Early-onset depression, anxiety, and risk of subsequent coronary heart disease: 37-year follow-up of 49,321 young Swedish men

Observational protocol on neuropsychological disorders in cardiovascular disease for holistic prevention and treatment

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. In view of the close correlation between the functions of the body, which cannot be examined in a piecemeal manner but as an integrated system, a holistic approach allows for a comprehensive assessment of the patient. Our study aims to (i) examine the connection between CVD and cognitive deficits; (ii) examine the presence of anxiety and depression; (iii) evaluate the presence of dysphagia, pneumophonic coordination disorders, respiratory and sleep disorders; (iv) analyze the impact of CVD on the caregiver; and (v) evaluate the effectiveness of psychoeducational intervention. At least 218 patients will participate in the survey. At T0, they will undergo neuropsychological, psychological and associated clinical condition assessment through standardized tests. In addition, at least one psychoeducation meeting will be held. After 6 months (T1), the same tests will be repeated, and the effectiveness of psychoeducation will be evaluated. Assessment of associated disorders will provide a comprehensive view of the patient. In addition, it will be observed how psychoeducational intervention can make changes on general well-being. Comprehensive, multi-step observation allows for identification of risk factors, tailoring of treatment, and prevention of future complications.Clinical Trial Registration: registered on Clinicaltrials.gov (ID: NCT06413823).

Risk factors for cardiovascular diseases: the focus on primary prevention

Views on the etiopathogenesis of atherosclerosis are subject to evolution. In addition to the classic well-known risk factors, new ones related to mental state, social life and environment are being discovered. Both acute and chronic stress stimulate inflammatory processes. Due to the change in lifestyle and eating habits, the accumulation of risk factors in childhood is an increasing problem. Knowledge of risk factors allows for effective primary prevention of cardiovascular diseases. The effectiveness of prevention increases when the activities cover the largest possible part of the society, and access to a doctor is easy. Therefore, government programs are being implemented offering patients easier access to diagnostics of cardiovascular diseases at the level of primary health care, which enables faster identification of people at the greatest cardiovascular risk. Easier access to primary care and a good doctor-patient relationship improve patient compliance. In this situation, the importance of the family doctor as a key link in the diagnosis, prevention and treatment of cardiovascular diseases is increasing.

Hospital admissions for anxiety disorder, depression, and bipolar disorder and venous thromboembolism: A UK biobank prospective cohort study

BACKGROUND

Few studies have investigated whether and which anxiety and affective disorders are associated with the risk of venous thromboembolism. We aimed to examine whether anxiety disorder, depression, and bipolar disorder increase the risk of venous thromboembolism, independent of socioeconomic confounders and each other, in a UK general population.

METHODS

This is a prospective cohort study using UK Biobank. Participants were excluded if they were diagnosed with venous thromboembolism before the baseline assessment, if they were first diagnosed with anxiety disorder, depression, or bipolar disorder thereafter, or if they had missing sociodemographic data. Diagnosed anxiety disorder, depression, and bipolar disorder were ascertained through hospital admission data and incident venous thromboembolism, pulmonary embolism, and deep vein embolism were ascertained through both hospital admission and death certificate data. Hazard ratios were calculated, adjusted for sociodemographic confounders and comorbid anxiety and affective disorders.

RESULTS

Our main analysis included 455,705 participants, of whom 53.6 % were female, with a mean age (standard deviation) of 56.6 (8.1) years. Anxiety disorder, depression, and bipolar disorder were associated with venous thromboembolism both before and after adjusting for sociodemographic confounders. After adjustment for comorbid anxiety and affective disorders, depression (HR: 2.00; 95 % CI: 1.68-2.38) and bipolar disorder (HR: 2.08; 95 % CI: 1.28-3.37) remained associated with venous thromboembolism, but anxiety did not (HR: 1.17; 95 % CI: 0.88-1.57). Similar results were found for pulmonary embolism and deep vein embolism.

CONCLUSIONS

Depression and bipolar disorder were associated with the risk of venous thromboembolism. Further research is required to understand the mechanism underlying their increased risk.

Association of mental health in childhood, adolescence and young adulthood with cardiovascular risk factors and carotid remodeling below age 30 - results from the KiGGS cohort study

An association of mental health and in particular depression with cardiovascular disease has been shown in adults and to a lesser extent in the young. Recently improved measurement methods of carotid-intima media thickness (CIMT) and carotid stiffness (CS) allow more differentiated analyses of this link. We examined 4,361 participants of the nationwide KiGGS cohort aged 3-17 years at baseline and 14-28 years at follow-up. Using linear and logistic regressions, we analyzed cross-sectional and longitudinal associations of mental health with systolic blood pressure (SBP), body mass index (BMI) and total cholesterol (TC) as well as CIMT and CS from high-resolution carotid sonography at follow-up. Mental health in children was measured with the Strength and Difficulties Questionnaire (SDQ) and in adults with the Mental Health Inventory (MHI-5) and the Patient Health Questionnaire (PHQ-9). Childhood SDQ scores were associated longitudinally with SBP, BMI and TC (-0.03≤ ß≥ 0.02) but not with CIMT or CS one decade later. Similarly, SDQ at follow-up was associated cross-sectionally with SBP, BMI and TC, but not CIMT or CS. MHI-5 scores were not linked to any outcome. PHQ-9 scores in young adults were associated cross-sectionally with SBP and BMI (-0.26≤ ß≥ 0.01), but not with CIMT or CS. Our study shows that children, adolescents and young adults with impaired mental health also have an increased long-term cardiovascular risk through higher BMI and TC. However, in this sample with predominantly mild mental health impairments carotid remodeling was not evident.

Types of depression in patients with coronary heart disease: Results from the THORESCI study

BACKGROUND

Both coronary heart diseases (CHD) and depression are highly prevalent and bidirectionally related. The precise nature of this relationship remains unclear. Defining depressive subtypes could help unravel this relationship. Therefore, the aim of this study was to explore depressive subtypes in patients with CHD.

METHODS

1530 patients (21.3 % women, mean age: 64.7 years (SD = 10.1)) were included in latent class analysis with nine indicators derived from the PHQ-9 and BDI-II representing symptoms of depression as described in the DSM-5 criteria. The best-fitting latent class model was confirmed with double cross-validation. Classes were characterized using demographic, medical, psychiatric, and cardiovascular (risk) factors.

RESULTS

A 3-class model demonstrated the best fit to the data, resulting in a depressed (5.4 %), fatigued (13.5 %), and non-depressed class (81.1 %). Having medical comorbidities, a history of psychiatric problems, negative affectivity, and anxiety symptoms increased the odds of belonging to the depressed group (OR 3.02, 95%CI 1.19-7.68, OR 3.61, 95%CI 1.44-9.02, OR 1.16, 95%CI 1.04-1.30, and OR 1.89, 95%CI 1.66-2.15, respectively). Belonging to the fatigued group was associated with increased odds of having an elective PCI (OR 2.12, 95%CI 1.27-3.55), insufficient physical activity (OR 2.19, 95%CI 1.20-3.99), comorbid medical conditions (OR 2.15, 95%CI 1.21-3.81), a history of psychiatric problems (OR 2.25, 95%CI 1.25-4.05), and anxiety symptoms (OR 1.48, 95%CI 1.34-1.63) compared with the non-depressed group.

LIMITATIONS

Future studies should include more people with depressive symptoms.

CONCLUSIONS

Patients with CHD and medical or psychiatric risk factors should be offered support to decrease or prevent depressive or fatigue symptoms.

Anxiety and depression are associated with heightened risk of incident deep vein thrombosis: Mediation through stress-related neural mechanisms

Controversy exists as to whether anxiety and depression increase deep vein thrombosis (DVT) risk, and the mechanisms mediating potential links remain unknown. We aimed to evaluate the association between anxiety and depression and DVT risk and determine whether upregulated stress-related neural activity (SNA), which promotes chronic inflammation, contributes to this link. Our retrospective study included adults (N = 118 871) enrolled in Mass General Brigham Biobank. A subset (N = 1520) underwent clinical 18F-FDG-PET/CT imaging. SNA was measured as the ratio of amygdalar to cortical activity (AmygAC). High-sensitivity C-reactive protein (hs-CRP) and heart rate variability (HRV) were also obtained. Median age was 58 [interquartile range (IQR) 42-70] years with 57% female participants. DVT occurred in 1781 participants (1.5%) over median follow-up of 3.6 years [IQR 2.1-5.2]. Both anxiety and depression independently predicted incident DVT risk after robust adjustment (HR [95% CI]: 1.53 [1.38-1.71], p < .001; and 1.48 [1.33-1.65], p < .001, respectively). Additionally, both anxiety and depression associated with increased AmygAC (standardized beta [95% CI]: 0.16 [0.04-0.27], p = .007, and 0.17 [0.05-0.29], p = .006, respectively). Furthermore, AmygAC associated with incident DVT (HR [95% CI]: 1.30 [1.07-1.59], p = .009). Mediation analysis demonstrated that the link between anxiety/depression and DVT was mediated by: (1) higher AmygAC, (2) higher hs-CRP, and (3) lower HRV ( < .05 for each). Anxiety and depression confer an attributable risk of DVT similar to other traditional DVT risk factors. Mechanisms appear to involve increased SNA, autonomic system activity, and inflammation. Future studies are needed to determine whether treatment of anxiety and depression can reduce DVT risk.

