Safety and efficacy of sertraline for depression in patients with heart failure: results of the SADHART-CHF (Sertraline Against Depression and Heart Disease in Chronic Heart Failure) trial

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).

Depression in patients with cardiovascular disease

It has been widely suggested that depression negatively affects patients with cardiovascular disease. There are several pathophysiological mechanisms as well as behavioral processes linking depression and cardiac events. Improvements in nursing and medical care have prolonged survival of this patient population; however, this beneficial outcome has led to increased prevalence of depression. Since mortality rates in chronic heart failure patients remain extremely high, it might be as equally important to screen for depression and there are several valid and reliable screening tools that healthcare personnel could easily employ to identify patients at greater risk. Consultation should be provided by a multidisciplinary team, consisting of cardiologists, psychiatrists, and hospital or community nurses so as to carefully plan, execute, and evaluate medical intervention and implement lifestyle changes. We aim to systematically review the existing knowledge regarding current definitions, prognostic implications, pathophysiological mechanisms, and current and future treatment options in patients with depression and cardiovascular disease, specifically those with heart failure.

Heartache and heartbreak--the link between depression and cardiovascular disease

The close, bidirectional relationship between depression and cardiovascular disease is well established. Major depression is associated with an increased risk of coronary artery disease and acute cardiovascular sequelae, such as myocardial infarction, congestive heart failure, and isolated systolic hypertension. Morbidity and mortality in patients with cardiovascular disease and depression are significantly higher than in patients with cardiovascular disease who are not depressed. Various pathophysiological mechanisms might underlie the risk of cardiovascular disease in patients with depression: increased inflammation; increased susceptibility to blood clotting (owing to alterations in multiple steps of the clotting cascade, including platelet activation and aggregation); oxidative stress; subclinical hypothyroidism; hyperactivity of the sympatho-adrenomedullary system and the hypothalamic-pituitary-adrenal axis; reductions in numbers of circulating endothelial progenitor cells and associated arterial repair processes; decreased heart rate variability; and the presence of genetic factors. Early identification of patients with depression who are at risk of cardiovascular disease, as well as prevention and appropriate treatment of cardiovascular disease in these patients, is an important and attainable goal. However, adequately powered studies are required to determine the optimal treatment regimen for patients with both depression and cardiovascular disorders.

Anxiety sensitivity moderates prognostic importance of rhythm-control versus rate-control strategies in patients with atrial fibrillation and congestive heart failure: insights from the Atrial Fibrillation and Congestive Heart Failure Trial

BACKGROUND

Patients with high anxiety sensitivity (AS) become extremely anxious with heart rate increases, palpitations, and symptoms of psychological arousal. AS predicts panic attacks. In atrial fibrillation (AF), AS correlates with symptom preoccupation and reduced quality of life. We assessed whether AS is associated with outcomes of rhythm-control versus rate-control in congestive heart failure (CHF) patients with AF.

METHODS AND RESULTS

Before random assignment, 933 participants (172 women) in the Atrial Fibrillation and Congestive Heart Failure Trial completed the Anxiety Sensitivity Inventory (ASI). Cox proportional hazards models showed no main effects of treatment (P=0.61) or AS (P=0.72) for time to cardiovascular death, but these factors interacted significantly (P=0.020). High AS patients (upper quartile, ASI ≥33) randomly assigned to rhythm-control had significantly lower cardiovascular mortality than those receiving rate-control (hazard ratio, 0.54; 95% confidence interval, 0.32-0.93; P=0.022). With lower ASI scores (<33), treatments did not differ (hazard ratio, 1.12; 95% confidence interval, 0.83-1.51; P=0.46). The interaction between treatment and dichotomized ASI scores remained significant (P=0.009) after adjustment for covariates including age, sex, hypertension, diabetes, creatinine, ejection fraction, time since first diagnosis of AF, New York Heart Association functional class, depression symptoms, marital status, and baseline β-blockers, angiotensin-converting enzyme inhibitors, oral anticoagulants, and implantable cardioverter-defibrillators.

