and treatment of coronary artery disease and its risk factors remain the cornerstones of preventive effort. Further research is needed to evaluate the complex nature of psychosocial determinants of cardiac health.

Level of cardiovascular disease knowledge, risk perception and intention towards healthy lifestyle and socioeconomic disparities among adults in vulnerable communities of Belgium and England

Background

The burden of cardiovascular diseases (CVDs) greatly varies between and within countries. Low- and middle-income countries (LMICs) and vulnerable communities of high-income countries (HIC) share disproportionately higher burden. Evidence is limited on the level of CVD knowledge and risk perception in vulnerable communities. Hence, in this study, we assessed the level of CVD knowledge, risk perception and change intention towards physical activity and healthy diet among vulnerable communities in Antwerp, Belgium and Nottingham, England. Furthermore, we investigated the socioeconomic disparities particularly in the Antwerp setting.

Method

A cross-sectional study was performed among 1,424 adults (958 in Antwerp and 466 in Nottingham) aged 18 or older among selected vulnerable communities. Districts or counties were selected based on socioeconomic and multiple deprivation index. A stratified random sampling was used in Antwerp, and purposive sampling in Nottingham. We determined the level of CVD knowledge, risk perception and intention towards a healthy lifestyle in Antwerp and Nottingham using a percentage score out of 100. To identify independent socioeconomic determinants in CVD knowledge, risk perception, intention to PA and healthy diet, we performed multilevel multivariable modeling using the Antwerp dataset.

Results

The mean knowledge percent score was 75.4 in Antwerp and 69.4 in Nottingham, and only 36.5% and 21.1% of participants respectively, had good CVD knowledge (scored 80% or above). In the multivariable analysis using the Antwerp dataset, level of education was significantly associated with (1) CVD knowledge score (Adjusted β = 0.11, 95%CI: 0.03, 0.18), (2) risk perception (0.23, 95%CI: 0.04, 0.41), (3) intention to physical activity (PA) (0.51, 95%CI: 0.35, 0.66), and (4) healthy diet intention (0.54, 95%CI: 0.32, 0.75). Furthermore, those individuals with a higher household income had a better healthy diet intention (0.44, 95%CI: 0.23, 0.65). In contrast, those who were of non-European origin scored lower on intention to have a healthy diet (-1.34, 95%CI:-2.07, -0.62) as compared to their European counterparts. On average, intention to PA was significantly higher among males (-0.43, 95%CI:-0.82, -0.03), whereas females scored better on healthy diet intention (2.02, 95%CI: 1.46, 2.57).

Conclusions

Knowledge towards CVD risks and prevention is low in vulnerable communities. Males have a higher intention towards PA while females towards a healthy diet and it also greatly varies across level of education. Moreover, those born outside Europe and with low household income have lower healthy diet intention than their respective counterparts. Hence, CVD preventive interventions should be participatory and based on a better understanding of the individuals’ socioeconomic status and cultural beliefs through active individual and community engagement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12608-z.

Anxiety is associated with higher recurrence of atrial fibrillation after catheter ablation: A meta‐analysis

Previous studies that evaluated the influence of anxiety on recurrence of atrial fibrillation (AF) after catheter ablation showed inconsistent results. We performed a meta‐analysis of cohort study to systematically evaluate the association between anxiety and AF recurrence after catheter ablation. Electronic databases of PubMed, Embase, and Web of Science were searched for relevant cohort studies from inception to January 20, 2021. We applied the random‐effect model to combine the results to incorporate the potential influence of heterogeneity among studies. Five cohort studies were eligible for the meta‐analysis, which included 549 patients with AF that received catheter ablation. No significant heterogeneity was observed among the included studies (I² = 7%, P for Cochrane's Q test = 0.37). During a mean follow‐up of 9.7 months, 216 (39.3%) cases of recurrent AF occurred. Results of the meta‐analysis showed that anxiety was independently associated with an increased risk of AF recurrence after catheter ablation (adjusted relative risk: 2.36, 95% confidence interval: 1.71–3.26; p < .001). Subgroup analyses did not show that differences in study characteristics including study design, ethnicity of the patients, sample size, AF type, anxiety evaluation method, follow‐up duration, or adjustment of LAD may significantly affect the association between anxiety and AF recurrence (p for subgroup difference all > .10). Anxiety may be an independent risk factor for AF recurrence after catheter ablation. Whether alleviating anxiety mood could reduce the risk of AF recurrence after catheter ablation should also be investigated.