Exploring the heart-brain and brain-heart axes: Insights from a bidirectional Mendelian randomization study on brain cortical structure and cardiovascular disease

INTRODUCTION

The bidirectional relationship between the brain cortex and cardiovascular diseases (CVDs) remains inadequately explored.

METHODS

This study used bidirectional Mendelian randomization (MR) analysis to explore the interactions between nine phenotypes associated with hypertension, heart failure, atrial fibrillation (AF), and coronary heart disease (CHD), and brain cortex measurements. These measurements included total surface area (SA), average thickness (TH), and the SA and TH of 34 regions defined by the Desikan-Killiany atlas. The nine traits were obtained from sources such as the UK Biobank and FinnGen, etc., while MRI-derived traits of cortical structure were sourced from the ENIGMA Consortium. The primary estimate was obtained using the inverse-variance weighted approach. A false discovery rate adjustment was applied to the p-values (resulting in q-values) in the analyses of regional cortical structures.

RESULTS

A total of 1,260 two-sample MR analyses were conducted. Existing CHD demonstrated an influence on the SA of the banks of the superior temporal sulcus (bankssts) (q=0.018) and the superior frontal lobe (q=0.018), while hypertension was associated with changes in the TH of the lateral occipital region (q=0.02). Regarding the effects of the brain cortex on CVD incidence, total SA was significantly associated with the risk of CHD. Additionally, 16 and 3 regions exhibited significant effects on blood pressure and AF risk, respectively (q<0.05). These regions were primarily located in the frontal, temporal, and cingulate areas, which are associated with cognitive function and mood regulation.

CONCLUSION

The detection of cortical changes through MRI could aid in screening for potential neuropsychiatric disorders in individuals with established CVD. Moreover, abnormalities in cortical structure may predict future CVD risk, offering new insights for prevention and treatment strategies.

Improving Cardiovascular Disease Prediction With Machine Learning Using Mental Health Data: A Prospective UK Biobank Study

Background

Robust and accurate prediction of cardiovascular disease (CVD) risk facilitates early intervention to benefit patients. The intricate relationship between mental health disorders and CVD is widely recognized. However, existing models often overlook psychological factors, relying on a limited set of clinical and lifestyle parameters, or being developed on restricted population subsets.

Objectives

This study aims to assess the impact of integrating psychological data into a novel machine learning (ML) approach on enhancing CVD prediction performance.

Methods

Using a comprehensive UK Biobank data set (n = 375,145), the correlation between CVD and traditional and psychological risk factors was examined. CVD included hypertensive disease, ischemic heart disease, heart failure, and arrhythmias. An ensemble ML model containing 5 constituent algorithms (decision tree, random forest, XGBoost, support vector machine, and deep neural network) was tested for its ability to predict CVD based on 2 training data sets: using traditional CVD risk factors alone, or using a combination of traditional and psychological risk factors.

Results

A total of 375,145 subjects with normal health status and with CVD were included. The ensemble ML model could predict CVD with 71.31% accuracy using traditional CVD risk factors alone. However, by adding psychological factors to the training data, accuracy increased to 85.13%. The accuracy and robustness of the ensemble ML model outperformed all 5 constituent learning algorithms.

Conclusions

Incorporating mental health assessment data within an ensemble ML model results in a significantly improved, highly accurate, CVD prediction model, outperforming traditional risk factor prediction alone.

Associations Between Cardiovascular Health (Life's Essential 8) and Mental Disorders

BACKGROUND

Mental health was closely associated with cardiovascular disease (CVD). We aimed to investigate the association between cardiovascular health (CVH), as defined by Life's Essential 8 (LE8), and the presence of depression and anxiety.

HYPOTHESIS

We hypothesized that CVH, as defined by LE8, was negatively associated with the prevalence of depression and anxiety.

METHODS

A cross-sectional study was conducted on participants (≥ 20 years old) from the National Health and Nutrition Examination Survey (NHANES). The LE8 score (ranging from 0 to 100) was composed of the health behavior score and the health factor score, which were further categorized into three levels as follows: low (0-49), moderate (50-79), and high (80-100). Weighted multivariable logistic regressions and restricted cubic splines were utilized to assess the association between LE8 and mental disorders.

RESULTS

Among the 13 028 participants included in this research, 1206 were determined to have depression symptoms and 2947 were determined to have anxiety symptoms. In the weighted and adjusted model, LE8 was negatively associated with the prevalence of depression (odds ratio [OR], 95% confidence interval [CI]: 0.61, 0.58-0.65) and anxiety (OR, 95% CI: 0.78, 0.75-0.81). Furthermore, a nonlinear dose-response relationship was observed between LE8 and anxiety.

CONCLUSIONS

CVH defined by the LE8 was independently and negatively associated with the prevalence of depression and anxiety. Interventions targeting LE8 components may improve both CVH and mental health.

Risk of Cardiovascular Disease Hospitalization After Common Psychiatric Disorders: Analyses of Disease Susceptibility and Progression Trajectory in the UK Biobank

Whether associations between psychiatric disorders and hospitalization for cardiovascular diseases (CVDs) can be modified by disease susceptibility and the temporal pattern of these associated CVDs remain unknown. In our study, we conducted a matched cohort study of the UK Biobank including 44,430 patients with common psychiatric disorders (anxiety, depression, and stress-related disorders) between 1997 and 2019, together with 222,150 sex-, Townsend deprivation index-, and birth year- individually matched unexposed individuals. The hazard ratios (HRs) for CVD hospitalization associated with a prior psychiatric disorder were derived from Cox models, adjusted for multiple confounders. We then stratified the analyses by self-reported family history of CVD and CVD polygenic risk score (PRS) calculated based on summary statistics of independent genome-wide association studies. We further conducted disease trajectory analysis and visualized the temporal pattern of CVDs after common psychiatric disorders. During a mean follow-up of 12.28 years, we observed an elevated risk of CVD hospitalization among patients with psychiatric disorders, compared with matched unexposed individuals (hazard ratios [HRs] = 1.20, 95% confidence interval [CI]: 1.18-1.23), especially during the first six months of follow-up (1.72 [1.55-1.91]). The stratification analyses by family history of CVD and by CVD PRS obtained similar estimates between subgroups with different susceptibilities to CVD. We conducted trajectory analysis to visualize the temporal pattern of CVDs after common psychiatric disorders, identifying primary hypertension, acute myocardial infarction, and stroke as three main intermediate steps leading to further increased risk of other CVDs. In conclusion, the association between common psychiatric disorders and subsequent CVD hospitalization is not modified by predisposition to CVD. Hypertension, acute myocardial infarction, and stroke are three initial CVDs linking psychiatric disorders to other CVD sequelae, highlighting a need of timely intervention on these targets to prevent further CVD sequelae among all individuals with common psychiatric disorders.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43657-023-00134-w.

Anxiety, a significant risk factor for coronary artery disease: what is the best index

BACKGROUND

Coronary artery disease (CAD) is known as the leading cause of disability and death globally. Anxiety disorders are also recognized as common types of mental disorders that substantially impact global health. Iran ranks among the countries with a high incidence of CAD and anxiety disorders. Therefore, the present study aims to determine the potential association and epidemiological aspects of anxiety and CAD within the population of Mashhad, the second most popoulos city in Iran.

METHODS

The present study is based on extracted data from the Mashhad stroke and heart atherosclerotic disorder (MASHAD) study which is a 10-year prospective cohort study intended to assess the effects of various CAD risk factors among Mashhad city residents. Anxiety scores were assessed at the baseline using Beck Anxiety Inventory and individuals were classified based on the BAI 4-factor structure model which included autonomic, cognitive, panic, and neuromotor components. Accordingly, the association between baseline anxiety scores and the BAI four-factor model with the risk of CAD events was analyzed using SPSS software version 21.

