The relationship between depressive symptoms and anxiety and quality of life and functional capacity in heart transplant patients

Low acceptance rate of COVID-19 vaccination and reduced quality of life among heart transplant recipients during the COVID-19 pandemic

OBJECTIVES

To investigate the impact of the current coronavirus disease 2019 (COVID-19) pandemic on the quality of life (QoL) and status of COVID-19 vaccination in heart transplant recipients (HTRs).

METHODS

Patients who underwent allogeneic heart transplants between June 2006 and December 2019, who survived were selected from a follow-up registration form at our center. Data were collected using questionnaires in 2021, the QoL survey was conducted using the MOS 36-item Short-Form Health Survey (SF-36) and compared to the same time frame in 2019. The patients were divided into two groups: post-epidemic (A) and pre-epidemic (B) groups. We also recorded whether the participants had been vaccinated against COVID-19 (Beijing Sinovac COVID-19 vaccine). All the data obtained were analyzed.

RESULTS

There were 88 patients who participated in the study. Only 12 (13.6%) were vaccinated. In terms of SF-36 scale assessments, after the outbreak of the COVID-19 pandemic, Group A scored lower in vitality [52.5(49.0, 58.0) vs. 75.0(69.0, 79.0), p < .001], social functioning [54.0(50.5, 58.0) vs. 74.0(67.5, 78.0), p < .001], role emotional [58.5(55.0, 62.0) vs. 67.0(63.0, 71.0), p < .001], and mental health [58.5(55.0, 62.0) vs. 76.0(72.0, 79.0), p < .001]. In Group A the mental component summary (MCS) significantly decreased [222.0(214.5, 230.0) vs. 289.0(277.5, 299.5), p < .001]. The PCS and MCS of HTRs who had been vaccinated against COVID-19 were significantly higher than those who had not [PCS: 283.5(280.0, 287.0) vs. 276.0(271.0, 279.0), p < .001; MCS: 245.0(141.5, 254.0) vs. 220.0(213.5, 226.5), p < .001].

CONCLUSION

Low acceptance levels of COVID-19 vaccination were observed in the HTRs. The QoL of the HTRs decreased after the COVID-19 pandemic.

A Systematic Review and Meta-Analysis of the Effectiveness of High-Intensity Interval Training in People with Cardiovascular Disease at Improving Depression and Anxiety

Background

To assess the effects of high-intensity interval training (HIIT) on depression and anxiety symptom in people with cardiovascular diseases (CVDs) compared with usual care (UC) and traditional aerobic continuous training (CT).

Methods

Randomized controlled trials (RCTs) that investigated the effectiveness of HIIT on depression and/or anxiety outcomes before and after treatment in people with CVDs were included. A systematic search of database containing PubMed, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, SPORTSDiscus, and CINAHL (EBSCOhost) was performed up to December 2021. The analyses of study characteristics, heterogeneity, and forest plot in analyses analogous were conducted via the pooled standardized mean difference (SMD) in random- or fixed-effect models as the measure of effectiveness.

Results

Twelve independent studies (515 participants) were included. One study was rated as low quality, and four studies were evaluated as high quality. The other studies were rated as moderate quality. Visual interpretation of funnel plots and Egger test indicated no evidence of publication bias. There was a statistically significant reduction in the severity of depression (12 studies, SMD = -0.42 [Random], 95% CI, -0.69 to -0.16, p=0.002, I ² = 52%) rather than that of anxiety symptoms (8 studies, SMD = -0.14 [Fixed], 95% CI, -0.35 to 0.06, p=0.18, I ² = 0%) following HIIT compared with UC and CT control groups. Subgroup analysis revealed that high-intensity treadmill training significantly improved (p=0.01) the depression symptom instead of training with a cycle ergometer (p=0.07) and strength training (p=0.40).

Conclusions

High-intensity interval treadmill training can significantly improve symptoms of depression rather than anxiety in cardiovascular patients compared to usual care and conventional aerobic continuous training.