Curcumin plays a local anti-inflammatory and antioxidant role via the HMGB1/TLR4/NF-ΚB pathway in rat masseter muscle under psychological stress

BACKGROUND AND OBJECTIVE

Psychological stress causes structural and metabolic dysfunction of masseter muscles. The anti-inflammatory and anti-oxidative polyphenol curcumin plays a local antioxidant role in rat masseter muscles under psychological stress by an as-yet-unknown mechanism. The present study aimed to assess curcumin anti-inflammatory and anti-oxidative effects on masseter muscle and its possible molecular mechanisms.

METHODS

We constructed a rat model of chronic unpredictable moderate stress (CUMS). Psychological stress was assessed by determining the levels of adrenocorticotropic hormone (ACTH) and cortisol in serum. Enzyme-linked immunosorbent assays measured inflammatory cytokines and markers of oxidative stress in masseter muscles. Levels of high-mobility group box 1 (HMGB1), interleukin (IL)-1β, IL-6 and tumour necrosis factor-alpha (TNF-α) were determined using quantitative PCR analyses and immunofluorescent staining. Toll-like receptor 4 (TLR4) and nuclear factor kappa B (NF-κB) activation were examined using western blotting.

RESULTS

The CUMS group showed increased serum cortisol and ACTH levels. Pathological changes in the ultrastructure, oxidative stress and inflammatory cytokines in the masseter muscles were also observed. Curcumin treatment (50, 100 mg/kg) ameliorated these changes significantly by varying degrees. Mechanistically, increased levels of phosphorylated NF-κB, toll-like receptor 4 and HMGB1 were observed, which were also ameliorated by curcumin treatment.

CONCLUSION

Curcumin can reduce local pathological changes, levels of oxidative stress and inflammatory factors in masseter muscles. Psychological stress activates HMGB1 expression and increases the expression of downstream TLR4 and p-NF-κB, which could be reduced by curcumin. Thus, curcumin might exert anti-inflammatory and antioxidant effects in masseter muscles via the HMGB1/TLR4/NF-κB pathway.

Special Considerations for Healthy Lifestyle Promotion Across the Life Span in Clinical Settings: A Science Advisory From the American Heart Association

At a population level, engagement in healthy lifestyle behaviors is suboptimal in the United States. Moreover, marked disparities exist in healthy lifestyle behaviors and cardiovascular risk factors as a result of social determinants of health. In addition, there are specific challenges to engaging in healthy lifestyle behaviors related to age, developmental stage, or major life circumstances. Key components of a healthy lifestyle are consuming a healthy dietary pattern, engaging in regular physical activity, avoiding use of tobacco products, habitually attaining adequate sleep, and managing stress. For these health behaviors, there are guidelines and recommendations; however, promotion in clinical settings can be challenging, particularly in certain population groups. These challenges must be overcome to facilitate greater promotion of healthy lifestyle practices in clinical settings. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with consideration for the demands of clinical settings. In this science advisory, we summarize specific considerations for lifestyle-related behavior change counseling using the 5A Model for patients across the life span. In all life stages, social determinants of health and unmet social-related health needs, as well as overweight and obesity, are associated with increased risk of cardiovascular disease, and there is the potential to modify this risk with lifestyle-related behavior changes. In addition, specific considerations for lifestyle-related behavior change counseling in life stages in which lifestyle behaviors significantly affect cardiovascular disease risk are outlined. Greater attention to healthy lifestyle behaviors during every clinician visit will contribute to improved cardiovascular health.

Strategies for Promotion of a Healthy Lifestyle in Clinical Settings: Pillars of Ideal Cardiovascular Health: A Science Advisory From the American Heart Association

Engagement in healthy lifestyle behaviors is suboptimal. The vast majority of the US population does not meet current recommendations. A healthy lifestyle is defined by consuming a healthy dietary pattern, engaging in regular physical activity, avoiding exposure to tobacco products, habitually attaining adequate amounts of sleep, and managing stress levels. For all these health behaviors there are well-established guidelines; however, promotion in clinical settings can be challenging. It is critical to overcome these challenges because greater promotion of heathy lifestyle practices in clinical settings effectively motivates and initiates patient behavior change. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with requisite attention to the demands of clinical settings. In this science advisory, we present strategies, based on the 5A Model, that clinicians and other health care professionals can use for efficient lifestyle-related behavior change counseling in patients at all levels of cardiovascular disease risk at every visit. In addition, we discuss the underlying role of psychological health and well-being in lifestyle-related behavior change counseling, and how clinicians can leverage health technologies when providing brief patient-centered counseling. Greater attention to healthy lifestyle behaviors during routine clinician visits will contribute to promoting cardiovascular health.

