Behavioral cardiology: current advances and future directions

Stress-Induced Hypercoagulability: Insights from Epidemiological and Mechanistic Studies, and Clinical Integration

By integrating findings from comprehensive reviews, meta-analyses, and cutting-edge genetic studies, this article illuminates the significance of stress-induced hypercoagulability in clinical medicine. In particular, the findings from numerous prospective cohort studies indicate that stress and hemostatic factors of a hypercoagulable state are associated with increased incident risk and poor prognosis for atherosclerotic cardiovascular disease and venous thromboembolism. Mendelian randomization studies suggest that these associations are partially causal. The review synthesizes extensive research on the link between acute and chronic stress and hypercoagulability, outlining a potential pathway from stress to thrombosis risk. Consistent with the allostatic load concept, acute stress-induced hypercoagulability, initially adaptive, can turn maladaptive under chronic stress or excessive acute stress, leading to arterial or venous thrombotic events. Individuals with predisposing factors, including atherosclerosis, thrombophilia, or immobilization, may exhibit an increased risk of thrombotic disease during stress. Contextual sociodemographic characteristics, the stress experience, and coping resources additionally modulate the extent of stress-induced hypercoagulability. Research into the neuroendocrine, cellular, and molecular bases reveals how stress influences platelet activation coagulation and fibrinolysis. The activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, along with vagal withdrawal, and the effects of catecholamines, cortisol, and vasopressin, are the central mechanisms involved. Hemoconcentration, inflammation, endothelial dysfunction, and thrombopoiesis additionally contribute to stress-induced hypercoagulability. Further research is needed to prove a causal link between chronic stress and hypercoagulability. This includes exploring its implications for the prevention and management of thrombotic diseases in stressed individuals, with a focus on developing effective psychosocial and pharmacological interventions.

Is self-perception of cardiac symptoms related to the psychological profile of patients? A cross-sectional study of individuals undergoing 24-hour Holter monitoring

BACKGROUND

Depression, anxiety, distress and Type D personality traits have been implicated in the pathogenesis of cardiovascular diseases. Mental health status is associated with arrhythmic events. Esler and Lampert reported that anxiety and distress contribute to the occurrence of atrial and ventricular arrhythmias. ■ Self-reported cardiac symptoms not associated with arrhythmias. ■ High prevalence of anxiety and depression symptoms. ■ Anxiety was correlated with self-reported cardiac symptoms.

OBJECTIVE

This study aimed to examine the presence of psychological characteristics and their association with self-reported cardiac symptoms in individuals undergoing 24-hour Holter monitoring.

METHODS

This observational cross-sectional study included 304 individuals who consecutively underwent 24-hour Holter monitoring. Clinical, demographic, and electrocardiographic data were collected. Psycho-behavioral characteristics were assessed using the Hospital Anxiety and Depression Scale and the Type D Scale. Logistic regression models were employed to examine associations between cardiac symptoms and anxiety, depression, distress, and Type D personality traits. Statistical significance was set at p<0.05.

RESULTS

Anxiety, depression, distress, and type D personality traits were observed in 42.7%, 15.1%, 26.3%, and 19% of the participants, respectively. Logistic regression analysis revealed a significant association between the perception of cardiac symptoms and both mild anxiety (odds ratio (OR) = 2.305, 95%CI= 1.098-4.841, p=0.027) and severe anxiety (OR = 9.245, 95%CI= 1.582-54.013, p=0.014) scores. No significant association was found between depression, distress, or Type D personality traits and an increased perception of cardiac symptoms.

CONCLUSION

A high prevalence of anxiety was observed among individuals undergoing 24-hour Holter recording. Anxiety was significantly associated with self-reported cardiac symptoms, though not with the presence of arrhythmias. The findings could have practical implications for clinical practice. The study suggests that patients reporting anxious palpitations should receive a more thorough cardiological assessment, with 24-hour Holter monitoring serving as an effective tool for this evaluation.

Brief Mindfulness-Based Cognitive Therapy in Women With Myocardial Infarction: Results of a Multicenter Randomized Controlled Trial

Background

Elevated perceived stress is associated with adverse outcomes following myocardial infarction (MI) and may account for poorer recovery among women vs men.

Objectives

This randomized controlled trial tested effects of a mindfulness-based intervention on stress levels among women with MI.

Methods

Women with elevated stress (Perceived Stress Scale [PSS-4]≥6) at least 2 months after MI were enrolled from 12 hospitals in the United States and Canada and via community advertising. Participants were randomized to a remotely delivered mindfulness intervention (MBCT-Brief) or heart disease education, both 8 weeks long. Follow-up was 6 months. Changes in stress (PSS-10; primary outcome) and secondary outcomes (depressive symptoms, anxiety, quality of life, disease-specific health status, actigraphy-assessed sleep) were compared between groups.

Results

The sample included 130 women with MI (mean age 59.8 ± 12.8 years, 34% racial/ethnic minorities). In intention-to-treat analysis, PSS-10 scores declined in the MBCT-Brief arm (-0.52 [95% CI: -0.77 to -0.28]) but not the heart disease education arm (-0.19 [95% CI: -0.45 to 0.06]; group×time interaction P = 0.070). The effect was stronger in per-protocol analysis of participants who completed ≥4 intervention sessions (P = 0.049). There were no significant differences in secondary outcomes in intention-to-treat or per-protocol analyses. Within the MBCT-Brief arm, more frequent mindfulness practice was associated with greater reductions in stress (P = 0.007), depressive symptoms (P = 0.017), and anxiety (P = 0.036).

Conclusions

MBCT-Brief was associated with greater 6-month reductions in stress than an active control among adherent participants. More frequent mindfulness practice was associated with greater improvements in psychological outcomes. Strategies to engage women with MI in mindfulness training and support regular home practice may enhance these effects.

Alexithymia and estimated 10-year cardiovascular disease risk in healthy adults: a community-based cross-sectional study

Background

This cohort study aimed to explore whether and to what extent alexithymia would be associated with cardiovascular disease (CVD) risk over an estimated 10-year period, over and above established clinical cofactors (i.e., depressive symptoms, quality of life, sociodemographic, anthropometric, lifestyle, and biological data), in a low-risk population of blood donors.

Methods

A sample of 1,021 adult Italian blood donors (age 46.9 ± 8.39; 61.2% men) was consecutively recruited. The 10-year-CVD risk score was estimated using the CUORE risk score (CRS). Sociodemographic, lifestyle, anthropometric, biological, and psychological (i.e., quality of life, depressive symptoms, and alexithymia) CVD risk data were assessed using validated self-report measures or clinical records.

Results

As expected, most participants (78.5%) had a low CVD risk (CRS < 3%) and an overall low-risk profile for all the parameters. Compared with subjects at low risk of CVD (n = 911, 78.5%), those with high risk (i.e., rated ≥3 on CUORE risk assessment; n = 250, 21.5%) reported higher levels of alexithymia (p < 0.001). Subjects with higher alexithymia (n = 236, 23.1%) reported higher levels of psychosocial impairment, depressive symptoms, and biological risk variables for CVD. Alexithymia was significantly associated with 10-year CVD risk (OR = 1.02, 95% CI = 1.01-1.04, p = 0.009), even after adjusting for key sociodemographic and clinical risk variables.