RESULTS

Based on the results, 60.4% of the sample were female, and 5.6% were classified as having severe forms of anxiety. Moreover, severe anxiety was more prevalent in females. Results showed a 1.7% risk of CAD (p-value < 0.001) over 10 years with one unit increase in anxiety score. Based on the 4-factor model structure, we found that only panic disorder could significantly increase the risk of CAD by 1.1% over the 10-year follow-up (p-value < 0.001).

CONCLUSION

Anxiety symptoms, particularly panic disorder, are independently and significantly associated with an increased overall risk of developing CAD over a 10-year period. Therefore, further studies are warranted to investigate the mechanisms through which anxiety may cause CAD, as well as possible interventions to mitigate these processes.

Exploring the Relationship of Anxiety and Depressive Symptoms and Impulsiveness with the Quality of Life of Older Patients with Cardiovascular Disease: A Cross-Sectional Study

BACKGROUND

This study aimed to evaluate the relationship of selected clinical (i.e., body mass index, BMI) and psychological factors (i.e., anxiety, depression, and impulsiveness) with the quality of life (QoL) of elderly patients with cardiovascular disease (CVD) in a single clinical center in Italy.

METHODS

A total of 238 patients of older age (≥65 years) with CVD who voluntarily attended a single clinical center for weight loss and cardiac rehabilitation were sequentially recruited and tested upon admission to the hospital based on pre-established inclusion criteria.

RESULTS

The findings indicated that anxiety and depressive symptoms were moderately associated with lower QoL. Additionally, there were noteworthy but minor negative connections between impulsivity and QoL. Furthermore, BMI was inversely associated with the perceived QoL of the participants, and when incorporated into the regression analysis, BMI alone significantly accounted for 11.8% of the variability in QoL. This percentage increased to 18.4% with the inclusion of impulsiveness in the model and further to 34.3% with the addition of anxiety and depressive symptoms. However, after introducing anxiety and depression, the association between impulsivity and QoL ceased to be statistically significant.

CONCLUSIONS

Integrating the routine assessment and treatment of psychological factors into the care of older patients with CVD is important for optimizing their overall health outcomes and improving their QoL.

Impact of Mental Health Treatment on Outcomes in Patients With Heart Failure and Ischemic Heart Disease

BACKGROUND

There is conflicting evidence as to the impact of mental health treatment on outcomes in patients with heart disease. The aim of this study was to examine whether individuals who received mental health treatment for anxiety or depression after being hospitalized for ischemic disorders or heart failure had a reduced frequency of rehospitalizations, emergency department visits, or mortality compared with those who did not receive treatment.

METHODS AND RESULTS

A population-based, retrospective, cohort design was used to examine the association between psychotherapy or antidepressant medication prescription and health service utilization and mortality in patients with coronary artery disease or heart failure and comorbid anxiety or depression. Those receiving versus not receiving mental health treatment were compared based on the frequency of rehospitalization, emergency department visits, and mortality. The study sample included 1563 patients who had a mean age of 50.1 years. Individuals who received both forms of mental health treatment for anxiety or depression were 75% less likely to be rehospitalized, 74% less likely to have an emergency department visit, and 66% less likely to die from any cause.

CONCLUSIONS

Mental health treatment for anxiety or depression has a significant impact on outcomes in patients with cardiovascular disease consisting of reduced hospitalizations, emergency department visits, and in some conditions improved survival.

Exposome in ischaemic heart disease: beyond traditional risk factors

Ischaemic heart disease represents the leading cause of morbidity and mortality, typically induced by the detrimental effects of risk factors on the cardiovascular system. Although preventive interventions tackling conventional risk factors have helped to reduce the incidence of ischaemic heart disease, it remains a major cause of death worldwide. Thus, attention is now shifting to non-traditional risk factors in the built, natural, and social environments that collectively contribute substantially to the disease burden and perpetuate residual risk. Of importance, these complex factors interact non-linearly and in unpredictable ways to often enhance the detrimental effects attributable to a single or collection of these factors. For this reason, a new paradigm called the 'exposome' has recently been introduced by epidemiologists in order to define the totality of exposure to these new risk factors. The purpose of this review is to outline how these emerging risk factors may interact and contribute to the occurrence of ischaemic heart disease, with a particular attention on the impact of long-term exposure to different environmental pollutants, socioeconomic and psychological factors, along with infectious diseases such as influenza and COVID-19. Moreover, potential mitigation strategies for both individuals and communities will be discussed.

Association of Depression and Cardiovascular Disease

BACKGROUND

Cardiovascular disease remains the leading worldwide cause of mortality. There has been increased awareness of the impact of psychological health on cardiovascular disease. In particular, major depression has been linked to increased all-cause mortality, development of cardiovascular disease, and worse outcomes in those with existing cardiovascular disease.

METHODS

We conducted a meta-analysis assessing the incidence of cardiovascular disease and cardiovascular disease outcomes among those with major depressive disorder.

RESULTS

Among 26 studies of 1,957,621 individuals, depression was associated with increased risk of incident stroke (hazard ratio [HR] 1.13; 95% confidence interval [CI], 1.00-1.28), myocardial infarction (HR 1.28; 95% CI, 1.14-1.45), congestive heart failure (HR 1.04; 95% CI, 1.00-1.09), or any cardiovascular disease (HR 1.16; 95% CI, 1.04-1.30). Depression was associated with increased risk of all-cause mortality (HR 1.43; 95% CI, 1.27-1.60), cardiovascular disease mortality (HR 1.44; 95% CI, 1.27-1.63), and congestive heart failure mortality (HR 3.20; 95% CI, 1.29-7.94).

CONCLUSION

Depression has a significant negative impact on development of cardiovascular disease and on cardiovascular disease outcomes. Further efforts to understand and mitigate these impacts are prudent.

Assessing the Feasibility, Acceptability, and Preliminary Effectiveness of a School-Aged Program that Supports Physical Activity and Wellness

The prevalence of anxiety symptoms in children and adolescents aged 4 to 18 years has nearly doubled after the first year of the pandemic. However, only one in five adolescents diagnosed with anxiety is treated. We R H.O.P. E. is a school-based mental health program that includes evidence-based principles designed to engage children and adolescents in anxiety treatment, including wellness and emotional regulation, and the emotional CPR method. We R H.O.P. E. augments traditional services provided by school administrators, school social workers, school teachers, and school nurses. The purpose of this study was to examine the feasibility, acceptability, and preliminary effectiveness of We R H.O.P. E.

Initial assessment of the feasibility and efficacy of a scalable digital CBT for generalized anxiety and associated health behaviors in a cardiovascular disease population

Generalized anxiety disorder (GAD) is a significant yet modifiable risk factor for worse cardiovascular disease (CVD) outcomes. The treatment of GAD in an accessible manner represents an unmet need in CVD, given that patients with CVD experience numerous barriers to in-person treatment engagement. This paper presents the rationale and design for an investigation of a strategy to enhance care for patients with CVD by introducing a scalable, affordable, and system-friendly digital intervention that targets a prominent modifiable risk factor (generalized anxiety and associated worry) for negative health behaviors in CVD. In the context of a randomized clinical trial design, we describe an experimental medicine approach for evaluating the degree to which a digital cognitive behavior therapy (dCBT), relative to a waitlist control group, engages anxiety and worry outcomes in a sample of 90 adults who have experienced an acute CVD event and who have comorbid GAD symptoms. We also investigate the degree to which dCBT leads to greater changes in GAD symptoms compared to the control condition and whether reductions in these symptoms are associated with corresponding reductions in cardiac anxiety and cardiac health behaviors (including smoking, physical activity, heart-healthy diet, and medication adherence). We propose that by targeting GAD symptoms in CVD in a way that does not tax ongoing medical care provision, we have the potential to improve the uptake of effective care and address both GAD and associated health behaviors.