CONCLUSIONS

Atrial fibrillation and congestive heart failure patients with high AS had better long-term prognosis with rhythm- than rate-control. If replicated, AS should be considered in treatment selection. Research is also needed concerning mechanisms and possible joint AS-AF treatments.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT88597077.

Depressive symptoms are common and associated with adverse clinical outcomes in heart failure with reduced and preserved ejection fraction

BACKGROUND

Little is known about depressive symptoms in heart failure with preserved ejection fraction (HFpEF, EF ≥50%). We aimed to assess the prevalence of depression, to clarify the impact of depressive symptoms upon clinical outcomes, and to identify factors associated with these symptoms in HF with reduced EF (HFrEF, EF <50%) and HFpEF.

METHODS AND RESULTS

A total of 106 HF outpatients were enrolled. Of them, 61 (58%) had HFpEF. Most patients were male (HFrEF 80%, HFpEF 70%) and the mean of plasma B-type natriuretic peptide (BNP) level in the HFrEF group was similar to that in the HFpEF group (164.8 ± 232.8 vs. 98.7 ± 94.8 pg/mL). HFrEF patients were treated more frequently with beta-blockers compared with HFpEF patients (71% vs. 43%, p=0.004). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). The prevalence of depression (CES-D score ≥16), and CES-D score did not significantly differ between HFrEF and HFpEF (24% vs. 25%, 14.1 ± 8.3 vs. 12.1 ± 8.3, respectively). During the 2-year follow-up, depressed patients had more cardiac death or HF hospitalization in HFrEF (55% vs. 12%, p=0.002) and HFpEF (35% vs. 11%, p=0.031). Cox proportional hazard analysis revealed that a higher CES-D score, indicating increased depressive symptoms, predicted cardiac events independent of BNP in HFrEF [hazard ratio (HR) 1.07, 95% confidence interval (CI) 1.01-1.13] and HFpEF (HR 1.09, 95% CI 1.04-1.15). Multiple regression analyses adjusted for BNP showed that independent predictors of depressive symptoms were non-usage of beta-blockers and being widowed or divorced in HFrEF. On the other hand, usage of warfarin was the only independent risk factor for depressive symptoms in HFpEF (all, p<0.05).

CONCLUSIONS

Depressive symptoms are common and independently predict adverse events in HFrEF/HFpEF patients. This study suggests that beta-blockers reduce depressive symptoms in HFrEF. In contrast, treatment for depression remains to be elucidated in HFpEF.

Commonality between depression and heart failure

Heart failure (HF) and depression are debilitating diseases with significant effects on functional status and real and perceived quality of life. Despite many advances in therapy for HF mortality remains high. Depression and HF have been recognized to coexist but this does not imply a causative relation. Depressed patients develop more symptoms, have worse compliance with medication regimens, are slower to return to work and social activities, and seem to have a poorer quality of life. In patients with known cardiac disease depression also predicts future events independent of disease severity and other risk factors such as smoking or diabetes mellitus. In conclusion, this review attempts to address the cause/effect relation, if any, between HF and depression and the role of treatment of depression in the setting of HF.

Selective serotonin reuptake inhibitor use is associated with right ventricular structure and function: the MESA-right ventricle study

PURPOSE

Serotonin and the serotonin transporter have been implicated in the development of pulmonary hypertension (PH). Selective serotonin reuptake inhibitors (SSRIs) may have a role in PH treatment, but the effects of SSRI use on right ventricular (RV) structure and function are unknown. We hypothesized that SSRI use would be associated with RV morphology in a large cohort without cardiovascular disease (N = 4114).

METHODS

SSRI use was determined by medication inventory during the Multi-Ethnic Study of Atherosclerosis baseline examination. RV measures were assessed via cardiac magnetic resonance imaging. The cross-sectional relationship between SSRI use and each RV measure was assessed using multivariable linear regression; analyses for RV mass and end-diastolic volume (RVEDV) were stratified by sex.