Conclusion

Although limited by the cross-sectional design, this study is the first to show that alexithymia leads to a higher risk for 10-year CVD estimate in healthy subjects with low-risk profile, regardless of known biomarkers and traditional CVD risk factors.

PsicoCare: a pilot randomized controlled trial testing a psychological intervention combining cognitive-behavioral treatment and positive psychology therapy in acute coronary syndrome patients

Background

Although psychological factors play a significant role in the onset and prognosis of acute coronary syndrome (ACS), psychological interventions (PIs) are rarely included in cardiac rehabilitation (CR) programs due to inconclusive evidence regarding specific intervention components and effect sizes. This study aimed to assess the efficacy of a PI based on cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in improving psychological and clinical outcomes in patients with ACS.

Methods

This PsicoCare trial was an open-label randomized controlled trial that compared a combined CBT and PPT-based PI (the PsicoCare program) with a standard CR program (control group). We recruited 87 ACS patients, and psychological outcomes, functional capacity, biochemical and anthropometric measures, and clinical outcomes were assessed at baseline, 2 months, and 9 months after the ACS event.

Results

The PsicoCare group showed significant improvements in depression, anger traits, anger-in, and anger control-out compared to the control group. Additionally, the PsicoCare intervention was associated with the improved maintenance of cognitive function, social support, and spiritual coping styles, while the control group showed deterioration in these areas. Patients experiencing severe ACS showed significant improvement in personal strength and meaning as a result of the PsicoCare intervention. However, no significant effects were observed on anxiety, anger-out, emotion regulation skills, dispositional optimism, other personal strengths, or quality of life. Both groups demonstrated similar improvements in functional capacity and clinical outcomes.

Conclusion

The study suggests that CBT and PPT-based PIs may offer additional benefits for ACS patients, particularly regarding their psychological health. Further larger trials are required to confirm these findings.

Clinical trial registration

identifier, NCT05287061.

Health-related quality of life in patients with inborn errors of immunity: A systematic review and meta-analysis

BACKGROUND

Inborn Errors of Immunity (IEI) significantly affect patients' health-related quality of life (HRQOL), presenting greater challenges than those faced by the healthy population and other chronic disease sufferers. Current research lacks comprehensive integration of this critical issue.

OBJECTIVE

This study explores HRQOL in IEI patients, identifies impacting factors, and advocates for increased research focus on their quality of life.

METHODS

Following systematic review and meta-analysis guidelines, a search of Scopus and PubMed until November 15, 2023, yielded 1633 publications. We evaluated the literature, assessed study quality, and compared the HRQOL of IEI patients to that of healthy individuals and other chronic disease patients.

RESULTS

Of 90 articles and 10,971 IEI patients analyzed, study quality varied (nine good, 63 moderate, and 18 poor). The Short Form-36 (SF-36) and Pediatric Quality of Life Inventory generic core scales (PedsQL) were the primary generic instruments used among adults and children, respectively, with 12 studies each using the disease-specific instruments. Meta-analysis showed IEI patients have significantly lower scores in general health, physical and mental health, and social and emotional roles compared to healthy populations. We noted significant differences between self and proxy reports, indicating caregiver anxiety and perception disparities.

CONCLUSION

Despite limitations like small sample sizes and reliance on generic instruments, this research underscores the substantially lower HRQOL among IEI patients, emphasizing the need for a patient-centered, multidisciplinary approach to improve their life quality and calling for more focused attention on IEI patients and their caregivers' HRQOL.

Lifestyle factors as determinants of atherosclerotic cardiovascular health

A sedentary lifestyle, low levels of physical activity and fitness, poor dietary patterns, and psychosocial stress are strongly associated with increased morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Conversely, engaging in regular physical activity, maintaining optimal fitness levels, adhering to a heart-healthy dietary pattern, effectively managing body weight, ensuring adequate sleep, implementing stress-reduction strategies, and addressing psychosocial risk factors are associated with a reduced risk of ASCVD. This comprehensive review synthesizes current evidence from large observational studies and randomized controlled trials on lifestyle factors as determinants of ASCVD health. It also briefly reviews mechanistic insights into how factors such as low shear stress, increased reactive oxygen species production, chronic inflammation, platelets and coagulation activation, endothelial dysfunction, and sympathetic hyperactivity contribute to the initiation and exacerbation of ASCVD risk factors. These include obesity, hyperglycemia, type 2 diabetes, hypertension, and dyslipidemia, subsequently leading to the development and progression of atherosclerosis, ultimately resulting in chronic ASCVD or acute cardiovascular events. To bridge the translational gap between epidemiologic and trial-based evidence and clinical practice, practical recommendations are summarized to facilitate the translation of scientific knowledge into actionable interventions to promote ASCVD health. Acknowledged is the gap between the evidence-based knowledge and adoption within healthcare systems, which remains a crucial objective in advancing cardiovascular health at the population level.

Emotion suppression and acute physiological responses to stress in healthy populations: a quantitative review of experimental and correlational investigations

Emotion suppression may be linked to poor health outcomes through elevated stress-related physiology. The current meta-analyses investigate the magnitude of the association between suppression and physiological responses to active psychological stress tasks administered in the laboratory. Relevant articles were identified through Medline, PsychINFO, PubMed, and ProQuest. Studies were eligible if they (a) used a sample of healthy, human subjects; (b) assessed physiology during a resting baseline and active psychological stress task; and (c) measured self-report or experimentally manipulated suppression. Twenty-four studies were identified and grouped within two separate random effects meta-analyses based on study methodology, namely, manipulated suppression (k = 12) and/or self-report (k = 14). Experimentally manipulated suppression was associated with greater physiological stress reactivity compared to controls (Hg = 0.20, 95% CI [0.08, 0.33]), primarily driven by cardiac, hemodynamic, and neuroendocrine parameters. Self-report trait suppression was not associated with overall physiological stress reactivity but was associated with greater neuroendocrine reactivity (r = 0.08, 95% CI [0.01, 0.14]). Significant moderator variables were identified (i.e., type/duration of stress task, nature of control instructions, type of physiology, and gender). This review suggests that suppression may exacerbate stress-induced physiological arousal; however, this may differ based upon the chosen methodological assessment of suppression.

Heart failure potentially affects the cortical structure of the brain

BACKGROUND

Heart failure (HF) has been reported to affect cerebral cortex structure, but the underlying cause has not been determined. This study used Mendelian randomization (MR) to reveal the causal relationship between HF and structural changes in the cerebral cortex.

METHODS

HF was defined as the exposure variable, and cerebral cortex structure was defined as the outcome variable. Inverse-variance weighted (IVW), MR-Egger regression and weighted median (WME) were performed for MR analysis; MR-PRESSO and Egger's intercept was used to test horizontal pleiotropy; and "leave-one-out" was used for sensitivity analysis.

RESULTS

Fifty-two single nucleotide polymorphisms (SNPs) were defined as instrumental variables (IVs), and there was no horizontal pleiotropy in the IVs. According to the IVW analysis, the OR and 95% CI of cerebral cortex thickness were 0.9932 (0.9868-1.00) (P=0.0402), and the MR-Egger intercept was -15.6× 10-5 (P = 0.7974) and the Global test pval was 0.078. The P-value of the cerebral cortex surface was 0.2205, and the MR-Egger intercept was -34.69052 (P= 0.6984) and the Global Test pval was 0.045. HF had a causal effect on the surface area of the caudal middle frontal lobule (P=0.009), insula lobule (P=0.01), precuneus lobule (P=0.049) and superior parietal lobule (P=0.044).