Depression and Anxiety Are Associated With Cardiovascular Health in Young Adults

Background Cardiovascular health (CVH) declines in young adulthood, and mood disorders commonly emerge during this life stage. This study examined the association between depression, anxiety, and CVH metrics among young adults. Methods and Results We conducted a cross-sectional analysis of participants aged 18 to 34 years who completed the Emory Healthy Aging Study Health History Questionnaire (n=875). We classified participants as having poor, intermediate, or ideal levels of the 8 CVH metrics using definitions set forth by the American Heart Association with adaptions when necessary. We defined depression and anxiety as absent, mild, or moderate to severe using standard cutoffs for Patient Health Questionnaire and General Anxiety Disorder scales. We used multivariable regression to examine the association between depression and anxiety and CVH, adjusting for age, sex, race and ethnicity, income, and education. The mean participant age was 28.3 years, and the majority identified as women (724; 82.7%); 129 (14.7%) participants had moderate to severe anxiety, and 128 (14.6%) participants had moderate to severe depression. Compared with those without anxiety, participants with moderate to severe anxiety were less likely to meet ideal levels of physical activity (adjusted prevalence ratio [aPR], 0.60 [95% CI, 0.44-0.82]), smoking (aPR, 0.90 [95% CI, 0.82-0.99]), and body mass index (aPR, 0.79 [95% CI, 0.66-0.95]). Participants with moderate to severe depression were less likely than those without depression to meet ideal levels of physical activity (aPR, 0.48 [95% CI, 0.34-0.69]), body mass index (aPR, 0.75 [95% CI, 0.61-0.91]), sleep (aPR, 0.79 [95% CI, 0.66-0.94]), and blood pressure (aPR, 0.92 [95% CI, 0.86-0.99]). Conclusions Anxiety and depression are associated with less ideal CVH in young adults. Interventions targeting CVH behaviors such as physical activity, diet, and sleep may improve both mood and CVH.

Neutrophilic granulocyte percentage is associated with anxiety in Chinese hospitalized heart failure patients

BACKGROUND

In patients with heart failure, anxiety disorder is common and associated with adverse prognosis. This study intended to find more confounding factors of Chinese heart failure patients.

METHODS

We enrolled 284 hospitalized heart failure patients, whose New York Heart Association (NYHA) classed as II-IV and left ventricular ejection fraction (LVEF) ≤ 45%. All the patients were scaled in Hamilton Rating Scale for Anxiety (14-items) (HAM-A14). Ordinal logistic regression analysis was performed to examine the association of correlated factors with anxiety disorder.

RESULTS

There were 184 patients had anxiety accounting for 64.8% of all 284 hospitalized heart failure patients. The neutrophilic granulocyte percentage, urea nitrogen, total bilirubin and brain natriuretic peptide were positively associated with HAM-A14 score, meanwhile, the hemoglobin, red blood cells counts, albumin and LVEF were negatively associated with HAM-A14 score (All P < 0.05). After the adjustments of sex, hemoglobin, urea nitrogen, total bilirubin, albumin and brain natriuretic peptide, the neutrophilic granulocyte percentage was significantly associated with anxiety (OR = 43.265, P = 0.012). The neutrophilic granulocyte percentage was 0.616 ± 0.111, 0.640 ± 0.102, 0.681 ± 0.106 and 0.683 ± 0.113 in heart failure patients with no anxiety, possible anxiety, confirmed anxiety and obvious anxiety, respectively.

CONCLUSIONS

Neutrophilic granulocyte percentage as well as the traditional risk factors such as sex, urea nitrogen and brain natriuretic peptide is associated with anxiety in hospitalized heart failure patients.

Hypertension, Anxiety and Obstructive Sleep Apnea in Cardiovascular Disease and COVID-19: Mediation by Dietary Salt

This perspective paper used a grounded theory method to synthesize evidence proposing that sodium toxicity from excessive dietary salt intake is a potential common pathophysiological mechanism that mediates the association of hypertension, obstructive sleep apnea, and anxiety with cardiovascular disease and COVID-19. Increased anxiety in these conditions may be linked to a high-salt diet through stimulation of the sympathetic nervous system, which increases blood pressure while releasing catecholamines, causing a "fight or flight" response. A rostral shift of fluid overload from the lower to the upper body occurs in obstructive sleep apnea associated with COVID-19 and cardiovascular disease, and may be related to sodium and fluid retention triggered by hypertonic dehydration. Chronic activation of the renin-angiotensin-aldosterone system responds to salt-induced dehydration by increasing reabsorption of sodium and fluid, potentially exacerbating fluid overload. Anxiety may also be related to angiotensin II that stimulates the sympathetic nervous system to release catecholamines. More research is needed to investigate these proposed interrelated mechanisms mediated by dietary salt. Furthermore, dietary interventions should use a whole-food plant-based diet that eliminates foods processed with salt to test the effect of very low sodium intake levels on hypertension, anxiety, and obstructive sleep apnea in cardiovascular disease and COVID-19.

Mind-Body Connection: Cardiovascular Sequelae of Psychiatric Illness

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the world. Mental health disorders are associated with the onset and progression of cardiac disease. The adverse sequelae of this association include worsened quality of life, adverse cardiovascular outcomes, and heightened mortality. The increased prevalence of CVD is partly explained by increased rates of traditional cardiovascular risk factors including hypertension, hyperlipidemia, diabetes mellitus, obesity, and smoking, but mental illness is an independent risk factor for CVD and mortality. Given the association between mental health disorders and poor cardiovascular health, it is vital to have an early and accurate identification and treatment of these disorders. Our review article shares the current literature on the adverse cardiovascular events associated with psychiatric disorders. We present a review on depression, anxiety, bipolar disorder, schizophrenia, type A and D personality disorders, obsessive-compulsive disorder, and stress.

Depression increased risk of coronary heart disease: A meta-analysis of prospective cohort studies

Background

Depression, as an independent risk factor, can lead to a substantially increased risk of coronary heart disease (CHD). The overall body of evidence involving depression and CHD is not consistent. Therefore, we performed an update meta-analysis to evaluate the association between depression and the risk of patients with CHD.

Methods

Studies were identified through a comprehensive literature search of the PubMed, Embase, and the Cochrane Library database from its inception to 28 September 2021 for titles/abstracts with restricted to English language articles. The literature was screened according to the inclusion and exclusion criteria. Along with data extraction, we evaluated the quality of eligible studies using the Newcastle-Ottawa Scale (NOS). The primary outcome was fatal or non-fatal CHD. We calculated relative risk (RR) with 95% confidence intervals (CIs) using a random-effects models. The protocol was registered in the PROSPERO registration (registration number CRD42021271259).

Results

From 9,151 records, we included 26 prospective cohort studies published from 1998 to 2018, consisting of 402,597 patients. Either in depression-exposured group or non-depression-exposured group, the mean age of all participants ranged from 18 to 99 years. Moreover, the NOS scores of these studies are eventually indicated that the quality of these eligible studies was reliable. In general, the pooled results showed that patients with depression had a higher risk of CHD compared to patients without depression (RR = 1.21, 95% CI: 1.14–1.29). Additionally, the funnel plot appeared to be asymmetry, indicating there existing publication bias for the pooled results between depression and CHD. A sensitivity analysis was used to assess the stability of the relationship between depression and CHD that indicating the results robust (RR = 1.15, 95% CI: 1.09–1.21).

Conclusion

Depression may increase risk of CHD. Future studies on the share pathogenic mechanisms of both depression and CHD may develop novel therapies.

Depression duration and risk of incident cardiovascular disease: A population-based six-year cohort study

BACKGROUND

Depression symptoms are significantly associated with an increased risk of cardiovascular disease (CVD). However, understanding of the magnitude of the association between depression duration and risk of CVD is limited. Therefore, we aimed to assess whether a longer duration of exposure to depression is associated with a higher risk of new-onset CVD.

METHODS

We conducted a territory-wide retrospective cohort study among patients (≥ 10 years old) with depression diagnosed between January and December 2014 in Hong Kong. The observation period spanned January 1, 2014, to December 31, 2019, and all participants had no CVD at baseline. Incidence of CVD was calculated. We used Cox proportional hazard regression to adjust confounders and estimate hazard ratios of CVD risk.

RESULTS

Among 11,651 participants with depression, 1306 (11.2%) individuals developed CVD. Multi-adjusted models showed individuals with depression duration of 2-5 years (Hazard Ratios [HRs]: 1.38 [95% confidence interval (CI): 1.19-1.60]) and ≥6 years (1.45 [1.25-1.68]) had a significantly escalated risk of developing CVD, compared to those with depression within one year. Stratified analyses indicated that the association was prominent in women and those under 65 years old.

LIMITATIONS

Lack of depression severity information and the small sample size in some subgroup analyses.

CONCLUSIONS

Longer exposure to depression is associated with significant increased risk of CVD. The interplay between mental and vascular health emphasizes the need for CVD prevention in patients with long-term depression.