RESULTS

After adjustment for multiple covariates including depression and left ventricular measures, SSRI use was associated with larger RV stroke volume (RVSV) (2.75 mL, 95% confidence interval [CI] 0.48-5.02 mL, p = 0.02). Among men only, SSRI use was associated with greater RV mass (1.08 g, 95% CI 0.19-1.97 g, p = 0.02) and larger RVEDV (7.71 mL, 95% 3.02-12.40 mL, p = 0.001). SSRI use may have been associated with larger RVEDV among women and larger RV end-systolic volume in both sexes.

CONCLUSIONS

SSRI use was associated with higher RVSV in cardiovascular disease-free individuals and, among men, greater RV mass and larger RVEDV. The effects of SSRI use in patients with (or at risk for) RV dysfunction and the role of sex in modifying this relationship warrant further study.

Incidence rates and predictors of major and minor depression in patients with heart failure

AIMS

Depression is common in heart failure (HF) and associated with adverse outcomes. This study aimed to investigate incidence rates and predictors of depression in patients sampled from four subprojects of the German Competence Network Heart Failure.

METHODS

Eight hundred thirty nine symptomatic HF patients free of depression at baseline underwent repeat depression screening (Patient Health Questionnaire, PHQ-9) after 12 months. Ordered logistic regression analysis was employed to search for predictors of incident depression.

RESULTS

Incident minor (major) depression was observed in 61 (7.3%) and 47 (5.6%) of the population. Depression was recurrent in 15 (25%) and 16 (34%), respectively. Multiple regression analysis revealed seven variables predicting minor or major depression: Previous depressive episode (odds ratio [OR] 4.04, 95% confidence interval [CI] 2.37-6.89, p ≤ 0.001), previous resuscitation (OR 2.44, CI 1.23-4.81, p=0.010), current smoking (OR 2.06, CI 1.08-3.50, p=0.008), >4 visits/year to general practitioner (OR 1.67, CI 1.06-2.63, p=0.026), New York Heart Association class (OR 1.54/class, 95% CI 1.05-2.25, p=0.027), PHQ-9 baseline sum-score (OR 1.18/point, CI 1.11-1.27, p<0.001), and SF-36 physical functioning (OR 1.08/-5 points, CI 1.03-1.13, p=0.002).

CONCLUSIONS

In these HF patients initially free of depression annual incidence rates were high. Several independent predictors allowed identification of patients at particular risk. Although obtained in a selected cohort these findings call, in view of the grave prognosis of HF patients with comorbid depression, for regular depression screening and development of specific supportive strategies to improve patient care and outcomes in HF.

Association of depression and survival in patients with chronic heart failure over 12 Years

OBJECTIVE

To examine the relationship between depression and survival in patients with chronic heart failure (HF) over a 12-year follow-up period.

BACKGROUND

The survival associated with depression has been demonstrated in HF patients for up to 7 years. Longer-term impact of depression on survival of these patients remains unknown.

METHODS

Prospectively conducted observational study examining adults with HF who were admitted to a cardiology service at Duke University Medical Center between March 1997 and June 2003 and completed the Beck depression inventory (BDI) scale. The national death index was queried for vital status. Cox proportional hazards modeling was used to determine the association of survival and depression.

RESULTS

During a mean follow-up of 1792.33 ± 1372.82 days (median 1600; range 0-4683), 733 of 985 participants with HF died of all causes, representing 80% of those with depression (BDI > 10) and 73% of those without (P = 0.01). Depression was significantly and persistently associated with decreased survival over follow-up (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.15-1.57), and was independent of conventional risk factors (HR 1.40, 95% CI 1.16-1.68). Furthermore, survival was inversely associated with depression severity (BDI (continuous) HR 1.02, 95% CI 1.006-1.025, P = 0.001).

CONCLUSIONS

The impact of co-morbid depression during the index hospitalization on significantly increased mortality of HF patients is strong and persists over 12 years. These findings suggest that more investigation is needed to understand the trajectory of depression and the mechanisms underlying the impact of depression as well as to identify effective management strategies for depression of patients with HF.