CONCLUSIONS

HF was potentially associated with changes in cortical thickness and in the surface area of the caudal middle frontal lobule, insula lobule, precuneus lobule and superior parietal lobule.

The Role of the Clinical Psychologist in the Care of Adults With Cardiovascular Disease

Cardiovascular disease (CVD) is on the rise globally and, along with mental health conditions, will represent the largest public health burden, especially in a world impacted by climate change. Behavior, psychological mechanisms, and CVD are closely correlated. Evidence-based psychological interventions targeting behavior and psychological mechanisms exist across the CVD spectrum. This statement proposes the development of a subspecialty "cardiovascular psychology" to develop integrated pathways of behavioral care delivered to CVD populations. Scope of practice is discussed as it relates to diagnosing and treating comorbid health disorders, behavioral change interventions, pain management, lifestyle and wellbeing, neuropsychological assessment, and cognitive rehabilitation. An agenda on reforms for financials, training pathways, and diversification of the workforce is presented. Finally, normalizing the integration of behavioral health as part of CVD treatment is a shared responsibility across professional organizations and the community to realize value-based CVD care.

One-year outcomes following a hypertensive urgency or emergency

There are scarce data on the comparative prognosis between patients with hypertensive emergencies (HE), urgencies (HU), and those without HU or HE (HP). Our study aimed to compare cardiovascular (CV) outcomes of HE, HU, and HP during a 12-month follow-up period. The population consisted of 353 consecutive patients presenting with HE or HU in a third-care emergency department and subsequently referred to our hypertension center for follow-up. After both groups completed scheduled follow-up visits, patients with HU were matched one-to-one by age, sex, and hypertension history with HP who attended our hypertension center during the same period. Primary outcomes were 1) a recurrent hypertensive HU or HE event and 2) non-fatal CV events (coronary heart disease, stroke, heart failure, or CV interventions), while secondary outcomes were 1) all-cause death, 2) CV death, 3) non-CV death, and 4) any-cause hospitalization. Events were prospectively registered for all three groups. During the study period, 81 patients were excluded for not completing follow-up. Among eligible patients(HE = 94; HU = 178), a total of 90 hospitalizations and 14 deaths were recorded; HE registered greater CV morbidity when compared with HU (29 vs. 9, HR 3.43, 95 % CI 1.7-6.9, p = 0.001), and increased CV mortality (8 vs. 1, HR 13.2, 95 % CI 1.57-110.8, p = 0.017). When opposing HU to HP, events did not differ substantially. Cox regression models were adjusted for age, sex, CV and chronic kidney disease, diabetes mellitus, and smoking. During 1-year follow-up, the prognosis of HU was better than HE but not different compared to HP. These results highlight the need for improved care of HU and HE.

Psychological Impact of a Prenatal Diagnosis of Congenital Heart Disease on Parents: Is It Time for Tailored Psychological Support?

The prenatal diagnosis of congenital heart disease (CHD) represents, for both parents, a particularly stressful and traumatic life event from a psychological point of view. The present review sought to summarize the findings of the most relevant literature on the psychological impact of prenatal diagnosis of CHD on parents, describing the most common mechanisms employed in order to face this unexpected finding. We also highlight the importance of counseling and the current gaps in the effects of psychological support on this population.

Stress-Mediated Abnormalities in Regional Myocardial Wall Motion in Young Women with a History of Psychological Trauma

BACKGROUND

Psychosocial stress has been associated with the development and progression of atherosclerotic cardiovascular disease (CVD). Previously, we reported subtle differences in global longitudinal strain in somatically healthy women with a psychiatric diagnosis of borderline personality disorder (BPD). This study aimed to investigate the impact of BPD on segmental myocardial wall motion using speckle tracking echocardiography (STE) analysis.

METHODS

A total of 100 women aged between 18 and 38 years were included in this study. Fifty patients meeting the diagnostic criteria for BPD were recruited from the Department of Psychiatry (LWL-University Hospital Bochum) and compared with fifty age-matched healthy control subjects without previous cardiac disease. Laboratory tests and STE were performed with segmental wall motion analysis.

RESULTS

The BPD group had a higher prevalence of risk factors for CVD, with smoking and obesity being predominant, when compared with the control group. Other cardiovascular parameters such as blood pressure, glucose, and cholesterol levels were also elevated, even though not to pathological values. Moreover, in the STE analysis, the BPD group consistently exhibited decreased deformation in nine myocardial wall regions compared with the control group, along with a shift toward higher values in the distribution of peak pathological segments. Additionally, significantly higher values of free thyroxine concentration and thyroid's secretory capacity were observed in the BPD group, despite falling within the (high-) normal range.

CONCLUSIONS

BPD is associated with chronic stress, classical risk factors, and myocardial wall motion abnormalities. Further exploration is warranted to investigate the relationship between high-normal thyroid metabolism, these risk factors, and myocardial function in BPD patients. Long-term follow-up studies would be valuable in confirming the potential for predicting adverse events.

Assessment of chronic stress in the adult population of the Vladimir region

Aim. To assess the prevalence of chronic stress in the adult population in the Vladimir region, taking into account sex characteristics.

Material and methods. This cross-sectional population study was performed in five cities of the Vladimir Oblast (Vladimir, Kovrov, Murom, Yuryev-Polsky and Vyazniki) from May 2018 to March 2020. From six health care facilities, 9 therapeutic areas were selected. Then, from the assigned population aged 30-69 years, respondents from each area were invited to the study. To identify chronic stress, the Reeder questionnaire was used, which makes it possible to identify three types of disorders: low, moderate and severe stress. The study analyzed fully completed Reeder L. chronic stress questionnaires from 1081 respondents (393 men and 688 women).

Results. Among men, every second person has a low chronic stress, 42% — moderate stress, while high chronic stress was found in 6.4% of cases. A similar trend is observed among women. High levels of chronic stress were detected in 8% of women, and the gap between the prevalence of low and moderate chronic stress was minimal. In general, the prevalence of various levels of chronic stress between men and women was comparable, without significant differences. Sex variability in the prevalence of chronic stress was revealed in various cities of the Vladimir Oblast. In Vladimir, the prevalence of high stress among men was three times higher than in women, while in Vyazniki and Kovrov the opposite pattern was observed. In the other two cities (Murom and Yuryev Polsky), the prevalence of high chronic stress between men and women was comparable.

Conclusion. In the working-age population, a high chronic stress level is detected in up to 10%. In some cities, there are sex differences between men and women. The mean level of chronic stress is determined in 42-43% of cases. The results obtained indicate the need for large-scale preventive measures to combat chronic stress among working-age men and women of in the Vladimir Oblast.

A randomized controlled trial evaluating a theory driven, complex intervention centered on task sharing and mobile health to improve selfcare and outcomes in heart failure - The PANACEA-HF RCT: Design and rationale

Background

We developed a three-pronged complex intervention to improve selfcare and deliver whole person care for patients with heart failure, underpinned by the 'extant cycle' theory - a theory based on our formative work.