Anxiety and Depression Following Aortic Valve Replacement

Background The aim of this study was to identify patients vulnerable for anxiety and/or depression following aortic valve replacement (AVR) and to evaluate factors that may mitigate this risk. Methods and Results This is a retrospective cohort study conducted using a claims database; 18 990 patients (1/2013-12/2018) ≥55 years of age with 6 months of pre-AVR data were identified. Anxiety and/or depression risk was compared at 3 months, 6 months, and 1 year following transcatheter aortic valve replacement or surgical AVR (SAVR) after risk adjustment using logistic regression and Cox proportional hazards models. Separate models were estimated for patients with and without surgical complications and discharge location. Patients with SAVR experienced a higher relative risk of anxiety and/or depression at 3 months (12.4% versus 8.8%; adjusted hazard ratio [HR] 1.39 [95% CI, 1.19-1.63]) and 6 months (15.6% versus 13.0%; adjusted HR, 1.24 [95% CI, 1.08-1.42]), with this difference narrowing by 12 months (20.1% versus 19.3%; adjusted HR, 1.14 [95% CI, 1.01-1.29]) after AVR. This association was most pronounced among patients discharged to home, with patients with SAVR having a higher relative risk of anxiety and/or depression. In patients who experienced operative complications, there was no difference between SAVR and transcatheter aortic valve replacement. However, among patients without operative complications, patients with SAVR had an increased risk of postoperative anxiety and/or depression at 3 months (adjusted HR, 1.47 [95% CI, 1.23-1.75]) and 6 months (adjusted HR 1.26 [95% CI, 1.08-1.46]), but not at 12 months. Conclusions There is an associated reduction in the risk of new-onset anxiety and/or depression among patients undergoing transcatheter aortic valve replacement (versus SAVR), particularly in the first 3 and 6 months following treatment.

Association between early-onset affective disorders and hypothyroidism in a larger number of psychiatric drug-free patients

AIMS

We aimed to assess the association between early onset of affective disorders and hypothyroidism in a larger number of psychiatric drug-free patients with bipolar disorder (BD) or major depressive disorder (MDD).

METHODS

Early onset of affective disorders was defined as BD and MDD developed before the age of 22 years. The hypothyroidism hierarchy were diagnosed biochemically and included subclinical and overt hypothyroidism in this study. Demographic and clinical data including diagnosis, illness duration and thyroid function parameters (TSH, T4, FT4, T3 and FT3) at admission were collected from patients' records. Adjusted odds ratio (OR) and 95% confidence interval (CI), which were estimated by logistic regression model, were used to assess the association between early-onset affective disorder and hypothyroidism.

RESULTS

The prevalence of hypothyroidism in early-onset affective disorders was higher than that in late-onset patients (in BD, 9.4% vs. 6.2%, χ² = 6.020, P = 0.014; and in MDD 12.7% vs. 6.6%, χ² = 13.295, P < 0.001). Early-onset affective disorders were 2.097 times (95% CI: 1.409-3.123) more likely to have hypothyroidism compared with late-onset patients, after adjustment for age, gender, duration of illness and mood episode (adjusted OR: 1.965, 95% CI: 1.198-3.221 in BD, and adjusted OR: 2.831, 95% CI: 1.378-5.817 in MDD, respectively).

LIMITATION

Because of the cross-sectional design of this study, we were unable to sort out causality between early-onset affective disorders and hypothyroidism.

CONCLUSION

Early-onset affective disorder may be associated with higher prevalence of hypothyroidism.

The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis

BACKGROUND

Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses.

OBJECTIVE

This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

RESULTS

Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low-quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (P=.70) and no intervention (P=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (P=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (P=.03).

CONCLUSIONS

This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety.

Association of Anxiety and Depression in Patients Undergoing Cardiac Catheterization With Number of Major Coronary Artery Stenosis: A Cross-Sectional Study

Introduction

The relationship between the level of anxiety and depression among coronary artery disease (CAD) patients and coronary angiographic findings is ambiguously mentioned in studies. Past evidence shows that the relationship between anxiety and depression with coronary artery disease can be bidirectional. There is a paucity of literature on the association of levels of anxiety and depression with the number of coronary arteries involved in coronary artery disease.

Methods

This study was conducted in a tertiary care hospital to find the level of anxiety and depression in patients undergoing cardiac catheterization and their association with the numbers of the major coronary artery involved. Patients undergoing cardiac catheterization in the Department of Cardiovascular Science of a tertiary care hospital in India from May 2020 to December 2020 were considered for inclusion in the study. Coronary artery disease was diagnosed based on the combination of clinical, ECG, echocardiography, or biomarker parameters in various combinations. These patients were further subjected to coronary angiogram to know the extent of stenosis and the number of coronary vessels involved in the disease. The level of anxiety and depression was measured by using the Hospital Anxiety and Depression Scale (HADS) during the period of admission and at least 24 hours after diagnosis and at least 12 hours before cardiac catheterization. The data was entered into SPSS software version 22.0 (Armonk, NY: IBM Corp.) for statistical analysis. Chi-square test, Kolmogorov-Smirnov test, and Kruskal-Wallis test were used for the interpretation of data and find an association between severity of anxiety and depression with the number of major coronary vessels involved.

Results

Anxiety was seen in 83.3% of the patients with 31.5% having severe anxiety. Depression was found in 77.8% with 38.9% suffering from severe depression. The anxiety and depression scores of HADS were significantly higher in those with triple-vessel disease compared to the double-vessel or single-vessel disease.

Conclusion

Screening and management of anxiety and depression is an essential part of the care of patients with coronary artery disease. People with triple-vessel disease need the most attention and appropriate management of anxiety and depression.

Ventromedial Hypothalamus Activation Aggravates Hypertension Myocardial Remodeling Through the Sympathetic Nervous System

Background: The ventromedial hypothalamus (VMH) is an important nuclei in responding to emotional stress, and emotional stress is a risk factor for cardiovascular diseases. However, the role of the VMH in cardiovascular diseases remains unknown. This study aimed to investigate the effects and underlying mechanisms of VMH activation on hypertension related cardiac remodeling in two-kidney-one-clip (2K1C) hypertension (HTN) rats. Methods: Eighteen male Sprague-Dawley rats were injected with AAV-hSyn-hM3D(Gq) into the VMH at 0 weeks and then randomly divided into three groups: (1) sham group (sham 2K1C + saline i.p. injection); (2) HTN group (2K1C + saline i.p. injection); (3) HTN+VMH activation group (2K1C + clozapine-N-oxide i.p. injection). One week later, rats were subjected to a sham or 2K1C operation, and 2 weeks later rats were injected with clozapine-N-oxide or saline for 2 weeks. Results: In the HTN+VMH activation group, FosB expression was significantly increased in VMH sections compared with those of the other two groups. Compared to the HTN group, the HTN+VMH activation group showed significant: (1) increases in systolic blood pressure (SBP); (2) exacerbation of cardiac remodeling; and (3) increases in serum norepinephrine levels and sympathetic indices of heart rate variability. Additionally, myocardial RNA-sequencing analysis showed that VMH activation might regulate the HIF-1 and PPAR signal pathway and fatty acid metabolism. qPCR results confirmed that the relative mRNA expression of HIF-1α was increased and the PPARα and CPT-1 mRNA expression were decreased in the HTN+VMH activation group compared to the HTN group. Conclusions: VMH activation could increase SBP and aggravate cardiac remodeling possibly by sympathetic nerve activation and the HIF-1α/PPARα/CPT-1 signaling pathway might be the underlying mechanism.

Effect of Exercise, Escitalopram, or Placebo on Anxiety in Patients With Coronary Heart Disease: The Understanding the Benefits of Exercise and Escitalopram in Anxious Patients With Coronary Heart Disease (UNWIND) Randomized Clinical Trial

IMPORTANCE

Anxiety is common among patients with coronary heart disease (CHD) and is associated with worse health outcomes; however, effective treatment for anxiety in patients with CHD is uncertain.

OBJECTIVE

To determine whether exercise and escitalopram are better than placebo in reducing symptoms of anxiety as measured by the Hospital Anxiety and Depression-Anxiety Subscale (HADS-A) and in improving CHD risk biomarkers.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted between January 2016 and May 2020 in a tertiary care teaching hospital in the US and included 128 outpatients with stable CHD and a diagnosed anxiety disorder or a HADS-A score of 8 or higher who were older than 40 years, sedentary, and not currently receiving mental health treatment.

INTERVENTIONS

Twelve weeks of aerobic exercise 3 times per week at an intensity of 70% to 85% heart rate reserve, escitalopram (up to 20 mg per day), or placebo pill equivalent.

MAIN OUTCOMES AND MEASURES

The primary outcome was HADS-A score. CHD biomarkers included heart rate variability, baroreflex sensitivity, and flow-mediated dilation, along with 24-hour urinary catecholamines.