A positive 2-item Patient Health Questionnaire depression screen among hospitalized heart failure patients is associated with elevated 12-month mortality

BACKGROUND

Given the association of depression with poorer cardiac outcomes, an American Heart Association Science Advisory has advocated routine screening of cardiac patients for depression using the 2-item Patient Health Questionnaire (PHQ-2) "at a minimum." However, the prognostic value of the PHQ-2 among HF patients is unknown.

METHODS AND RESULTS

We screened hospitalized HF patients (ejection fraction [EF] <40%) that staff suspected may be depressed with the PHQ-2, and then determined vital status at up to 12-months follow-up. At baseline, PHQ-2 depression screen-positive patients (PHQ-2+; n = 371), compared with PHQ-2 screen-negative patients (PHQ-2-; n = 100), were younger (65 vs 70 years) and more likely to report New York Heart Association (NYHA) functional class III/IV than class II symptoms (67% vs. 39%) and lower levels of physical and mental health-related quality of life (all P ≤ .002); they were similar in other characteristics (65% male, 26% mean EF). At 12 months, 20% of PHQ-2+ versus 8% of PHQ-2- patients had died (P = .007) and PHQ-2 status remained associated with both all-cause (hazard ratio [HR] 3.1, 95% confidence interval [CI] 1.4-6.7; P = .003) and cardiovascular (HR 2.7, 95% CI 1.1-6.6; P = .03) mortality even after adjustment for age, gender, EF, NYHA functional class, and a variety of other covariates.

CONCLUSIONS

Among hospitalized HF patients, a positive PHQ-2 depression screen is associated with an elevated 12-month mortality risk.

Depression is associated with cognitive dysfunction in older adults with heart failure

Persons with heart failure (HF) frequently exhibit cognitive impairment with deficits in attention and memory. Depression is common in HF though its possible contribution to cognitive impairment is unknown. Cognitive dysfunction and depression may share common mechanisms in HF, as both are associated with similar abnormalities on neuroimaging. A total of 116 participants with HF (68.53 ± 9.30 years) completed a neuropsychological battery and self-report measures of depression. Regression models showed depression incrementally and independently predicted test performance in all cognitive domains. Follow-up partial correlations revealed that greater depressive symptoms were associated with poorer performance on tests of attention, executive function, psychomotor speed, and language. These results indicate that depressive symptoms are associated with poorer cognitive performance in HF though further work is needed to clarify mechanisms for this association and possible cognitive benefits of treating depression in persons with HF.

Prevalence of antidepressant prescription or use in patients with acute coronary syndrome: a systematic review

BACKGROUND AND OBJECTIVES

Depression is common among acute coronary syndrome (ACS) patients and is associated with poor prognosis. Cardiac side effects of older antidepressants were well-known, but newer antidepressants are generally thought of as safe to use in patients with heart disease. The objective was to assess rates of antidepressant use or prescription to patients within a year of an ACS.

METHODS

PubMed, PsycINFO, and CINAHL databases searched through May 29, 2009; manual searching of 33 journals from May 2009 to September 2010. Articles in any language were included if they reported point or period prevalence of antidepressant use or prescription in the 12 months prior or subsequent to an ACS for ≥100 patients. Two investigators independently selected studies for inclusion/exclusion and extracted methodological characteristics and outcomes from included studies (study setting, inclusion/exclusion criteria, sample size, prevalence of antidepressant prescription/use, method of assessing antidepressant prescription/use, time period of assessment).

RESULTS

A total of 24 articles were included. The majority were from North America and Europe, and most utilized chart review or self-report to assess antidepressant use or prescription. Although there was substantial heterogeneity in results, overall, rates of antidepressant use or prescription increased from less than 5% prior to 1995 to 10-15% after 2000. In general, studies from North America reported substantially higher rates than studies from Europe, approximately 5% higher among studies that used chart or self-report data.

CONCLUSIONS

Antidepressant use or prescription has increased considerably, and by 2005 approximately 10% to 15% of ACS patients were prescribed or using one of these drugs.

Cognitive therapy improves three-month outcomes in hospitalized patients with heart failure

BACKGROUND

Patients with heart failure (HF) experience depressive symptoms that contribute to poorer outcomes. We tested the effects of a brief cognitive therapy intervention on depressive symptoms, negative thinking, health-related quality of life, and cardiac event-free survival.