Methods

This is a 3 centre, 2-arm, 1:1, open, adaptive stratified, randomized controlled trial. We included patients aged ≥ 18 years with heart failure, taking any of the key guideline directed medical treatments, with a history of or currently on a high ceiling diuretic. We excluded end stage renal disease, clinically diagnosed severe mental illness or cognitive dysfunction and having no caregivers. Interventions included, (i) trained hospital based lay health worker mediated assessment of patients' current selfcare behaviour, documenting barriers and facilitators and implementing a plan to 'transition' the patient toward optimal selfcare. (ii) m-health mediated remote monitoring and (iii) dose optimization through a 'physician supervisor'.

Results

We recruited 301 patients between Jan 2021 and Jan 2022. Mean age was 59.8 (±11.7) years, with 195 (64.8 %) from rural or semi-urban areas and 67.1 % having intermediate to low health literacy. 190 (63.1 %) had an underlying ischemic cardiomyopathy. In the intervention arm, 142 (94.1 %) had a Selfcare in Heart Failure Index (SCHFI) score of ≤70, with significant barriers being 'lack of knowledge' 105 (34.5 %) and 'behavioural passivity' 23 (7.5 %).

Conclusion

This is the first South Asian trial evaluating a complex intervention underpinned by behaviour change theory for whole person heart failure care. These learnings can be applied to heart failure patient care in other resource constrained health systems.

A mHealth intervention to reduce perceived stress in patients with ischemic heart disease: study protocol of the randomized, controlled confirmatory intervention "mStress-IHD" trial

BACKGROUND

Stress is highly prevalent in patients with ischemic heart disease (IHD) and is associated with lower health-related quality of life and impaired cardiovascular outcome. The importance of stress management is now recognized in recent guidelines for the management of cardiovascular disease. However, effective stress management interventions are not implemented in clinical routine yet. The development of easily disseminated eHealth interventions, particularly mHealth, may offer a cost-effective and scalable solution to this problem. The aim of the proposed trial is to assess the efficiency and cost-effectiveness of the mHealth intervention "mindfulHeart" in terms of reducing stress in patients with IHD.

METHODS AND ANALYSIS

This randomized controlled confirmatory interventional trial with two parallel arms has assessments at six measurement time points: baseline (T0, prior randomization), post-treatment (T1), and four follow-ups at months 1, 3, 6, and 12 after intervention (T2, T3, T4, and T5). We will include patients with confirmed diagnosis of IHD, high-perceived stress, and use of an internet-enabled smartphone. Patients will be randomized into two groups (intervention vs. control). The proposed sample size calculation allocates 128 participants in total. The primary analysis will be performed in the intention-to-treat population, with missing data imputed. An ANCOVA with the outcome at T1, a between-subject factor (intervention vs. control), and the participants' pre-intervention baseline values as a covariate will be used. Different ANOVAs, regression, and descriptive approaches will be performed for secondary analyses.

ETHICS

The Ethics Committee of the Medical Faculty of the University of Duisburg-Essen approved the study (22-11,015-BO).

TRIAL REGISTRATION

ClinicalTrials NCT05846334. Release 26.04.2023.

Meta-analysis of Shugan Jieyu Capsule for depression in patients with coronary heart disease

INTRODUCTION

Shugan Jieyu Capsule (SGJYC) has been prescribed to treat primary and secondary depression; however, whether it can benefit depression of patients with coronary heart disease (CHD) remains controversial. This meta-analysis aimed to evaluate the efficacy and safety of SGJYC in treating depression in patients with CHD.

PATIENT CONCERNS

A total of 644 CHD patients with depression were selected from China National Knowledge Infrastructure, Wanfang, China Biomedical Database, MEDLINE, the Cochrane library from their inceptions until June, 2021.

DIAGNOSIS

All patients with CHD or coronary artery disease were confirmed to suffer from depression based on recognized criteria.

INTERVENTION

Patients were assigned randomly to receive SGJYC-based regimens or conventional antidepressants alone.

OUTCOMES

Meta-analysis of 6 studies showed that antidepressants (MD, 2.12; 95% confidence interval [CI], 0.73~3.50) or sertraline (MD, 2.15; 95%CI, 0.61~3.68) significantly alleviated depression level compared to SGJYC; however, SGJYC plus antihypertensive drugs (AHD) (MD, -8.33; 95%CI, -13.90 ~ -2.75) significantly improved depression symptoms compared to AHD. A significant difference in risk of adverse cardiac events (risk ratios [RR], 2.72; 95%CI, 1.07~6.94) between SGJYC and sertraline was detected in patients with simple CHD.

CONCLUSIONS

SGJYC has a poor effect on depressive symptoms, and the effect of combination with AHD is better than AHD but its efficacy and cardiac safety are inferior to antidepressants.

How to Improve Clinical Outcomes and Reduce Cardiovascular Risk in Older People with Cardiovascular Disease: Bridging Evidence Gaps

The geriatric population is greatly impacted by cardiovascular disease. Thus, it becomes essential to 'geriatricise' the cardiologist through the dissemination of geriatric cardiology. In the early days of geriatric cardiology, it was discussed whether it was simply cardiology 'well done'. Today, 40 years later, it seems clear that this is indeed the case. Patients with cardiovascular disease usually have several chronic conditions. Clinical practice guidelines often address a single condition and do not provide sufficient guidance for patients with multimorbidity. There are several evidence gaps regarding these patients. Physicians and members ofthe care team need a multidimensional understanding ofthe patient to better promote the optimisation of care. It is important to understand that ageing is inevitable, heterogeneous and increases vulnerability. Caregivers must know how to assess elderly patients in a multidomain practical way and how to recognise the factors that may have implications on treatment.

Cardiology and lifestyle medicine

Poor lifestyle habits, such as physical inactivity and poor diets, are highly prevalent within society and even more so among patients with chronic disease. The need to stem poor lifestyle habits has led to the development of a new field of Lifestyle Medicine, whose mission is to prevent, treat, and even reverse chronic diseases through lifestyle interventions. Three fields within Cardiology relate to this mission: Cardiac Rehabilitation, Preventive Cardiology, and Behavioral Cardiology. Each of these three fields have contributed substantially to the reduction of cardiovascular disease (CVD) morbidity and mortality. The historic contributions of these three cardiac fields are reviewed as well as the challenges each of these fields has faced in optimizing the application of lifestyle medicine practices. A shared agenda between Cardiology and the American College of Lifestyle Medicine could further the utilization of behavioral interventions. This review suggests seven steps that could be shared by these organizations and other medical societies. First, there is a need to develop and promulgate the assessment of lifestyle factors as "vital signs" during patient visits. Second, developing a strong partnership between the fields of Cardiology and Physiatry could improve important aspects of cardiac care, including a potential redesign of cardiac stress testing. Third, behavioral evaluations should be optimized at patients' entrée points into medical care since these may be considered "windows of opportunity". Fourth, there is a need to broaden cardiac rehabilitation into inexpensive programs and make this program eligible for patients with risk factors but no known CVD. Fifth, lifestyle medicine education should be integrated into the core competencies for relevant specialties. Sixth, there is a need for inter-societal advocacy to promote lifestyle medicine practices. Seventh, the well-being effects of healthy lifestyle behaviors, such as their impact on one's sense of vitality, should be emphasized.