RESULTS

The study included 128 participants. The mean (SD) age was 64.6 (9.6) years, and 37 participants (29%) were women. Participants randomized to the exercise group and escitalopram group reported greater reductions in HADS-A (exercise, -4.0; 95% CI, -4.7 to -3.2; escitalopram, -5.7; 95% CI, -6.4 to -5.0) compared with those randomized to placebo (-3.5; 95% CI, -4.5 to -2.4; P = .03); participants randomized to escitalopram reported less anxiety compared with those randomized to exercise (-1.67; 95% CI, -2.68 to -0.66; P = .002). Significant postintervention group differences in 24-hour urinary catecholamines were found (exercise z score = 0.05; 95% CI, -0.2 to 0.3; escitalopram z score = -0.24; 95% CI, -0.4 to 0; placebo z score = 0.36; 95% CI, 0 to 0.7), with greater reductions in the exercise group and escitalopram group compared with the placebo group (F1,127 = 4.93; P = .01) and greater reductions in the escitalopram group compared with the exercise group (F1,127 = 4.37; P = .04). All groups achieved comparable but small changes in CHD biomarkers, with no differences between treatment groups.

CONCLUSIONS AND RELEVANCE

Treatment of anxiety with escitalopram was safe and effective for reducing anxiety in patients with CHD. However, the beneficial effects of exercise on anxiety symptoms were less consistent. Exercise and escitalopram did not improve CHD biomarkers of risk, which should prompt further investigation of these interventions on clinical outcomes in patients with anxiety and CHD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02516332.

The Mental and Physical Health Profiles of Older Adults Who Endorse Elevated Autistic Traits

OBJECTIVES

The mental and physical health profile of autistic people has been studied in adolescence and adulthood, with elevated rates of most conditions being reported. However, this has been little studied taking a dimensional approach to autistic traits and in older age.

METHODS

A total of 20,220 adults aged 50-81 years from the PROTECT study reported whether they experienced persistent sociocommunicative traits characteristic of autism. Approximately 1%, 276 individuals, were identified as endorsing elevated autistic traits in childhood and currently, henceforth the "Autism Spectrum Trait" (AST) group. An age- and gender-matched comparison group was formed of 10,495 individuals who did not endorse any autistic behavioral traits, henceforth the "Control Older Adults" (COA) group. Differences between AST and COA groups were explored in self-reported psychiatric diagnoses, self-reported symptoms of current depression and anxiety, and self-reported physical health diagnoses. Associations were also examined between autistic traits and health across the whole sample.

RESULTS

The AST group reported significantly elevated rates of psychiatric diagnoses compared to the COA group. Additionally, the AST group showed significantly higher self-reported symptoms of current depression and anxiety than the COA group. However, few differences were observed in individual physical health conditions, and no differences in total co-occurring physical diagnoses between groups. Similar associations between autistic traits and health were also found taking a dimensional approach across the whole sample.

DISCUSSION

These findings suggest that older adults with elevated autistic traits may be at greater risk of poorer mental, but not physical, health in later life. Future studies should incorporate polygenic scores to elucidate the possible genetic links between the propensity to autism/high autistic traits and to psychiatric conditions, and to explore whether those with elevated autistic traits experience particular barriers to mental health care.

Early age of onset of mood, anxiety and alcohol use disorders is associated with sociodemographic characteristics and health outcomes in adults: results from a cross-sectional national survey

PURPOSE

This cross-sectional study investigated distribution, sociodemographic correlates, and health outcomes in early versus late age of onset (AOO) of mood, anxiety, and alcohol use disorders in Singapore.

METHODS

The Composite International Diagnostic Interview established lifetime diagnoses of major depressive, bipolar, generalized anxiety, obsessive compulsive and alcohol use disorders in a representative sample of residents aged 18 years and over (n = 6126). The AOO of the individual and any mental disorders were classified into early and late onset using median values as cut-offs. Data included socio-demographic and health background, health utility score, and productivity losses. Multivariable logistic regression analysis was conducted to assess sociodemographic correlates of early versus late AOO of any mental disorder while linear regression analysis investigated the associations between AOO of individual disorders with health utility score and productivity loss.

RESULTS

Respondents' mean (SD) age was 45.6 (16.5) years, comprising 50.5% women and majority of Chinese ethnicity (75.8%). The median AOO for any of the five studied disorders was 21 years (IQR: 15-29). Lowest AOO was observed for obsessive compulsive disorder (Median: 14, IQR: 11-26). Those aged 35 years and over (versus 18-34) were less likely to have earlier AOO [35-49 years (OR: 0.287; 95% CI: 0.154-0.534); 50-64 years (OR:0.156; 95% CI: 0.068-0.361) and 65 and over (OR:0.112; 95% CI:0.027-0.461)], while Malay ethnicity (versus Chinese) (OR: 2.319; 95% CI: 1.384-3.885) and being never married (versus married) (OR: 2.731; 95% CI: 1.493-4.993) were more likely to have early AOO for any mental disorder. Sample with early (versus late) AOO had a lower health utility score (β =  - 0.06,95% CI: - 0.08 to - 0.03) and higher number of days cut down on the type of work (β = 1.61,95% CI: 0.12-3.10) in those with any mental disorders.

CONCLUSION

This study showed that half of the adults with mood, anxiety or alcohol use disorders in Singapore experienced their illness onset by 21 years of age. Early AOO is associated with sociodemographic background and poor health outcomes. Prevention, early detection, and interventions to improve health outcomes in mental disorders should consider the sociodemographic profile and age at first onset of symptoms in the population.

Efficacy of CPET Combined with Systematic Education of Cardiac Rehabilitation After PCI: A Real-World Evaluation in ACS Patients

Introduction

There are scarce real-world data on the long-term efficacy and safety of cardiopulmonary exercise testing (CPET) combined with the systematic education of cardiac rehabilitation (CR) approach for patients post-coronary stenting, which is, therefore, the subject of this study.

Methods

Data collected between 1 April 2015 and 20 May 2017 from 11,345 patients in the rehabilitation center database at our hospital were retrospectively analyzed. Five hundred thirty-six patients with incomplete information, or unable to cooperate with telephone follow-up, were excluded; 4001 patients received the combined CR approach; and 6808 patients received only routine post-procedure education (controls). Of these, 2805 CR participants (CR group) were matched 1:1 to controls (control group) using propensity scores. The main outcome was quality of life in Seattle Angina Questionnaire (SAQ) scores. SAQ was measured in hospital and at follow-up; meanwhile, volume/type of habitual exercise, major adverse cardiovascular event (MACE), and its components of target vessel revascularization, myocardial infarction, and cardiac death were recorded and analyzed.

Results

At median 583 (range 184–963) day follow-up, compared with controls, the CR group showed fewer patients not engaging in physical exercise (22 vs. 956, p < 0.05); more cumulative exercise time (h/week) (8.22 ± 6.17 h vs. 3.00 ± 1.65 h, p < 0.05); higher SAQ scores (physical limitation, 69.59 ± 10.96 vs. 57.49 ± 7.19; anginal stability, 80.50 ± 18.21 vs. 58.82 ± 11.95; anginal frequency, 78.58 ± 11.07 vs. 67.14 ± 22.41; treatment satisfaction, 82.33 ± 13.21 vs. 56.84 ± 21.61; quality of life, 68.69 ± 18.33 vs. 60.26 ± 17.13, all p < 0.01), but a similar MACE rate (log-rank p = 0.621).

Conclusion

Compared with only routine post-procedure education, CR combining at least one-time CPET with a systematic cardiac education program before discharge improved engagement in physical activity and quality of life for patients after percutaneous coronary intervention (PCI) without increasing clinical adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01871-y.

The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.29137]

BACKGROUND

Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses.

OBJECTIVE

This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

RESULTS

Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low–quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (<i>P</i>=.70) and no intervention (<i>P</i>=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (<i>P</i>=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (<i>P</i>=.03).

CONCLUSIONS

This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety.