Dyadic effects of anxiety and depression on quality of life among couples facing cardiovascular disease

OBJECTIVE

Anxiety and depression are frequently comorbid in patients with cardiovascular disease (CVD) and a patient's poor mental health may implicate the quality of life (QoL) of a partner. The bidirectional effects of comorbid anxiety and depression on patient and partner outcomes are inadequately understood. The aim of this study was to investigate associations of the combined role of depression and anxiety on patients' and partners' QoL.

METHOD

In this cross-sectional study, patients with CVD and their partners completed questionnaires measuring anxiety, depression, and QoL. Dyadic data was analyzed using the Actor-Partner Interdependence Model and polynomial interaction for examining the synergistic and dysergistic effects of anxiety and depression (i.e., in combination).

RESULTS

181 dyads comprised the study sample (66.3% coronary artery disease; 25.9% female patients). Anxiety and depression, in synergy was associated with poorer QoL in patients and partners (actor effects). Patients that are more anxious than depressed have greater physical QoL whereas partners that are more depressed than anxious have greater emotional QoL (dysergistic actor effects). Patients' more severe symptoms of anxiety and depression, in synergy, was associated with partners' poorer QoL (partner effect).

CONCLUSION

Anxiety and depression are comorbid and associated with poor QoL in patients and their partners. The results may have implications for secondary prevention programming but future longitudinal studies are warranted to substantiate the cross-sectional findings.

Influence of Non-Occupational Physical Activity on Burnout Syndrome, Job Satisfaction, Stress and Recovery in Fitness Professionals

BACKGROUND

This study aimed (1) to analyse the effect of non-occupational physical activity (NOPA) on the stress levels of fitness professionals, and (2) to apply a questionnaire to workers measuring burnout syndrome, working conditions and job satisfaction, and to compare the results with physiological stress and recovery measured objectively through heart rate variability (HRV).

METHODS

The HRV of 26 fitness instructors was recorded during 2-5 workdays using Firstbeat Bodyguard 2. Participants also completed a questionnaire (CESQT) measuring working conditions and job satisfaction variables and occupational burnout syndrome.

RESULTS

NOPA showed a negative association with both the percentage of stress (p < 0.05) and stress-recovery ratio (p < 0.01), and a positive association with the percentage of recovery (p < 0.05). Better work conditions (working hours, salary satisfaction and length of service) were associated with lower stress in fitness professionals.

CONCLUSION

NOPA appears to improve the stress levels of fitness instructors in this study cohort. Self-reported burnout levels measured through the CESQT questionnaire do not coincide with the physiological stress responses measured through HRV. Better working conditions appear to reduce the stress response in fitness professionals.

Major Cardiac-Psychiatric Drug-Drug Interactions: a Systematic Review of the Consistency of Drug Databases

PURPOSE

Major depressive disorder (MDD) and anxiety disorders (AD) are both highly prevalent among individuals with arrhythmia, ischemic heart disease, heart failure, hypertension, and dyslipidemia. There should be increased support for MDD and AD diagnosis and treatment in individuals with cardiac diseases, because treatment rates have been low. However, cardiac-psychiatric drug interaction can make pharmacologic treatment challenging.

METHODS

The objective of the present systematic review was to investigate cardiac-psychiatric drug interactions in three different widely used pharmacological databases (Micromedex, Up to Date, and ClinicalKey).

RESULTS

Among 4914 cardiac-psychiatric drug combinations, 293 significant interactions were found (6.0%). When a problematic interaction is detected, it may be easier to find an alternative cardiac medication (32.6% presented some interaction) than a psychiatric one (76.9%). Antiarrhythmics are the major class of concern. The most common problems produced by these interactions are related to cardiotoxicity (QT prolongation, torsades de pointes, cardiac arrest), increased exposure of cytochrome P450 2D6 (CYP2D6) substrates, or reduced renal clearance of organic cation transporter 2 (OCT2) substrates and include hypertensive crisis, increased risk of bleeding, myopathy, and/or rhabdomyolysis.