New principles, the benefits, and practices for fostering a physically active lifestyle

The modern environment has led to an increased risk and incidence of sedentary lifestyles. When physical activity (PA) becomes insufficient, pathophysiological pathways are invoked and the future risk for chronic diseases and premature mortality increases. As a consequence, since the 1970s governmental agencies and medical societies have published guidelines to promote PA. The 2018 Guidelines for Physical Activity for Americans contain important updated guidelines, but many of these guidelines are not yet sufficiently known by the public or health providers. In addition, to make use of these guidelines, they need to be integrated with optimal behavioral interventions. Accordingly, this narrative review critically assesses five tenets that stem from the 2018 Guidelines and illustrates how these tenets can be integrated with tools and techniques for motivating individuals to initiate and maintain a more physically active lifestyle. The first tenet indicates that there is no lower threshold of PA that must be obtained before health benefits begin to accrue. Second, it is no longer required that PA be obtained in bouts of 10 min or more to "count". Bouts of lesser duration also count. Pending further study, new accelerometry data suggest that vigorous intermittent PA of just 1-2 min may also benefit health, such as that acquired by stair climbing or carrying heavy groceries. This has led to a new concept of promoting "lifestyle physical activity". Third, excessive sitting is health damaging if it is not accompanied by sufficient daily life PA or accrues over long uninterrupted bouts. Fourth, it is essential to incorporate resistance exercises for optimal health and to promote successful aging. Fifth, a wealth of new evidence indicates that PA strongly protects and promotes all aspects of brain health and may improve cognition even after a single bout of exercise.

Using motivational interviewing and brief action planning for adopting and maintaining positive health behaviors

Lifestyle medicine practice can be enhanced with interpersonal communication skills to help patients adopt and maintain positive health behaviors, such as improving diet or initiating exercise. We review two approaches that incorporate evidenced-based skills for this purpose: motivational interviewing and brief action planning (BAP). Motivational interviewing involves four processes conducted in a climate of compassion, acceptance, partnership, and empowerment. First, "engaging" (or connecting) with patients uses "relational" skills of active listening and empathic communication. Second, "focusing" elicits patients' full spectrum of concerns, expectations, and desires to negotiate a collaborative agenda. Third, "evoking motivation," utilizes uniquely innovative skills (e.g., "softening sustain talk" and "cultivating change talk") to increase intrinsic motivation of patients with ambivalence (or resistance) to become more open to choosing healthier behaviors for themselves. Fourth, "planning for change," uses collaborative goal-setting skills to help patients specify concrete action plans for health. To this end, brief action planning (BAP) has been developed as a specific pragmatic algorithmic approach, utilizing collaborative "SMART" (specific, measurable, achievable, relevant, and time-based) action planning, encouragement of patient commitment statements, scaling for confidence, problem-solving to reduce barriers for change, fostering patient accountability, and emphasizing follow-up. BAP can be introduced at any point in a patient encounter when patients are ready or nearly ready for change.

Validity of a German Comprehensive Psychosocial Screening Instrument based on the ESC Cardiovascular Prevention Guidelines

Background: Following guidelines for cardiovascular disease prevention of the European Society for Cardiology (ESC), the current study validated the German Comprehensive Psychosocial Screening Instrument in participants who underwent coronary angiography. Methods: 314 participants (M_age = 69.7 ± 12.0; 69 % male) completed the German Comprehensive Psychosocial Screening Instrument and validated comparison scales to measure depression (PHQ-9), anxiety (GAD-7), Type D personality (DS14), work stress (ERI), family stress (SMSS), trauma (PC-PTSD), and anger and hostility (Z-scale of MMPI-2). Results: Confirmatory factor analysis (CFA) confirmed that the psychosocial risk factors were separate entities rather than a signs or symptoms of a single broad indication of distress (CFI = .872, RMSEA = .056, SRMR = .058). Intraclass coefficients (ICC), kappa and diagnostic accuracy indicators (receiver operator characteristic [ROC] curves, sensitivity, specificity, and the positive and negative predictive values [PPV; NPV]) indicated that most screener scales were sufficient to good. We also compared patients with established coronary heart disease (CHD; n = 213) to those with no current CHD (n = 100) and found overall similar results. Discussion: The German version of the Comprehensive Psychosocial Screening Instrument has an acceptable performance. Aside from minor improvements, the screening instrument could be implemented in the cardiological practice to screen patients on multidimensional psychosocial risk.

Psychoemotional risk factors for non-communicable diseases in outpatient practice. Guidelines for internists

Methodological guidelines "Psychoemotional risk factors in outpatient practice" were developed as a practical document for primary care physicians in order to expand and improve knowledge, as well as provide care to the adult population within the studied theme. The methodological guidelines include an information and content part for medical specialists and a practical part for patients, presented in the format of memos. The guidelines include the main sections: definition, structure and epidemiology of psychoemotional risk factors, psychoemotional risk factors in the clinics of internal diseases, screening of psychoemotional risk factors, prevention and correction of psychoemotional risk factors for noncommunicable diseases, non-drug care for patients, pharmacotherapy of psychoemotional disorders. The guidelines are intended for primary care physicians, for specialists who develop and implement educational programs for patients, as well as for therapeutic residents.

Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy

BACKGROUND

Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption.

METHODS

We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients.

RESULTS

We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support.

CONCLUSIONS

We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

Meta-Analysis of Antidepressant Pharmacotherapy in Patients Eligible for Cardiac Rehabilitation: ANTIDEPRESSANT AMBIVALENCE

PURPOSE

Many patients exhibit clinically significant depression upon enrollment in cardiac rehabilitation (CR). Antidepressants are a first-line treatment option for depression, but the effectiveness of antidepressants in patients with heart disease is mixed. The purpose of this meta-analysis was to evaluate the efficacy of antidepressants for depression in patients eligible for CR.

METHODS

A meta-analysis was conducted including randomized controlled trials of antidepressants from January 1990 to September 2021 that compared antidepressants with placebo. Random-effects models were used between group effect sizes (Hedges' g ).

RESULTS

A total of 13 trials with predominately White (68% ± 12; n =7) male (70% ± 11) samples averaging 61 ± 5 yr compared antidepressants (1128 participants) with placebo (1079 participants). Antidepressants reduced depressive symptoms ( g = 0.17: 95% CI, 0.08-0.27), but the effect was small. Heterogeneity among study effects was low ( I2 = 6.42) and nonsignificant ( Q = 10.75, P = .46), although patients with heart failure ( gHF = 0.05: 95% CI, -0.09 to 0.18) demonstrated smaller effects compared with patients with other cardiovascular disease conditions (g non-HF = 0.22: 95% CI, 0.11-0.32) ( QB [1] = 3.97; P < .05). No study reported safety concerns associated with antidepressants.

SUMMARY

The effect size of antidepressant pharmacotherapy in this population is small. No trials reported on the combined effects of exercise and pharmacotherapy. If the patient is not suicidal, CR staff may consider patient preference and refer patients for additional treatment as necessary.