Cardiac rehabilitation for coronary artery disease: latest updates

PURPOSE OF REVIEW

To summarize recent innovations in cardiac rehabilitation and provide a view towards the future of cardiac rehabilitation as it adjusts to the pressures of a global pandemic.

RECENT FINDINGS

Although cardiac rehabilitation has been shown to result in a mortality benefit, research continues to enumerate the benefits of cardiac rehabilitation to patient function and quality of life in a growing range of cardiovascular diseases. In addition, new methodologies and new models of cardiac rehabilitation have emerged with the goal of increasing patient referral and participation.

SUMMARY

Cardiac rehabilitation continues to evolve and adapt to serve a growing and diversifying number of patients with cardiovascular disease with the goal of both decreasing mortality and improving patient function.

The impact of psychiatric disorders on outcomes following heart transplantation in children

Psychiatric disorders are common in pediatric HTx recipients. However, the impact of psychiatric comorbidities on patient outcomes is unknown. We aimed to assess the impact of disorders of adjustment, depression, and anxiety on HTx outcomes in children; hypothesizing that the presence of psychiatric disorders during or preceding HTx would negatively impact outcomes. All pediatric HTx recipients ≥8 years of age who survived to hospital discharge were identified from a novel linkage between the PHIS and SRTR databases (2002-2016). Psychiatric disorders were identified using ICD codes during or preceding the HTx admission. Post-transplant graft survival, freedom from readmission, and freedom from rejection were analyzed using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to adjust for covariates. A total of 1192 patients were included, of which 133 (11.2%) had depression, 197 (16.5%) had anxiety, and 218 (18.3%) had adjustment disorders. The presence of depression was independently associated with higher rates of readmission (60.9% vs 54.1% at 6 months) (AHR 1.63, 95% CI 1.22-2.18, P = .001) and inferior graft survival (70.2% vs 83.4% at 5 years) (AHR 1.62, 95% CI 1.14-2.3, P = .007). Anxiety was independently associated with higher rates of readmission (60.4% vs 53.9% at 6 months) (AHR 1.46, 95% CI 1.09-1.94, P = .01). Anxiety and depression in the pretransplant period are independently associated with outcomes following HTx in children. Evaluation and management of psychiatric comorbidities represents an important component of care in this vulnerable population.

High-intensity interval training and health-related quality of life in de novo heart transplant recipients - results from a randomized controlled trial

Background

Studies on the effect of high-intensity interval training (HIT) compared with moderate intensity continuous training (MICT) on health-related quality of life (HRQoL) after heart transplantation (HTx) is scarce. No available studies among de novo HTx recipients exists. This study aimed to investigate the effect of HIT vs. MICT on HRQoL in de novo recipients.

Methods

The HITTS study randomized eighty-one de novo HTx recipients to receive either HIT or MICT (1:1). The HIT intervention were performed with 2–4 interval bouts with an intensity of 85–95% of maximal effort. The MICT group exercised at an intensity of 60–80% of their maximal effort with a duration of 25 min. HRQoL was assessed by the Short Form-36 version 2 (SF-36v2) and the Hospital Anxiety and Depression Scale, mean 11 weeks after surgery and after a nine months’ intervention. The participants recorded their subjective effect of the interventions on their general health and well-being on a numeric visual analogue scale. Clinical examinations and physical tests were performed. Differences between groups were investigated with independent Student t-tests and with Mann-Whitney U tests where appropriate. Within-group differences were analyzed with Paired-Sample t-tests and Wilcoxon Signed Rank tests. Correlations between SF-36 scores and VO_2peak were examined with Pearson’s correlations.

Results

Seventy-eight participants completed the intervention. Both exercise modes were associated with improved exercise capacity on the physical function scores of HRQoL. Mental health scores remained unchanged. No differences in the change in HRQoL between the groups occurred except for Role Emotional subscale with a larger increase in the HIT arm. Better self-reported physical function was associated with higher VO_2peak and muscle strength.