CONCLUSION

Unfortunately, there is considerable inconsistency among the databases searched, such that a clinician's discretion and clinical experience remain invaluable tools for the management of patients with comorbidities present in psychiatric and cardiac disorders. The possibility of an interaction should be considered. With a multidisciplinary approach, particularly involving a pharmacist, the prescriber should be alerted to the possibility of an interaction. MDD and AD pharmacologic treatment in cardiac patients could be implemented safely both by cardiologists and psychiatrists.

TRIAL REGISTRATION

PROSPERO Systematic Review Registration Number: CRD42018100424.

Validation of the Dutch-Flemish translated ABCD questionnaire to measure cardiovascular diseases knowledge and risk perception among adults

Valid and reliable measurement of an individual's knowledge and risk perception is pivotal to monitor and evaluate the effectiveness of interventions aimed at preventing cardiovascular diseases (CVDs). The recently developed Attitudes and Beliefs about Cardiovascular Disease (ABCD) knowledge and risk questionnaire is shown to be valid in England. In this study, we evaluated the psychometric properties of the modified and Dutch (Flemish)-translated ABCD questionnaire using both the classical test and item response theory (IRT) analysis. We conducted a community-based survey among 525 adults in Antwerp city, Belgium. We assessed the item- and scale-level psychometric properties and validity indices of the questionnaire. Parameters of IRT, item scalability, monotonicity, item difficulty and discrimination, and item fit statistics were evaluated. Furthermore, exploratory and confirmatory factorial validity, and internal consistency measures were explored. Descriptive statistics showed that both the knowledge and risk scale items have sufficient variation to differentiate individuals' level of knowledge and risk perception. The overall homogeneity of the knowledge and risk subscales was within the acceptable range (> 0.3). The exploratory and confirmatory factor analyses of the risk scale supported a three-factor solution corresponding to risk perception (F1), perceived benefits and intention to change physical activity (F2), and perceived benefit and intention to change healthy dietary habit (F3). The two parametric logistic (2-PL) and rating scale models showed that the item infit and outfit values for knowledge and risk subscales were within the acceptable range (0.6 to 1.4) for most of the items. In conclusion, this study investigated the Dutch (Flemish) version of the ABCD questionnaire has good psychometric properties to assess CVD related knowledge and risk perception in the adult population. Based on the factor loadings and other psychometric properties, we suggested a shorter version, which has comparable psychometric properties.

Upregulation of KDM6B contributes to lipopolysaccharide-induced anxiety-like behavior via modulation of VGLL4 in mice

Histone H3K27me3 demethylase KDM6B (also known as Jumonji domain-containing protein D3, JMJD3) plays vital roles in the etiology of inflammatory responses; however, little is known about the role of KDM6B in neuroinflammation-induced anxiety-like behavior. The present study aimed to investigate the potential role of KDM6B in lipopolysaccharide (LPS)-induced anxiety-like behavior and to evaluate whether it is associated with the modulation of vestigial-like family member 4 (VGLL4). The elevated plus maze, light-dark box, and open-field test were performed to test the anxiety-like behavior induced by LPS in C57BL/6 J male mice. Levels of relative protein expression in the hippocampus were quantified by western blotting. KDM6B inhibitor GSK-J4 and microglia inhibitor minocycline as well as adeno-associated virus of Vgll4 shRNA were used to explore the underlying mechanisms. We found that KDM6B, VGLL4, interleukin-1β (IL-1β), and ionized calcium-binding adaptor molecule-1 (Iba-1, microglia marker) protein levels were increased in LPS-dose dependent manner in the hippocampus but not in prefrontal cortex. GSK-J4 treatment attenuated LPS-induced VGLL4, the signal transducer and activator of transcription 3 (STAT3), IL-1β and Iba-1 upregulation and anxiety-like behavior. Knockdown VGLL4 with Vgll4 shRNA prevented the increase of anxiety-like behavior and levels of STAT3, IL-1β, and Iba-1 expression in the hippocampus of LPS-treated mice. Moreover, minocycline, an inhibitor of microglia treatment blunted LPS-induced anxiety-like behavior. Collectively, these results demonstrate that the induction of neuroinflammation by LPS promotes KDM6B activation in the hippocampus, and LPS-induced anxiety-like behavior is associated with upregulation of VGLL4 by KDM6B in the hippocampus.

Efficacy of a web application for stress management among Iranian college students during COVID-19 outbreak: a study protocol for randomized controlled trials

BACKGROUND

The prevalence of mental health disorders is increasing globally, and the prevalence of COVID-19 has made it worse. Evidence has indicated a major mental health burden and elevated anxiety associated with the new coronavirus outbreak in the general population. This study aims to evaluate an evidence-based web application (Naranj) for stress management among Iranian college students.