Challenges during Electroconvulsive Therapy—A Review

Electroconvulsive therapy (ECT) is one of the most successful treatment techniques employed in psychiatric practice. ECT is usually administered as a last resort to a patient who fails to respond to medical management or on an urgent basis as a life-saving procedure when immediate response is desired. It is performed under general anesthesia and is often associated with autonomic changes. All attempts should be made to minimize the resulting hemodynamic disturbances in all the patients using various pharmacological methods. Anesthesiologists providing anesthesia for ECT frequently encounter patients with diverse risk factors. Concurrent cardiovascular, neurological, respiratory, and endocrine disorders may require modification of anesthetic technique. It is ideal to optimize patients before ECT. In this review, the authors discuss the optimization, management, and modification of anesthesia care for patients with various cardiac, neurological, respiratory, and endocrine disorders presenting for ECT to improve the safety of the procedure. It is not infrequent that an anesthesiologist also plays an important role in inducing a seizure. Proconvulsants such as caffeine, adjuvants like opioids, hyperventilation, and appropriate choice of anesthetic agent for induction such as etomidate or ketamine can help. The use of BIS monitoring to guide the timing of electric stimulation is also elaborated in this review.

Subclinical depression and anxiety as an additional risk factor for cardiovascular events in low- and moderate-risk patients: data from 10-year follow-up

Aim. To assess the contribution of anxiety (A) and depression (D) to the increased risk of cardiovascular events (CVEs) in patients with Systematic Coronary Risk Evaluation (SCORE) <5% according to 10-year follow-up.

Material and methods. The work included 190 patients with SCORErisk <5%, examined in 2009-2010. In addition to the standard examination, a questionnaire was carried out using Hospital Anxiety and Depression Scale (HADS). In 2019, we contacted participants by telephone to identify CVEs over the past time: death from cardiovascular diseases (CVDs), acute myocardial infarction (MI), unstable angina, stroke, revascularization. The response was 86,3%.

Results. CVEs occurred in 17 (10,2%) patients and included following outcomes: 3 deaths from CVDs, 6 acute MIs, 4 cases of unstable angina, 12 revascularizations. Patients with and without CVEs differed only in the depression level — 7 (5; 7) vs 5.0 (4; 5) points (p=0,0001). HADS-D score >6 increased the probability of CVEs — odds ratio (OR) 2,9 (1,1-7,7). In individuals with HADS-D score >6 and/or HADS-A score >7, the probability of CVEs increased — OR 4,9 (1,4-17,9). A combination of impaired two or more parameters of the lipid profile, systolic blood pressure >130 mm Hg and HADS-D score >6 and/or HADS-A score >7 increased the risk of CVE — OR 7,3 (2,48-21,36).

Conclusion. Depression, including subclinical depression, is associated with an increased risk of CVEs in patients with a SCORE risk <5%.

The emotional heart: prospective associations of anger, depression, and anxiety as risk factors for myocardial infarction in a 22-year follow-up of a working cohort of middle-aged men

Aim

The study aim was to further clarify the relationship between psychological factors and myocardial infarction (MI) by simultaneously examining anger, depression, and anxiety as risk factors for incident MI in a healthy working sample.

Subject and method

Baseline measurements of psychological variables were assessed through a self-reported questionnaire in a healthy cohort of 968 middle-aged men working at the Volvo Corporation. Single-item questions assessed depression and anxiety. Anger was assessed by the Trait Anger subscale of the Spielberger State-Trait Anger Expression Inventory. The endpoint was incident MI verified by national registers or medical records with follow up after 22 years. The main outcome was computed through logistic regression, reported as odds ratios. Additional correlation analyses were performed between psychological variables and coronary risk factors.

Results

None of the psychological variables was significantly associated with the outcome; thus, the results failed to show an association between anger, depression, or anxiety and incident MI in this sample. There were some significant, but weak, correlations between psychological factors and negative health behaviors. Other components of traditional risk scoring instruments did not correlate with the psychological factors.

Conclusion

A cohort restricted to middle-age healthy men limits applicability. However, our failure to replicate earlier results of population samples suggests a need for further research on associations between psychological factors and MI in healthy samples.

The association between accelerated vascular aging and cyclothymic affective temperament in women

OBJECTIVE

Affective temperaments (depressive, anxious, irritable, hyperthymic, cyclothymic) are regarded as the biologically stable core of personality. Accumulating data suggest their relationship with cardiovascular diseases. However, there are currently limited data on the association of affective temperaments and accelerated vascular aging. The aim of our study was to evaluate the relationship between affective temperaments and vascular age, as assessed by coronary artery calcium scoring (CACS).

METHODS

In our cross-sectional study, 209 consecutive patients referred to coronary computed tomography angiography (CCTA) due to suspected coronary artery disease (CAD) were included. All patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) and the Beck Depression Inventory (BDI). Vascular age was estimated using CACS and its difference from chronological age for each patient was calculated. Linear regression analysis was used to identify predictors of accelerated vascular aging in the entire cohort and in male and female sub-populations.

RESULTS

Besides traditional risk factors, cyclothymic temperament score proved to be an independent predictor of accelerated vascular aging in women (β = 0.89 [95%CI: 0.04-1.75]), while this association was absent in men.

CONCLUSIONS

Our results suggest that cyclothymic affective temperament is associated with accelerated vascular aging in women. Assessment of affective temperaments may potentiate more precise cardiovascular risk stratification of patients.

Clinical outcomes and survival analysis in patients with psycho-cardiological disease: a retrospective analysis of 132 cases

Objectives

The deleterious effects of psychological problems on coronary heart disease (CHD) are not satisfactorily explained. We explored influential factors associated with mortality in psycho-cardiological disease in a Chinese sample.

Methods

Of 7460 cardiac patients, we selected 132 patients with CHD and mental illness. Follow-up was conducted via telephone. We analyzed clinical characteristics, clinical outcomes, and survival.

Results

The clinical detection rate of psycho-cardiological disease in the overall patient population was 1.8%. Of these, 113 patients completed follow-up; 18 died owing to cardiovascular diseases during follow-up. Kaplan–Meier analysis showed dysphagia, limb function, self-care ability, percutaneous coronary intervention, low-density lipoprotein, total cholesterol, pro-brain natriuretic peptide and high-sensitivity (hs) troponin T had significant associations with cumulative survival. Cox regression analysis showed total cholesterol (hazard ratio [HR]: 2.765, 95% confidence interval [CI]: 1.001–7.641), hs troponin T (HR: 4.668, 95% CI: 1.293–16.854), and percutaneous coronary intervention (HR: 3.619, 95% CI: 1.383–9.474) were independently associated with cumulative survival.

Conclusions

The clinical detection rate of psycho-cardiological disease was far lower than expected. Normal total cholesterol and hs troponin T were associated with reduced cardiovascular disease mortality over 2 years. Percutaneous coronary intervention is a prognostic risk factor in patients with psycho-cardiological disease.

What about heart and mind in the COVID-19 era?

From the time of Hippocratic medicine, heart-brain interactions have been recognized and contributed to both mental and physical health. Heart-brain interactions are complex and multifaceted and appear to be bidirectional. Exposure to chronic and daily stressors such as quarantine, or severe psychological trauma like a significant person in danger of life can affect the cardiovascular system and the emotional experience of the individual, leading to an increased risk of developing a cardiovascular disease or mental illness. Subjects with comorbidities between mental disorders and heart diseases are obviously more susceptible to be influenced by emotional burden due to the spread of COVID-19, with emotional responses characterized by fear, panic, anger, frustration. Psychological services and crisis interventions are needed at an early stage to reduce anxiety, depression and post-traumatic stress disorder in such a stressful period, with a special attention to special groups of patients, such as women, children, or the elderly.

Association Between Serum Lipid Levels, Resilience, and Self-Esteem in Japanese Adolescents: Results From A-CHILD Study

Previous studies have found that serum lipid levels independently associate with mental health problems in adulthood. However, little is known about the association between serum lipid levels and positive aspects of mental health such as resilience and self-esteem, which develop in adolescence. The aim of this study is to examine the association between serum lipid levels and resilience and self-esteem in Japanese adolescents. Data were pooled data from the Adachi Child Health Impact of Living Difficulty (A-CHILD) study in 2016 and 2018, a school-based, cross-sectional study in Adachi City, Tokyo, Japan (N = 1,056, aged 13–14 years). Resilience of the child was assessed by caregivers, and self-esteem was self-identified via questionnaires. Serum lipid levels [total cholesterol, low-density lipoproteins (LDL), and high-density lipoproteins (HDL)] were assessed in school health checkup, in addition to height and weight measurements. Multiple linear regression was applied to investigate the association between standardized serum lipid levels and resilience and self-esteem. LDL showed inverse association with resilience [β = −1.26, 95% confidence interval (CI) = −2.39 to −0.14] after adjusting for child’s BMI, month of birth, sex, absence of parent, household income, caregiver’s mental health, and lifestyle (e.g., habits of eating, physical activity, and sleep). We also found an inverse association of total cholesterol and higher LDL cholesterol with self-esteem (β = −0.58, 95% CI = −0.99 to −0.18; β = −0.42, 95% CI = −0.83 to −0.01, respectively). HDL cholesterol was not associated with resilience and self-esteem. Among Japanese adolescent, total and LDL cholesterol may be biomarkers of resilience and self-esteem.