Conclusion

HIT and MICT resulted in similar mean changes in HRQoL the first year after HTx. Both groups experienced significant improvements in the physical SF-36v2.

Trial registration

ClinicalTrials.gov number: NCT01796379 Registered 18 February 2013.

Importance of physical capacity and the effects of exercise in heart transplant recipients

One of the most important prognostic factors in heart failure patients is physical capacity. Patients with very poor physical performance and otherwise eligible, may be listed as candidates for heart transplantation (HTx). After such surgery, life-long immunosuppression therapy is needed to prevent rejection of the new heart. The dark side of immunosuppression is the increased risk of infections, kidney failure, cancer and advanced atherosclerosis (cardiac allograft vasculopathy), with the two latter conditions as the main causes of later mortality. In a worldwide perspective, 50% of the HTx patients survive past 10 years. Poor aerobic capacity prior to graft deterioration is not only limited to the failing heart, but also caused by peripheral factors, such as limited function in the skeletal muscles and in the blood vessels walls. Exercise rehabilitation after HTx is of major importance in order to improve physical capacity and prognosis. Effects of high-intensity interval training (HIT) in HTx recipients is a growing field of research attracting worldwide focus and interest. Accumulating evidence has shown that HIT is safe and efficient in maintenance HTx recipients; with superior effects on physical capacity compared to conventional moderate exercise. This article generates further evidence to the field by summarizing results from a decade of research performed at our center supported by a broad, but not strict formal, literature review. In short, this article demonstrates a strong association between physical capacity measured after HTx and long-term survival. It describes the possible “HIT-effect” with increased levels of inflammatory mediators of angiogenesis. It also describes long-term effects of HIT; showing a positive effect in development of anxiety symptoms despite that the improved physical capacity was not sustained, due to downregulation of exercise and intensity. Finally, our results are linked to the ongoing HITTS study, which investigates safety and efficiency of HIT in de novo HTx recipients. Together with previous results, this study may have the potential to change existing guidelines and contribute to a better prognosis for the HTx population as a whole.

Immediate response in markers of inflammation and angiogenesis during exercise: a randomised cross-over study in heart transplant recipients

Background

The present study explored and compared the immediate responses in markers of inflammation and angiogenesis in maintenance heart transplant (HTx) recipients before, during and after sessions of high-intensity interval training (HIT) versus moderate-intensity continuous training (MICT). The study aimed to explain some of the trigger mechanisms behind HIT in HTx recipients.

Methods

This cross-over study included 14 HTx patients (mean±SD age: 53±13 years; time since HTx, 3±2 years). All participants underwent baseline blood samples and a cardiopulmonary exercise test during their first visit. The next two visits included one HIT session and one MICT session, in randomised order. Blood samples were taken during and after each exercise session. Myokines and inflammatory markers related to vascular inflammation, blood-platelet activation and modulation of angiogenesis were analysed.

Results

The main findings in this study were (1) exercise, regardless of intensity, induced a significant immediate response in several vascular, angiogenetic and in particular platelet-derived inflammatory mediators in HTx recipients. (2) HIT showed trends to induce an increased response in von Willebrand factor, vascular endothelial growth factor-1 and angiopoetin-2, and a decreased response in growth differentiation factor-15, compared with MICT.

Conclusions

This pattern and in particular the trend towards an increased angiogenetic mediator response could contribute to the beneficial effects of HIT in HTx recipients.

Trial registration number

NCT02602834.