METHODS AND DESIGN

This study aims to present a protocol related to a randomized controlled trial among Iranian college students. The study will be conducted on 100 students from two colleges of Shiraz University of Medical Sciences in Iran. The participants will be randomly assigned to the intervention and control groups. The intervention group participants will be provided with a web application, whereas the control group ones will be provided with an app unrelated to stress management. The primary outcome for this study will be the Perceived Stress Scale, and the two groups will be compared with respect to stress level and sleep quality.

DISCUSSION

A web application will be developed according to psychological theories and will be scientifically approved for managing college students' stress and improving their sleep quality during the COVID-19 outbreak.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20160427027647N2 . Registered on 14 May 2020.

Myocardial infarction-induced anxiety-like behavior is associated with epigenetic alterations in the hippocampus of rat

Epidemiological and experimental animal studies indicate that there is a high risk for the incidence of neuropsychiatric disorders suffering from cardiovascular diseases such as myocardial infarction (MI). However, the potential mechanism of this association remains largely unknown. This study sought to evaluate whether epigenetic alterations in the hippocampus is associated with MI-induced anxiety-like behavior in rats. MI was induced by occlusion of the left anterior descending artery in adult female rats. Anxiety-like behavior was examined by elevated plus maze, light-dark box, and open field test. Relative gene and protein levels expression in the hippocampus were tested by qRT-PCR and western blotting, respectively. We found that MI rats exhibited anxiety-like behavior compared with those in controls, and there is a positive correlation between MI and anxiety-like behavior. We also found that MI decreased KDM6B while increased SIRT1 expression in the hippocampus of MI rats relative to those in controls. In addition, MI not only increased levels of IL-1β, bax, and cleaved-caspase 3, but also increased Iba-1 and GFAP expression in the hippocampus, as compared to those in controls, suggesting a promotion of neuro-inflammation and apoptosis in hippocampus. Co-immunoprecipitation assay illustrated that H3K27me3 functioned by counteracting with YAP activation in the hippocampus of MI rats relative to those in controls. Together, these results suggest a potential role of hippocampal epigenetic signaling in MI-induced anxiety-like behavior in rats, and pharmacological targeting KDM6B or SIRT1 could be a strategy to ameliorate anxiety-like behavior induced by MI.

Resilience and CVD-protective Health Behaviors in Older Women: Examining Racial and Ethnic Differences in a Cross-Sectional Analysis of the Women's Health Initiative

Little is known about the relationship between self-reported psychological resilience (resilience) and health behaviors shown to reduce the risk of cardiovascular disease (CVD). This study examines the associations between resilience and CVD-related risk factors, such as diet, smoking, physical activity, sleep, and alcohol consumption among older American women from diverse backgrounds.

METHODS

A cross-sectional secondary analysis was conducted on 77,395 women (mean age 77 years, Black (N = 4475, 5.8%), non-Hispanic white (N = 69,448, 89.7%), Latina (N = 1891, 2.4%), and Asian or Pacific Islander (N = 1581, 2.0%)) enrolled in the Women's Health Initiative Extension Study II. Resilience was measured using an abbreviated version of the brief resilience scale. Multivariable logistic regression models were used to evaluate the association between resilience and health behaviors associated with risk for CVD, while adjusting for stressful life events and sociodemographic information. To test whether these associations varied among racial/ethnic groups, an interaction term was added to the fully adjusted models between resilience and race/ethnicity.

RESULTS

High levels of resilience were associated with better diet quality (top 2 quintiles of the Healthy Eating Index 2015) (OR = 1.22 (95% Confidence Interval (1.15-1.30)), adhering to recommended physical activity (≥ 150 min per week) (1.56 (1.47, 1.66)), sleeping the recommended hours per night (7-9) (1.36 (1.28-1.44)), and moderate alcohol intake (consuming alcoholic drink(s) 1-7 days per week) (1.28 (1.20-1.37)). The observed association between resilience and sleep is modified by race/ethnicity (p = 0.03).

CONCLUSION

Irrespective of race/ethnicity, high resilience was associated with CVD-protective health behaviors. This warrants further investigation into whether interventions aimed at improving resilience could increase the effectiveness of lifestyle interventions.