METHODS AND RESULTS

Hospitalized patients with depressive symptoms (n = 41, 66 ± 11 years, 45% female, 81% New York Heart Association Class III/IV) were randomly assigned to control group or a brief, nurse-delivered cognitive therapy intervention, delivered during hospitalization and followed by a 1-week booster phone call. Depressive symptoms, negative thinking, and health-related quality of life were measured at 1 week and 3 months. Cardiac event-free survival was assessed at 3 months. Mixed models repeated measures analysis of variance, Kaplan-Meier, and Cox regression were used for data analysis. There were significant improvements in depressive symptoms and health-related quality of life in both groups but no interactions between group and time. The control group had shorter 3-month cardiac event-free survival (40% versus 80%, P < .05) and a 3.5 greater hazard of experiencing a cardiac event (P = .04) than the intervention group.

CONCLUSION

Nurses can deliver a brief intervention to hospitalized patients with heart failure that may improve short-term, event-free survival. Future research is needed to verify these results with a larger sample size.

Plasma omega-3 polyunsaturated fatty acids and survival in patients with chronic heart failure and major depressive disorder

The omega-3 fatty acid (FA) concentration is low in patients with coronary heart disease (CHD). Supplement of omega-3 FA improves cardiovascular outcomes in patients with CHD and heart failure (HF). However, plasma omega-3 FA and its role for prognosis in HF patients have not been examined previously. In this study, we explore the prognostic value of omega-3 polyunsaturated FA in HF patients with major depressive disorder (MDD). Plasma was obtained from HF patients with MDD who participated in the Sertraline Against Depression and Heart Disease in Chronic Heart Failure trial. FA methyl esters were analyzed by the method of a flame ionization detector. Weight percent is the unit of the omega compounds. The primary outcome was survival which was analyzed using Cox proportional hazards regression modeling. A total of 109 depressed HF patients had adequate volume for completion of the FA assays. Plasma total omega-3 (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.43-0.98) and EPA_(0.1 unit) (HR 0.73, 95% CI 0.56-0.96) were significantly associated with survival of patients with HF and co-morbid MDD. The results suggest that low plasma omega-3 FA is a significant factor for reduced survival in HF patients with MDD.

Trajectory classes of depression in a randomized depression trial of heart failure patients: a reanalysis of the SADHART-CHF trial

OBJECTIVE

The objective of this article was to determine whether, in drug intervention trials, growth mixture modeling (GMM) is able to identify drug-responsive trajectory classes that are not evident in traditional growth modeling approaches.

METHODS

We reanalyzed acute phase (biweekly data up to 7 occasions) and longitudinal (12 months) data on the 469 patients in the SADHART-CHF study of the safety and efficacy of sertraline for depression in patients with heart failure. GMM was used to identify the trajectory classes present in the treatment and placebo groups, based on Hamilton Depression Rating Scale scores.

RESULTS

Two distinct trajectory classes were identified in the treatment group: (1) chronic depressives (12%), who remained depressed through the treatment phase; and (2) responders (88%), who had scores indicating nondepression at the conclusion of the acute phase. At baseline, chronic depressives were distinguished by higher Hamilton Depression Rating Scale scores, the presence of implantable cardioverter defibrillators, and a history of anxiety. During follow-up, they were more likely to have unstable angina. Only responders remitted (70%). Three distinct trajectories were identified in the placebo group: (1) moderating depressives (19%), (2) temporary improvers (13%), and (3) responders (68%). At baseline, the classes differed in mean Hamilton Depression Rating Scale scores, responders' scores falling between the other 2 classes, and the proportion with renal disease. Only remission differed at follow-up: responders (76%), moderating depressives (21%), and temporary improvers (3%). Where the traditional analytic approach found improvement from moderate to mild depression but no significant treatment effect, GMM found response in 20% more people in the treatment group than in the placebo group.