Depression in Cardiovascular Patients in Middle Eastern Populations: A Literature Review

Cardiovascular disease (CVD) is increasing in Middle Eastern countries. Depression is associated with increased morbidity and mortality rates among cardiovascular (CV) patients. Early detection of and intervention for depression among CV patients can reduce morbidity and mortality and save health care costs. Public information on mental health care needs of Arab CV patients living in Middle East regions is scattered and limited. This literature review surveyed and summarized research studies to learn what is known about the relationship between depression and CVD in Middle Eastern populations. The information will raise awareness among health care professionals and policy makers regarding the clinical significance of depression in Arab CV patients. It might contribute to development of culturally appropriate and effective mental health care services. Multiple databases were searched and 60 articles were assessed, including studies that investigated depression in Arab CV patient populations, physiological mechanisms of depression-CVD comorbidity, and intervention strategies that affect CV risk in depressed Arab patients. We discuss the extent to which this issue has been explored in Arab populations living in Middle East regions and Arab populations living abroad. We recommend that more comprehensive and in-depth research studies be conducted with Arab cardiac patients to enable implementation of culturally appropriate and effective mental health care interventions.

The effect of major depression on quality of life after surgery for stress urinary incontinence: a secondary analysis of the Trial of Midurethral Slings

BACKGROUND

Depression has been associated with symptom amplification, functional impairment, and lower incontinence-specific quality of life in women with urinary incontinence. Although depression has been shown to impact both subjective and objective outcomes after many different surgeries, there are limited data on the effects of major depression on postoperative outcomes after antiincontinence surgery.

OBJECTIVE

The purpose of this study was to determine whether major depression affects urinary incontinence severity and quality of life after midurethral sling surgery.

STUDY DESIGN

This was a secondary analysis of the Trial of Midurethral Slings. Participants were assigned randomly either to a retropubic or transobturator sling for stress urinary incontinence. Each was classified as having major depression or not by the validated depression screening Patient Health Questionnaire-9. Pre- and postoperative urinary incontinence severity (which was assessed by the International Consultation on Incontinence Questionnaire), urinary incontinence-specific quality of life (which was assessed by the Incontinence Impact Questionnaire and the Urinary Distress Inventory), and sexual function (which was assessed by the Prolapse/Urinary Incontinence Sexual Questionnaire) was compared between groups at baseline and at 12 months.

RESULTS

Five hundred twenty-six patients were included: 79 patients (15%) had major depression before surgery; 447 patients (85%) did not. Baseline incontinence severity was higher in women with major depression than in those without (International Consultation on Incontinence Questionnaire, 14.7 ± 4.1 vs 12.9 ± 4.0; P < .001). Similarly, baseline quality of life and sexual function were worse in depressed women than in nondepressed women (Incontinence Impact Questionnaire, 235.6 ± 95.8 vs 134.8 ± 89.8; P < .001; Urinary Distress Inventory, 162.7 ± 46 vs 128.6 ± 41.3; P < .001; and Prolapse/Urinary Incontinence Sexual Questionnaire-12, 27.2 ± 7.3 vs 33.9 ± 6.4; P < .001). After adjustment for differences between groups, baseline major depression did not negatively affect 12-month incontinence severity or quality of life. However, at 12 months after surgery, despite significant improvement in sexual function scores in depressed women, the 12-month scores were still significantly worse in the major depression group (Prolapse/Urinary Incontinence Sexual Questionnaire-12, 34.1 ± 7.1 vs 37.7 ± 6.1; P < .001); multivariable analysis showed independent association of baseline major depression with 12-month sexual function. At 12 months, 83% of those women (66/79) with baseline major depression were no longer depressed.

CONCLUSION

Women with major depression who are planning surgery for stress urinary incontinence have worse quality of life than nondepressed women. However, women with major depression improve significantly more than those without major depression such that, at 12 months postoperatively, incontinence severity and quality of life are not different between groups. Sexual function is worse before and after the operation for depressed women.