Evaluation of an Intervention to Promote Self-Management Regarding Cardiovascular Disease: The Social Engagement Framework for Addressing the Chronic-Disease-Challenge (SEFAC)

BACKGROUND

Cardiovascular diseases (CVD) are predominantly lifestyle related. Mental health issues also influence CVD progression and quality of life. Self-management of lifestyle behaviors and mental well-being may play a significant role in reducing the CVD burden. Previous studies have shown that mindfulness practices are associated with psychological well-being, but their effects on CVD self-management are mainly unknown.

METHODS

The study had a before-after design and included adults over 50 years with CVD and/or one or more risk factors from three European countries. Follow-up was six months. The intervention was a 7-week mindfulness-based intervention (MBI) in a group setting focusing on chronic disease self-management. Outcomes were measured with validated self-report questionnaires at baseline and follow-up: self-efficacy, physical activity, nutrition, smoking, alcohol use, sleep and fatigue, social support, stress, depression, medication adherence, and self-rated health.

RESULTS

Among 352 participants, 324 (92%) attended ≥4 of the 7 group sessions and completed follow-up. During follow-up, self-efficacy, stress, social support, depressive symptoms, and self-rated health significantly improved. No significant changes were detected for other outcomes.

CONCLUSIONS

A 7-week MBI focusing on chronic disease self-management was conducive to improved self-efficacy, emotional well-being, social support, and self-rated overall health during six months. These findings support the use of MBIs for improving self-management in cardiovascular care. ISRCTN registry-number ISRCTN11248135.

Anxiety and depression as risk factors for ICD shocks and mortality in patients with an implantable cardioverter defibrillator - A systematic review

OBJECTIVE

To examine associations between baseline anxiety and depression and occurrence of ICD shocks and risk of mortality in patients with an implantable cardioverter defibrillator (ICD).

METHOD

We systematically searched EMBASE, PubMed, PsycINFO, and CINAHL for eligible studies fulfilling the predefined criteria.

RESULTS

We included 37 studies based on 25 different cohorts following 35,003 participants for up to seven years. We observed no association between baseline anxiety nor depression and the occurrence of ICD shocks. More than half of the identified studies (respectively 56% and 60%) indicated a significant association between baseline anxiety or depression and increased risk of mortality (anxiety: n = 5, ranging from Hazard ratios (HR):1.02 [Confidence intervals (CI) 95% 1.00-1.03] to HR:3.45 [CI 95% 1.57-7.60]; depression: n = 6, ranging from HR:1.03 [CI 95% 1.00-1.06] to HR:2.10 [CI 95% 1.44-3.05]). We found a significant association between high methodological quality of the primary study and the detection of a significant association (p < 0.01).

CONCLUSIONS

Baseline anxiety and depression are associated with increased risk of mortality in patients with an ICD, but not with occurrence of ICD shocks. Inclusion of baseline anxiety and depression in risk stratification of mortality may be warranted.

Frontiers and Hotspots Evolution in Psycho-cardiology: A Bibliometric Analysis From 2004 to 2022

In the last 20 years, research on the topic of psycho-cardiology has gradually entered the public eye, with more innovations and applications of evidence-based medical research, biological mechanism research, and guideline consensus in the field of psycho-cardiology. This study uses a bibliometric approach to visualize and analyze the literature within the field of psycho-cardiology over the last 20 years to visualize the development process, research hotspots, and cutting-edge trends in clinical practice, mechanisms, and management strategies related to psycho-cardiology. Quantitative description and evaluation of 409 articles published in the field from 2004-2022 were conducted using CiteSpace and VOSviewer, to provide a theoretical reference for the development of psycho-cardiology.

The Impact of Mental Stress on Cardiovascular Health-Part II

Endothelial dysfunction is one of the earliest manifestations of atherosclerosis, contributing to its development and progression. Mental stress induces endothelial dysfunction through increased activity of the sympathetic nervous system, release of corticotropin-releasing hormone from the hypothalamus, inhibition of nitric oxide (NO) synthesis by cortisol, and increased levels of pro-inflammatory cytokines. Mental-stress-induced increased output of the sympathetic nervous system and concomitant withdrawal of the parasympathetic inflammatory reflex results in systemic inflammation and activation of a neural-hematopoietic-arterial axis. This includes the brainstem and subcortical regions network, bone marrow activation, release of leukocytes into the circulation and their migration to the arterial wall and atherosclerotic plaques. Low-grade, sterile inflammation is involved in all steps of atherogenesis, from coronary plaque formation to destabilisation and rupture. Increased sympathetic tone may cause arterial smooth-muscle-cell proliferation, resulting in vascular hypertrophy, thus contributing to the development of hypertension. Emotional events also cause instability of cardiac repolarisation due to brain lateralised imbalance of cardiac autonomic nervous stimulation, which may lead to asymmetric repolarisation and arrhythmia. Acute emotional stress can also provoke severe catecholamine release, leading to direct myocyte injury due to calcium overload, known as myocytolysis, coronary microvascular vasoconstriction, and an increase in left ventricular afterload. These changes can trigger a heart failure syndrome mimicking acute myocardial infarction, characterised by transient left ventricular dysfunction and apical ballooning, known as stress (Takotsubo) cardiomyopathy. Women are more prone than men to develop mental-stress-induced myocardial ischemia (MSIMI), probably reflecting gender differences in brain activation patterns during mental stress. Although guidelines on CV prevention recognise psychosocial factors as risk modifiers to improve risk prediction and decision making, the evidence that their assessment and treatment will prevent CAD needs further evaluation.

The Impact of Mental Stress on Cardiovascular Health—Part II

Endothelial dysfunction is one of the earliest manifestations of atherosclerosis, contributing to its development and progression. Mental stress induces endothelial dysfunction through increased activity of the sympathetic nervous system, release of corticotropin-releasing hormone from the hypothalamus, inhibition of nitric oxide (NO) synthesis by cortisol, and increased levels of pro-inflammatory cytokines. Mental-stress-induced increased output of the sympathetic nervous system and concomitant withdrawal of the parasympathetic inflammatory reflex results in systemic inflammation and activation of a neural–hematopoietic–arterial axis. This includes the brainstem and subcortical regions network, bone marrow activation, release of leukocytes into the circulation and their migration to the arterial wall and atherosclerotic plaques. Low-grade, sterile inflammation is involved in all steps of atherogenesis, from coronary plaque formation to destabilisation and rupture. Increased sympathetic tone may cause arterial smooth-muscle-cell proliferation, resulting in vascular hypertrophy, thus contributing to the development of hypertension. Emotional events also cause instability of cardiac repolarisation due to brain lateralised imbalance of cardiac autonomic nervous stimulation, which may lead to asymmetric repolarisation and arrhythmia. Acute emotional stress can also provoke severe catecholamine release, leading to direct myocyte injury due to calcium overload, known as myocytolysis, coronary microvascular vasoconstriction, and an increase in left ventricular afterload. These changes can trigger a heart failure syndrome mimicking acute myocardial infarction, characterised by transient left ventricular dysfunction and apical ballooning, known as stress (Takotsubo) cardiomyopathy. Women are more prone than men to develop mental-stress-induced myocardial ischemia (MSIMI), probably reflecting gender differences in brain activation patterns during mental stress. Although guidelines on CV prevention recognise psychosocial factors as risk modifiers to improve risk prediction and decision making, the evidence that their assessment and treatment will prevent CAD needs further evaluation.