CONCLUSIONS

Unlike conventionally used, standard analytic approaches, which focus on intervention impact at study end or change from baseline to study end, GMM enables maximum use of repeated data to identify unique trajectories of latent classes that are responsive to the intervention.

Palliative care and hospice in advanced heart failure

Advanced heart failure (HF) is a disease process that carries a high burden of symptoms, suffering, and death. Palliative care can complement traditional care to improve symptom amelioration, patient-caregiver communication, emotional support, and medical decision making. Despite a growing body of evidence supporting the integration of palliative care into the overall care of patients with HF and some recent evidence of increased use, palliative therapies remain underused in the treatment of advanced HF. Review of the literature reveals that although barriers to integrating palliative care are not fully understood, difficult prognostication combined with caregiver inexperience with end-of-life issues specific to advanced HF is likely to contribute. In this review, we have outlined the general need for palliative care in advanced HF, detailed how palliative measures can be integrated into the care of those having this disease, and explored end-of-life issues specific to these patients.

[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.

[Psychosomatic aspects of chronic heart failure. Nothing but depression?]

Psychosocial factors are bi-directionally associated with the pathophysiology, symptoms, and prognosis observed in heart failure. Cardiac symptom severity is both dependent on psychological appraisal processes and causally related to feelings of exhaustion and distress. Distress and depression have been shown to affect physiological processes involved in the pathogenesis and course of chronic heart failure as well as illness behaviors. Conversely, physiological consequences of heart failure such as inflammatory activation may lead to sickness behavior and depression. However, there are some indications that the secretion of natriuretic peptides observed in response to cardiac overload may also have beneficial psychological effects (e.g., anxiolysis). Quality of life is typically reduced in heart failure but functional impairment and psychological maladjustment seem to be more important for quality of life than cardiac severity markers such as systolic or diastolic function per se. Current guidelines therefore recommend complementing optimal medical care with good communication, the creation of a trustful physician-patient relationship, patient education and partnership building, as well as specialized mental health care in cases of severe or enduring mental disorders or inappropriate illness behavior. While the evidence for antidepressant drug treatment in heart failure appears inconclusive, behavioral treatments such as exercise and psychotherapy may be more promising in treating comorbid anxiety and depression.

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.

Depression and cardiac disease: a review

Depression is highly prevalent in cardiac patients, with 20% to 40% of patients meeting criteria for major depressive disorder or experiencing an elevation in depressive symptoms. These depressive symptoms are often chronic and persistent, and they have been associated with the development and progression of coronary artery disease, worse health-related quality of life, poor physical functioning, recurrent cardiac events, and a 2- to 2.5-fold increased risk of mortality. Impaired adherence to health behaviors and adverse physiological effects of depression, including inflammation, endothelial dysfunction, platelet hyperactivity, and autonomic nervous system abnormalities, may link depression with adverse cardiac outcomes. Pharmacologic and psychotherapeutic interventions appear to be safe and effective at reducing depressive symptoms in patients with cardiovascular disease and may impact cardiac outcomes. Unfortunately, depression often is unrecognized and untreated in this population, despite the availability of brief screening tools that can be used for this purpose. We recommend the routine screening of cardiac patients for depression when there are adequate mechanisms for management and referral, such as available consulting psychiatrists or care management programs that facilitate the delivery of pharmacologic and psychotherapeutic treatments in this vulnerable population.

Epidemiology and treatment of depression in patients with chronic medical illness

There is a bidirectional relationship between depression and chronic medical disorders. The adverse health risk behaviors and psychobiological changes associated with depression increase the risk for chronic medical disorders, and biological changes and complications associated with chronic medical disorders may precipitate depressive episodes. Comorbid depression is associated with increased medical symptom burden, functional impairment, medical costs, poor adherence to self-care regimens, and increased risk of morbidity and mortality in patients with chronic medical disorders. Depression may worsen the course of medical disorders because of its effect on proinflammatory factors, hypothalamic-pituitary axis, autonomic nervous system, and metabolic factors, in addition to being associated with a higher risk of obesity, sedentary lifestyle, smoking, and poor adherence to medical regimens. Both evidence-based psychotherapies and antidepressant medication are efficacious treatments for depression. Collaborative depression care has been shown to be an effective way to deliver these treatments to large primary care populations with depression and chronic medical illness.