Benefit Finding in Cardiac Patients: Relationships with Emotional Well-Being and Resources after Controlling for Physical Functional Impairment

Benefit finding (BF) is defined as the individual's perception of positive change as a result of coping with an adverse life event. The beneficial effects of BF on well-being could be because BF favors the improvement of resources like self-efficacy, social support and effective coping. The main objective of this longitudinal 8 week study was to explore, in a sample of cardiac patients (n = 51), the combined contribution of BF and these resources to the positive affect. Moreover, we wanted to check whether these resources were derived from BF or, on the contrary, these resources were antecedents of BF. Results showed that after controlling for functional capacity, only effective coping could predict the positive affect at Time 1 (β = .32, p < .05), while the BF predicted it at Time 2 (β = .23, p < .001). Only social support predicted BF (β = .26, p < .05), but not the opposite. We discussed the desirability of promoting these processes to improve the emotional state of cardiac patients.

Peak oxygen uptake and self-reported physical health are strong predictors of long-term survival after heart transplantation

BACKGROUND

Peak oxygen uptake (VO2peak ) is known as the gold standard measure of cardiopulmonary fitness. We therefore hypothesized that measures of physical health would predict long-term survival in heart transplant recipients (HTx).

METHODS

This retrospective study investigated survival in two HTx populations; the cardiopulmonary exercise test (CPET) cohort comprised 178 HTx patients who completed a VO2peak test during their annual follow-up (1990-2003), and the SF-36 cohort comprised 133 patients who completed a quality of life questionnaire, SF-36v1 (1998-2000).

RESULTS

Mean (SD) age in the CPET cohort was 52 (12) yr and 54 (11) yr in the SF-36 cohort. Mean observation time was, respectively, 11 and 10 yr. Mean (SD) VO2peak was 19.6 (5.3) mL/kg/min, and median (IR) physical function (PF) score was 90 (30). VO2peak and PF scores were both significant predictors in univariate Cox regression. Multiple Cox regression analyses adjusted for other potential predictors showed that VO2peak , age, and cardiac allograft vasculopathy (CAV) were the most important predictors in the CPET cohort, whereas age, PF score, smoking, and CAV were the most important predictors in the SF-36 cohort. In Kaplan-Meier analysis, VO2peak and PF scores above the median value were related to significant longer survival time.

CONCLUSION

Peak oxygen uptake and self-reported physical health are strong predictors for long-term survival in HTx recipients. VO2peak is a crucial measurement and should be more frequently used after HTx.

Association of depression symptoms with quality of life and chronic artery vasculopathy: a cross-sectional study in heart transplant patients

OBJECTIVE

Depression represents a relevant co-morbidity in patients with chronic heart disease and may diminish the overall success for long-term survival after heart transplantation (HTx). This study aimed to assess the prevalence of depression symptoms in long-term HTx survivors, and to compare depressive patients to those without depression with respect to chronic artery vasculopathy (CAV).

METHODS

A sample of 203 HTx patients, median 11.5 (IQR 7-17) years after transplant, provided detailed data of depression symptoms, and other psychosocial symptoms including anxiety, family support, professional re-integration, and health-related quality of life (HRQoL). Data were analyzed for an association with CAV.

RESULTS

Overall, 14.8% patients (95% CI: 10.2-20.4) showed relevant depression symptoms. No significant differences were seen between non-depressed vs. depressed patients with respect to demographics, clinical variables, and cardiovascular risk factors. Anxiety was prevalent in 9.0% (95% CI: 5.4-13.9) of the sample. Depression symptoms showed impaired HRQoL in the SF-36 physical (P=.012) and psychosocial (P=.0001) components. CAV was prevalent in 34.0% (95% CI: 27.5-41.0), and depression symptoms and CAV were not significantly associated. CAV-patients did not report their physical HRQoL being lower relative to those without CAV (P=.40). Multivariate analysis revealed overweight BMI (OR=2.20; P=.04), longer time since transplant (OR=1.10; P=.001), and older age (OR=1.04; P=.01) being associated with CAV.