Validity of a multidimensional comprehensive psychosocial screening instrument based on the ESC cardiovascular prevention guidelines - Evidence from the general and cardiovascular patient population

AIM

To evaluate the psychometric properties and validity of the updated version of the Dutch multidimensional Comprehensive Psychosocial Screening Instrument in patients with coronary heart disease and the general population, based upon guideline recommendations from the European Society for Cardiology.

METHOD

678 participants (M_age = 48.2, SD = 16.8; 46% male) of the Dutch general population and 312 cardiac patients (M_age = 65.9, SD = 9.9; 77% male) who recently received percutaneous coronary intervention completed the Comprehensive Psychosocial Screening Instrument and validated questionnaires for depression (PHQ-9), anxiety (GAD-7), Type D personality (DS14), hostility (CMHS), anger (STAS-T), trauma (SRIP), and chronic work and family stress (ERI, MMQ-6).

RESULTS

Confirmatory factor analysis (CFA) confirmed that the eight screened risk factors were best measured as separate entities, rather than broader indications of distress. Inter-instrument agreement, assessed with the intraclass coefficient (ICC) and the screening accuracy indicators (receiving operator characteristic [ROC] curves, sensitivity, specificity, and the positive and negative predictive values [PPV; NPV]) were good for most screened risk factors. PPV was low in low prevalence risk factors like anxiety, trauma, and depression.

CONCLUSION

Overall, the current version of the Comprehensive Psychosocial Screening Instrument has an acceptable performance in both populations, with a fair to excellent level of agreement with established full questionnaires. Besides a few suggestions for further refinement, the screener may be implemented in primary care and cardiological practice.

Association of patient-reported psychosocial healthcare and risk of readmissions and mortality in patients with ischemic heart disease: A population-based cohort study

OBJECTIVE

Psychosocial risk factors are common in patients with ischemic heart disease (IHD) and linked to poor prognosis. Psychosocial healthcare is recommended in international guidelines and has demonstrated positive effects, primarily on psychosocial symptoms. We examined the association between patient-reported psychosocial healthcare and hospital readmissions and mortality in patients with IHD.

METHODS

A population-based cohort study with register-based follow-up. Patient-reported psychosocial healthcare was measured by seven items in a survey sent to a random sample of patients with incident IHD in Denmark in 2014. We used multivariable Cox proportional hazards models and Poisson regression to examine the association between psychosocial healthcare and readmissions and all-cause mortality.

RESULTS

In total, 1083 (57%) patients were followed up to 4½ years. Low psychosocial support was reported by 53.4%, medium by 26.2% and high by 20.4% patients. The hazard of acute cardiac readmission for patients reporting low psychosocial healthcare was 2.08 higher than for patients reporting high psychosocial healthcare (95%CI:1.01-4.30). No association was found with time to first all-cause readmission. The acute cardiac readmission rate was 3.24 (95%CI:1.66-6.29) and 4.23 (95%CI:2.15-8.33) times higher among patients reporting low and medium psychosocial healthcare compared to high, and the all-cause readmission rate was 1.30 (95%CI:1.16-1.46) and 1.32 (95%CI:1.17-1.49) times higher. The hazard of death was 2.86 (95%CI:1.23-6.69) and 2.88 (95%CI:1.18-7.04) times higher among patients reporting low and medium psychosocial healthcare compared to high.

CONCLUSION

In patients with IHD, a high level of patient-reported psychosocial healthcare was significantly associated with reduced hospital readmissions and all-cause mortality.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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How to Mitigate Risk of Premature Cardiovascular Disease Among Children and Adolescents with Mental Health Conditions

PURPOSE OF REVIEW

The goal of this article is to characterize the myriad of ways that children with mental health conditions can be at risk for premature cardiovascular disease (CVD) and various modalities to ameliorate this risk in childhood in order to improve the life course of these children.

REVIEW FINDINGS

Child and adolescent mental health conditions are a common yet underrecognized risk factor for premature CVD. The American Heart Association has recently included psychiatric conditions as a CVD risk factor (CVDRF) and the evidence linking childhood adversity to cardiometabolic disease. There are bidirectional and additive effects from the intrinsic emotional dysregulation and inflammatory changes from the mental health condition, the associations with risky health behaviors, and in some cases, metabolic side effects from pharmacotherapy. These pathways can be potentiated by toxic stress, a physiologic response to stressors from childhood adversity. Toxic stress is also associated with development of mental health conditions with epigenetic effects that can result in transgenerational inheritance of cardiometabolic risk. Exposure to toxic stress and mental health conditions in isolation sometimes compounded by pharmacotherapies used in treatment increase the risk of cardiometabolic diseases in childhood. The multiple pathways, which adversely influence cardiometabolic outcomes, encourage clinicians to consider strategies to mitigate these factors and justify the importance of early screening and treatment for CVDRFs. Mental health, health behaviors, and environmental factors co-occur and intersect in complex pathways that can increase CVD risk over the lifespan. Early detection and response can mitigate the risks associated with premature development of CVD.

Efficacy of psychological interventions on clinical outcomes of coronary artery disease: Systematic review and meta-analysis

OBJECTIVES

Psychological factors influence clinical outcomes in patients with coronary artery disease (CAD). Therefore, psychological interventions (PIs) may have beneficial effects in these patients. We evaluated the efficacy of PIs based on cognitive-behavioral therapy (CBT) and positive psychology therapy (PPT) on clinical and laboratory outcomes in CAD.

METHODS

Randomized controlled trials evaluating CBT or PPT in CAD patients published until May 2020 were systematically reviewed and analyzed. Primary outcomes were all-cause mortality, cardiovascular mortality, any cardiovascular event, myocardial infarction (MI), stroke, coronary revascularization, angina, and readmission. Random effects meta-analyses using the inverse variance method were performed. Effects were expressed as risk ratios (RR) or standardized mean difference (SMD) with 95% confidence intervals (CIs).

RESULTS

Twenty-five trials were included (n = 8119); 22 evaluating the effects of multi-component CBT (n = 7909), and three PPT (n = 210). Thirteen RCTs were at high risk of bias due to limitations in randomization or blinding. Compared with control groups any cardiovascular event (RR 0.82; 0.70 to 0.97; 5 studies), MI (RR 0.72; 0.52 to 0.98; 9 studies), and angina duration and intensity (SMD -0.64; -0.98 to -0.30; 4 studies; and -0.64; -1.17 to -0.11; 2 trials) were significantly reduced with PIs at the end of follow-up. PIs had no effect on other primary outcomes, laboratory or anthropometrical results and presented a moderate to high heterogeneity.

CONCLUSIONS

CBT- and PPT-based PIs reduce the risk of cardiovascular events, MI and angina in patients with CAD. Future research should assess the individual role of CBT and PPT in CAD populations.

Optimism is associated with respiratory symptoms and functional status in chronic obstructive pulmonary disease

BACKGROUND

Optimism is the general belief that good things will occur in the future; optimism is modifiable by cognitive behavioral therapy (CBT). Previous studies have associated higher optimism with improved health outcomes and lower all-cause mortality.

RESEARCH QUESTION

Investigate association between optimism and disease-related characteristics in chronic obstructive pulmonary disease (COPD).