Factors Affecting Health-Promoting Behaviors in Patients with Cardiovascular Disease

Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.

Anxiety and psychological management of heart disease and heart surgery

Anxiety is associated with many forms and facets of heart disease, and, by extension, neurologic manifestations of heart disease. Despite its seeming self-evidence, anxiety is challenging to consistently define, measure, and operationalize in the context of medical research. Various diagnostic nosologies have been defined and refined over time, but anxiety is also a universal human experience that may be "normal" in many circumstances, particularly in the face of major medical issues. For these and other reasons, the research on anxiety and heart disease is mixed, incomplete, and often characterized by challenging questions of causality. Nonetheless, a broad body of literature has established clear connections between anxiety and vascular risk factors, cardiac disease, and cardiac surgery. These relationships are often intuitive, with research suggesting, for example, that chronic activation of the sympathetic nervous system is associated with increased risk of heart disease. However, they are sometimes complexly reciprocal or even surprising (e.g., with high-anxiety individuals found to have better outcomes in some cardiac conditions by virtue of seeking evaluation and treatment earlier). This chapter reviews the construct of anxiety and its complexities, its associations with heart disease, and the established treatments for anxiety, concluding with questions about anxiety, heart disease, and their optimal management that still need to be answered.

Exercise Intervention in Treatment of Neuropsychological Diseases: A Review

Faced with a constant inundation of information and increasing pressures brought by the continuous development of modern civilization, people are increasingly faced with mental health challenges that are only now being actively researched. Mental illness is caused by brain dysfunction due to internal and external pathogenic factors that destroy the integrity of the human brain and alter its function. Regular participation in physical exercise can stimulate the cerebral cortex and simultaneously increase the supply of oxygen and nutrients, helping to preserve or restore normal functioning of the nervous system. In conjunction with other systems of the body, the nervous system constitutes the neuro-humoral regulation system responsible for maintaining the stable state of the human body. This paper is a systematic review of studies investigating the effects of exercise intervention on several common neuropsychological diseases, including depression, anxiety disorder, autism, and attention-deficit/hyperactivity disorder. Furthermore, we discuss possible physiological mechanisms underlying exercise-induced benefits and study limitations that must be addressed by future research. In many cases, drug therapy is ineffective and brings unwanted side effects. Based on the literature, we conclude that exercise intervention plays a positive role and that certain standards must be established in the field to make physical activity consistently effective.

The positive and negative cardiovascular effects of cannabis

INTRODUCTION

The use of cannabis and its derivatives have increased steadily over the past few decades, prompting patients and clinicians to increasingly inquire about its health effects and safety profile. However, despite promising evidence suggesting therapeutic utilization, cannabis remains a controlled substance in most countries and is largely considered to have no medical or recreational benefit; thus, a lack of observational studies and randomized control trials exist to outline positive and negative health implications. Ultimately, this leaves patients, health-care professionals, and policymakers without necessary evidence required to make informed decisions on cannabis use.

AREAS COVERED

This review outlines cannabis in a clinical setting and delves into specific effects of cannabinoids on cardiovascular health and disease. It discusses positive and negative health implications associated with cannabis, mechanisms in cardiovascular disease, and reveals methods guiding cannabis use in the clinical setting.

EXPERT OPINION

Advances in research are necessary to guide decisions regarding cannabinoid use. Countries that have federally legalized cannabis have a unique opportunity to study cardiovascular implications in an unbiased and comprehensive manner. Ultimately, as cannabis use will inevitably increase, researchers, clinicians, and policymakers must work together to ensure cannabis is utilized in a way that is therapeutically beneficial.

Sex- and Gender-Stratified Risks of Psychological Factors for Incident Ischemic Heart Disease: Systematic Review and Meta-Analysis

Background

Psychological factors are associated with an increased risk of developing ischemic heart disease (IHD). Women more often report psychological factors, and sex and gender differences are present in IHD. In this meta‐analysis we examine the risks of psychological factors for IHD incidence in women and men. We hypothesize that a broad range of psychological factors are related to a higher risk for incident IHD, with a higher risk for women.

Methods and Results

PubMed, EMBASE, and PsycINFO were searched for studies assessing the risk between psychological factors and incident IHD. Psychological factors included depression, anxiety or panic disorder, social support, hostility, anger, personality (type D), type A behavior pattern, posttraumatic stress disorder, and psychological distress. In the primary analyses, 62 studies (77 separate reports) that included 2 145 679 women and 3 119 879 men and reported confounder‐adjusted hazard ratios or relative risks were included. Pooled effect confounder‐adjusted estimates from random‐effects models showed that psychological factors (all combined) were associated with incident IHD in women (hazard ratio: 1.22; 95% CI, 1.14–1.30) and men (hazard ratio: 1.25; 95% CI, 1.19–1.31). No sex and gender differences were found for these pooled effect estimates (P=0.547).

Conclusions

Psychological factors are associated with incident IHD in both women and men, but no significant differences were observed between women and men. IHD is predominantly being studied as obstructive coronary artery disease, which is more prevalent in men. Data are needed on psychological predictors and other manifestations of IHD such as coronary microvascular disease, which is more common in women.

Higher Anxiety Is Associated with Lower Cardiovascular Autonomic Function in Female Twins

Anxiety symptoms co-occur with cardiovascular health problems, with increasing evidence suggesting the role of autonomic dysfunction. Yet, there is limited behavior genetic research on underlying mechanisms. In this twin study, we investigated the phenotypic, genetic and environmental associations between a latent anxiety factor and three cardiovascular autonomic function factors: interbeat interval (IBI, time between heart beats), heart rate variability (HRV, overall fluctuation of heart-beat intervals) and baroreflex sensitivity (BRS, efficiency in regulating blood pressure [BP]). Multivariate twin models were fit using data of female twins (N = 250) of the Twin Interdisciplinary Neuroticism Study (TWINS). A significant negative association was identified between latent anxiety and BRS factors (r = -.24, 95% CI [-.40, -.07]). Findings suggest that this relationship was mostly explained by correlated shared environmental influences, and there was no evidence for pleiotropic genetic or unique environmental effects. We also identified negative relationships between anxiety symptoms and HRV (r = -.17, 95% CI [-.34, .00]) and IBI factors (r = -.13, 95% CI [-.29, .04]), though these associations did not reach statistical significance. Findings implicate that higher anxiety scores are associated with decreased efficiency in short-term BP regulation, providing support for autonomic dysfunction with anxiety symptomatology. The baroreflex system may be a key mechanism underlying the anxiety-cardiovascular health relationship.

Cardiac autonomic tone, plasma BDNF levels and paroxetine response in newly diagnosed patients of generalised anxiety disorder

Objective: The study examined the effect on cardiac autonomic tone via heart rate variability (HRV), brain derived neurotrophic factor (BDNF) in newly diagnosed generalised anxiety disorder (GAD) cases with paroxetine-controlled release (PX) CR intervention.Methods: Fifty GAD cases using DSM-5 criteria, matched with healthy controls (HC) were assessed with clinical measures (Hamilton Anxiety Scale (HAM-A), Clinical Global Impression- Severity Scale (CGI-Severity), General Health Questionnaire -12 (GHQ-12), HRV, plasma BDNF levels initially and 6 weeks postintervention with paroxetine CR.Results: HRV parameters were significantly lower in GAD vs HC at baseline for standard deviation of normal to normal intervals (SDNN) and proportion of differences in consecutive NN intervals that are longer than 50 ms (pNN50). Significantly higher plasma BDNF levels were noted between HC versus GAD at baseline. Postintervention HAM-A, CGI scores, GHQ-12 item scores showed significant reduction. Significant differences also noted in square root of mean squared difference of successive NN intervals (RMSSD), (SDNN), pNN50 and in plasma BDNF levels after intervention within GAD group. Significant negative correlation observed between HAM-A scores and SDNN parameter after taking PX CR in GAD.Conclusion: GAD showed cardiac autonomic dysfunction, lowered plasma BDNF levels and their improvement with paroxetine CR.Key messageGAD is associated with significantly lower HRV, suggestive of cardiac autonomic dysfunction and lowered plasma BDNF levels, an indicator of stress.Therapeutic intervention with Paroxetine in GAD patients showed clinically significant improvement reflecting restoration of the cardiac autonomic tone and BDNF levels, thus implying their role as potential biomarkers.