CONCLUSION

Depression symptoms are prevalent in long-term survivors after HTx, and psychological impairments decrease patients' perceptions of HRQoL. More research seems necessary to identify the inter-relationship between depression symptoms and CAV, in order to develop targeted interventions to overcome this problem.

Exercise after heart transplantation: An overview

While life expectancy is greatly improved after a heart transplant, survival is still limited, and compared to the general population, the exercise capacity and health-related quality of life of heart transplant recipients are reduced. Increased exercise capacity is associated with a better prognosis. However, although several studies have documented positive effects of exercise after heart transplantation (HTx), little is known about the type, frequency and intensity of exercise that provides the greatest health benefits. Moreover, the long-term effects of exercise on co-morbidities and survival are also unclear. Exercise restrictions apply to patients with a denervated heart, and for decades, it was believed that the transplanted heart remained denervated. This has since been largely disproved, but despite the new knowledge, the exercise restrictions have largely remained, and up-to-date guidelines on exercise prescription after HTx do not exist. High-intensity, interval based aerobic exercise has repeatedly been documented to have superior positive effects and health benefits compared to moderate exercise. This applies to both healthy subjects as well as in several patient groups, such as patients with metabolic syndrome, coronary artery disease or heart failure. However, whether the effects of this type of exercise are also applicable to heart transplant populations has not yet been fully established. The purpose of this article is to give an overview of the current knowledge about the exercise capacity and effect of exercise among heart transplant recipients and to discuss future exercise strategies.

Heart-focused anxiety in the general population

OBJECTIVE

Heart-focused anxiety is a common phenomenon that is related to psychological disorders and cardiac diseases. We investigated heart-focused anxiety in the general population and provided standard values using the Cardiac Anxiety Questionnaire (CAQ). Furthermore, we assessed the reliability of the CAQ and investigated the influence of social variables on heart-focused anxiety.

METHODS AND RESULTS

The questionnaire was applied to 2,396 individuals (age range: 18-92; mean age 49 ± 17, 50% male). Three aspects of heart-focused anxiety (fear, attention, and avoidance) were captured by the CAQ. To test the influence of age, gender, and social factors, we performed analyses of variance, correlative statistics, and regression analyses. Heart-focused anxiety showed a linear increase with age (P < 0.001). No gender differences were observed. The degree of anxiety was affected by relationship (P < 0.001), level of education (P < 0.001), employment (P < 0.001), and income (P < 0.001).

CONCLUSION

We evaluated heart-focused anxiety in the general population and validated the CAQ. Using percentiles based on a normative sample allows screening for heart-focused anxiety in patients with or without cardiac diseases and the measurement of therapy success after psychotherapeutic or pharmacological intervention.

The occurence of mood and anxiety disorders in heart transplant recipients

Fortynine heart transplant recipients were evaluated during the first weeks after orthotopic heart transplantation. Using the ICD-10 (International Classification of Diseases-10th revision) criteria, we studied the incidence of anxiety disorders as well as 17 demographic and medical factors potentially influencing the probability of their occurrence. A smaller 36-person group was evaluated using standard psychopathologic scales for anxiety and mood disorders. Cox regression analysis was used to specify which of 11 demographic and medical factors influenced the time to occurrence of the first episode of a mental disorder. Anxiety episodes occurred in 25 patients, depressive episodes in 27, (hypo)manic in 3, and 12 manifested a slightly elevated mood. The risk of occurrence of anxiety and mood disorders was highest during the first 3 weeks after OHT. "False alarms," namely, calls to the clinic not ending up in transplantation, and coexisting illnesses were related to higher incidences and earlier appearance of anxiety and mood disorders. The risk of occurrence of an anxiety syndrome was greater among older patients. Anxiety syndromes were manifested earlier in patients who underwent transplantation due to ischemic cardiomyopathy than in patients with heart failure caused by other factors. A greater number of false alarms, of long-lasting hospitalizations, and of low mean cyclosporine levels were risk factors for depressive episodes.