Outpatient palliative care for chronic heart failure: a case series

BACKGROUND/OBJECTIVES

Although the palliative care needs of outpatients with chronic heart failure (HF) are numerous, there is limited published experience in providing outpatient HF palliative care. This article describes the patients seen and the issues addressed in an outpatient palliative care program for patients with HF.

METHODS

Case series involving a retrospective medical record review using descriptive quantitative and qualitative analysis.

RESULTS

Over a 3 ½ year time period, 50 patients were seen, resulting in 228 total visits. Fifty percent of patients were seen only once. Fifty-eight percent of patients had New York Heart Association (NYHA) Class III-IV HF. Within a year of the initial palliative care visit, 14% of patients died. Depression, anxiety, pain, fatigue, breathlessness, and sleep disturbance were common symptoms addressed during visits. Advance care planning topics were discussed with 48% of patients; hospice and resuscitation status were each discussed with 16% of patients. Fears or concerns about the future arose in 34% of patients. Care coordination was commonly addressed with patients' other health care providers (58%). The most common referrals were to social work (26%) and rehabilitation/physical therapy (20%).

CONCLUSIONS

Several findings reflect how outpatient HF palliative care differs from that of inpatient hospital-based palliative care. Many of the issues addressed, including care coordination, advance care planning, and psychosocial issues, imply that palliative HF care is complementary to standard HF care at all stages of the disease process and that future programs should consider dedicating a nurse and/or social worker. Research is needed to test how such a care model affects patient-centered outcomes, utilization, and cost.

Screening for cognitive deficits using the Montreal cognitive assessment tool in outpatients ≥65 years of age with heart failure

There is strong evidence to suggest that heart failure (HF) is an independent risk factor for cognitive impairment (CI). The combination of CI and HF is associated with increased mortality, repeat hospitalization, and poor quality of life. The purpose of this pilot study was to determine the presence of CI in older patients with HF using the Montreal Cognitive Assessment (MoCA), a brief screening instrument for CI. We conducted a cross-sectional descriptive study using the MoCA in outpatients with HF who were ≥ 65 years of age. Forty-four patients (mean ± SD 76 ± 6.6 years of age) completed the MoCA. More than 70% of patients scored below the MoCA cutoff score of 26, suggesting the presence of CI. However, 91% of patients with New York Heart Association classes III to IV versus 52% of patients with classes I to II had a MoCA score < 26 (p = 0.004). Patients with a recent hospital admission were more likely to have a MoCA score < 26 versus patients without a recent hospital admission (89% vs 62%, respectively, p < 0.045). Cognitive domain subscores showing significant differences (p <0.01) were short-term memory, visuospatial function, executive function, and language. In conclusion, this study sample represented a group of older patients with HF and no suspected or documented CI, but screening with the MoCA detected CI in >70% of the sample. The presence of CI was significantly more common in patients with advanced HF symptoms or a recent hospitalization. Future studies need to determine if the MoCA can identify the presence of CI that is predictive of adverse clinical outcomes in the HF population.

Depression in heart failure: biobehavioral mechanisms

The etiology, predictive value, and biobehavioral aspects of depression in heart failure (HF) are described in this article. Clinically elevated levels of depressive symptoms are present in approximately 1 out of 5 patients with HF. Depression is associated with poor quality of life and a greater than 2-fold risk of clinical HF progression and mortality. The biobehavioral mechanisms accounting for these adverse outcomes include biological processes (elevated neurohormones, autonomic nervous system dysregulation, and inflammation) and adverse health behaviors (physical inactivity, medication nonadherence, poor dietary control, and smoking). Depression often remains undetected because of its partial overlap with HF-related symptoms and lack of systematic screening. Behavioral and pharmacologic antidepressive interventions commonly result in statistically significant but clinically modest improvements in depression and quality of life in HF, but not consistently better clinical HF or cardiovascular disease outcomes. Documentation of the biobehavioral pathways by which depression affects HF progression will be important to identify potential targets for novel integrative behavioral and pharmacologic interventions.