Anxiety and clinical outcomes of patients with acute coronary syndrome: a meta-analysis

OBJECTIVES

Anxiety has been suggested to be associated with poor outcomes in patients with acute coronary syndrome (ACS). However, results of previous follow-up studies were inconsistent. The aim of this meta-analysis was to evaluate the association between anxiety and clinical outcomes in patients with ACS, and to investigate the potential role of depression underlying the above association.

DESIGN

A meta-analysis of prospective follow-up studies.

SETTING

Hospitals.

PARTICIPANTS

Patients with ACS.

INTERVENTIONS

We included related prospective follow-up studies up through 20 July 2019 that were identified by searching PubMed and Embase databases. A random-effect model was used for the meta-analysis. Anxiety was evaluated by validated instruments at baseline.

PRIMARY AND SECONDARY OUTCOME MEASURES

We determined the association between anxiety and risks of mortality and adverse cardiovascular events (MACEs) in patients with ACS.

RESULTS

Our analysis included 17 studies involving 39 038 patients wqith ACS. Anxiety was independently associated with increased mortality risk (adjusted risk ratio (RR) 1.21, 95% CI 1.07 to 1.37, p=0.002) and MACEs (adjusted RR 1.47, 95% CI 1.24 to 1.74, p<0.001) in patients with ACS. Subgroup analyses showed that depression may at least partly confound the association between anxiety and poor outcomes in patients with ACS. Adjustment of depression significantly attenuated the association between anxiety and MACEs (adjusted RR 1.25, 95% CI 1.04 to 1.52, p=0.02). Moreover, anxiety was not significantly associated with mortality risk after adjusting for depression (adjusted RR 0.88, 95% CI 0.66 to 1.17, p=0.37).

CONCLUSIONS

Anxiety is associated with increased risk of mortality and MACEs in patients with ACS. However, at least part of the association may be confounded by concurrent depressive symptoms in these patients.

Association Between Hospital Anxiety Depression Scale and Autonomic Recovery Following Exercise

The hospital anxiety depression scale (HADS) is a benchmark used to investigate possible and probable cases of psychosomatic illness. Its affiliation with autonomic recovery after exercise is unclear and, as a technique applied to evaluate cardiovascular risk. We assessed a possible link between HADS and autonomic recovery after exercise. We studied healthy subjects split into two groups: Low HADS (n = 20) and High HADS (n = 21). Subjects consented to moderate aerobic exercise on a treadmill at 60% to 65% of the maximum heart rate (HR) for 30 min. We studied HR variability (HRV) before and during 30 min after exercise. Subjects with higher HADS values presented delayed recovery of HR and root-mean square of differences between adjacent normal RR intervals (RMSSD) after submaximal exercise. RMSSD during recovery from exercise had a significant association with HADS. In summary, subjects with higher HADS presented slower vagal recovery following exercise.

Metabolic Activity in Central Neural Structures of Patients With Myocardial Injury

Background

Increasing evidence suggests a psychosomatic link between neural systems and the heart. In light of the growing burden of ischemic cardiovascular disease across the globe, a better understanding of heart‐brain interactions and their implications for cardiovascular treatment strategies is needed. Thus, we sought to investigate the interaction between myocardial injury and metabolic alterations in central neural areas in patients with suspected or known coronary artery disease.

Methods and Results

The association between resting metabolic activity in distinct neural structures and cardiac function was analyzed in 302 patients (aged 66.8±10.2 years; 70.9% men) undergoing fluor‐18‐deoxyglucose positron emission tomography and ^99mTc‐tetrofosmin single‐photon emission computed tomography myocardial perfusion imaging. There was evidence for reduction of callosal, caudate, and brainstem fluor‐18‐deoxyglucose uptake in patients with impaired left ventricular ejection fraction (<55% versus ≥55%: P=0.047, P=0.022, and P=0.013, respectively) and/or in the presence of myocardial ischemia (versus normal perfusion: P=0.010, P=0.013, and P=0.016, respectively). In a sex‐stratified analysis, these differences were observed in men, but not in women. A first‐order interaction term consisting of sex and impaired left ventricular ejection fraction or myocardial ischemia was identified as predictor of metabolic activity in these neural regions (left ventricular ejection fraction: P=0.015 for brainstem; myocardial ischemia: P=0.004, P=0.018, and P=0.003 for callosal, caudate, or brainstem metabolism, respectively).

Conclusions

Myocardial dysfunction and injury are associated with reduced resting metabolic activity of central neural structures, including the corpus callosum, the caudate nucleus, and the brainstem. These associations differ in women and men, suggesting sex differences in the pathophysiological interplay of the nervous and cardiovascular systems.