Characteristics of depression remission and its relation with cardiovascular outcome among patients with chronic heart failure (from the SADHART-CHF Study)

Depression is prevalent in patients with heart failure and is associated with a significant increase in hospitalizations and death. Primary results of the Sertraline Against Depression and Heart Disease in Chronic Heart Failure (SADHART-CHF) trial revealed that sertraline and placebo had comparable effects on depression and cardiovascular outcomes. In this study, we explored whether remission from depression was associated with better survival and aimed to characterize participants who remitted during the trial. Based on depression response during the 12-week treatment phase, SADHART-CHF participants were divided into 2 groups: (1) remission, defined as participants whose last measured Hamilton Depression Rating Scale (HDRS) score was <8, and (2) nonremission, defined as participants whose last measured HDRS score was ≥8. Patients who dropped out before having any repeat HDRS were not included. Baseline characteristics and survival differences up to 5 years were evaluated between the remission and nonremission groups. Of the 469 SADHART-CHF participants, 208 (44.3%) achieved remission, 194 (41.4%) remained depressed, and 67 (14.3%) dropped out or died without any repeat HDRS assessment. Patients in the remission group had significantly fewer cardiovascular events than those in the nonremission group (1.34 ± 1.86 vs 1.93 ± 2.71, adjusted p = 0.01). Men patients were more likely to remit than women patients (56.5 vs 44.8%, p = 0.02). The remission group had milder depressive symptoms at baseline compared to the nonremission group (HDRS 17.0 ± 5.4 vs 19.6 ± 5.5, Beck Depression Inventory scale 17.9 ± 6.5 vs 20.3 ± 7.2, p <0.001 for the 2 comparisons). In conclusion, this study indicates that remission from depression may improve the cardiovascular outcome of patients with heart failure.

Management of depression in patients with coronary heart disease: association, mechanisms, and treatment implications for depressed cardiac patients

IMPORTANCE OF THE FIELD

Coronary heart disease (CHD) and depression are two leading causes of death and disability in the United States and worldwide. Depression is especially common in cardiac patients, and there is growing evidence that depression is a risk factor for fatal and nonfatal events in CHD patients.

AREAS COVERED IN THIS REVIEW

This paper reviews current literature of depression as a risk factor for CHD along with pharmacologic and non-pharmacologic treatments for depression in cardiac patients.

WHAT THE READER WILL GAIN

Readers will gain knowledge about the importance of depression as a CHD risk factor and learn the results of efforts to treat depressed CHD patients.

TAKE HOME MESSAGE

Although randomized clinical trials (RCTs) of medication and non-pharmacologic therapies have not demonstrated that treating depression improves survival, there is evidence that treating depressed patients can reduce depressive symptoms and improve quality of life. Additional RCTs are needed, including evaluation of non-pharmacologic therapies such as exercise, to examine the effects of treatment of depression on medical and psychosocial outcomes.

Synthesis of dinucleoside tetraphosphates in transfected cells by a firefly luciferase reporter gene

The firefly luciferase gene is widely used as a reporter gene and its expression is generally considered to be non-toxic. In addition to its light-producing reaction, luciferase can synthesise dinucleoside polyphosphates, intracellular signalling molecules, in vitro. Here we show that COS-7 cells transfected with a luciferase expression vector accumulate up to 0.5 mM adenine-containing dinucleoside tetraphosphates (Ap4N) during the 24 h following luciferin addition. The optimal external concentration of luciferin was 0.4-0.6 mM. In agreement with its poor ability to synthesise adenine-containing dinucleoside triphosphates in vitro, the level of these compounds did not increase after transfection. Consequently, the results of experiments involving luciferase-mediated light production by live cells should now be viewed in the light of the possible effects of an increased intracellular Ap4N concentration on the properties of the system under investigation. This observation also points to a useful non-invasive procedure for the specific enhancement of intracellular Ap4N for studies directed at understanding the functions of these compounds.