STUDY DESIGN AND METHODS

Current and former smokers with/without COPD and Preserved Ratio Impaired Spirometry (PRISm) from the 10-year follow-up visit for the Genetic Epidemiology of COPD (COPDGene) study were included. Optimism was assessed at the 10-year visit using the Life Orientation Test-Revised. Models of optimism as a predictor of lung function, COPD-associated phenotypes including exacerbations, and functional assessments, were adjusted for demographic confounders, smoking status, and comorbidities.

RESULTS

Among 1967 subjects, higher optimism was significantly associated with older age, non-Hispanic white race, marital status, quitting smoking status, absence of COPD, and absence of depression. In multivariable analysis, higher optimism was independently associated with fewer prior exacerbations of COPD (coef = - 0.037, P < 0.001). Higher optimism was also related to better MMRC scores (coef = - 0.041, P < 0.001), CAT scores (coef = - 0.391, P < 0.001), SGRQ scores (coef = - 0.958, P < 0.001), BODE index (coef = - 0.059, P < 0.001), and longer 6-min walk distance (coef = 10.227, P < 0.001). After stratification by severity of COPD, these associations with optimism were still significant in all groups. No significant association was observed for cross-sectional FEV1 (%) or FVC (%) with optimism score.

INTERPRETATION

Fewer exacerbations and less severe respiratory symptoms and higher functional capacity were associated with higher optimism, which may impact health outcomes in current and former smokers with and without COPD. Optimism is a modifiable trait and these results may further support a role for CBT to improve outcomes in COPD.

Supervised Exercise Therapy is Effective for Patients With Intermittent Claudication Regardless of Psychological Constructs

OBJECTIVE

According to current guidelines, supervised exercise therapy (SET) is the treatment of choice for intermittent claudication (IC). Little is known about the potential consequences of psychological factors on the effectiveness of treatment. The aim of this study was to determine possible associations between a set of psychological constructs and treatment outcomes, and to investigate whether self efficacy increased after SET.

METHODS

This was a substudy of the ELECT Registry, a multicentre Dutch prospective cohort study in patients with IC receiving primary SET. A complete set of validated questionnaires scoring extraversion, neuroticism, conscientiousness, anxiety, depression, self control, optimism, and self efficacy was obtained in 237 patients (median age 69 years, 40% female). Anxiety and depression were dichotomised using established cutoff scores, whereas other scores were analysed as continuous measures. Multiple linear regression analyses determined possible associations between these independent variables and maximum and functional walking distances (MWD and FWD, respectively), Six Minute Walk Test (6MWT), and VascuQol-6 (dependent variables). Self efficacy during 12 months of SET was analysed using a linear mixed model.

RESULTS

Neuroticism and anxiety were associated with lower overall VascuQol-6 scores (estimate -1.35 points [standard error (SE) 0.57; p = .018] and -1.98 points [SE 0.87, p = .023], respectively). Optimism and self efficacy demonstrated higher overall 6MWT (5.92 m [SE 2.34; p = .012] and 1.35 m [SE 0.42; p = .001], respectively). Self control was associated with lower overall log MWD (-0.02 [SE 0.01; p = .038] and log FWD (-0.02 [SE 0.01; p = .080), whereas self efficacy had a higher overall log MWD (0.01 [SE 0.003; p = .009]) and log FWD (0.01 [SE 0.003; p = .011]). Depressive patients with IC demonstrated a greater improvement in 6MWT during follow up (17.56 m [SE 8.67; p = .044]), but this small effect was not confirmed in sensitivity analysis. Self efficacy did not increase during follow up (0.12% [SE 0.49; p = .080]).

CONCLUSIONS

The beneficial effects of SET occur regardless of the psychological constructs, supporting current guidelines recommending a SET first strategy in each patient with IC.

Prevalence and associated factors of depression among older adults in rural Tanzania

OBJECTIVES

Depression is the commonest mental disorder in older adults worldwide, affecting 7% of the world's older population and accounting for 5.7% of years lived with disability among adults aged over 60 years. We conducted a secondary data analysis to determine the point prevalence, associated risk factors and treatment gap for DSM-IV depression among older adults in the Hai District, rural Tanzania.

METHODS

The primary data source was a cross-sectional two-stage community-based dementia study where older adults aged ≥70 years (n = 296) were fully-assessed for dementia and depression in the second stage. Age-adjusted prevalence of depression was determined based on the WHO standard population using the Direct Method. Univariate and multivariate logistic regression models were performed.

RESULTS

Of the 296 older adults assessed for depression, 48 were diagnosed with depression based on Diagnostic and Statistical Manual of Mental Disorders-IV criteria. The median (Inter Quartile Range; QR) age was 80 (75-88) years. Age-adjusted point prevalence of depression was 21.2% (95% CI: 16.6-21.9) and the treatment gap for depression was 100%. There was reduced odds of depression in older adults who rated their physical health as good or very good (adjusted odds ratio [AOR] = 0.22; 95%CI: 0.10-0.46; p < 0.001), or moderate (AOR 0.26; 95%CI: 0.10-0.66; p = 0.005).

CONCLUSIONS

Depression in older adults is associated with physical health status and there is an alarmingly high treatment gap. Future research on depression in older adults should focus on effective interventions to address physical morbidity, psychosocial factors and the treatment gap.

Efficacy of psychological interventions on psychological outcomes in coronary artery disease: systematic review and meta-analysis

BACKGROUND

The benefits of cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in patients with cardiovascular disease are still not well defined. We assessed the efficacy of CBT and PPT on psychological outcomes in coronary artery disease (CAD) patients.

METHODS

Randomized controlled trials evaluating CBT or PPT in CAD patients published until May 2018 were systematically analyzed. Primary outcomes were depression, stress, anxiety, anger, happiness, and vital satisfaction. Random effects meta-analyses using the inverse variance method were performed. Effects were expressed as standardized mean difference (SMD) or mean differences (MD) with their 95% confidence intervals (CIs); risk of bias was assessed with the Cochrane tool.

RESULTS

Nineteen trials were included (n = 1956); sixteen evaluated CBT (n = 1732), and three PPT (n = 224). Compared with control groups, depressive symptoms (13 trials; SMD -0.80; 95% CI -1.33 to -0.26), and anxiety (11 trials; SMD -1.26; 95% CI -2.11 to -0.41) improved after the PI, and depression (6 trials; SMD -2.08; 95% CI -3.22 to -0.94), anxiety (5 trials; SMD -1.33; 95% CI -2.38 to -0.29), and stress (3 trials; SMD -3.72; 95% CI -5.91 to -1.52) improved at the end of follow-up. Vital satisfaction was significantly increased at follow-up (MD 1.30, 0.27, 2.33). Non-significant effects on secondary outcomes were found. Subgroup analyses were consistent with overall analyses.

CONCLUSION

CBT and PPT improve several psychological outcomes in CAD patients. Depression and anxiety improved immediately after the intervention while stress and vital satisfaction improve in the mid-term. Future research should assess the individual role of CBT and PPT in CAD populations.

Longitudinal association between cognitive depressive symptoms and D-dimer levels in patients following acute myocardial infarction

BACKGROUND

A prothrombotic tendency could partially explain the poor prognosis of patients with coronary heart disease and depression. We hypothesized that cognitive depressive symptoms are positively associated with the coagulation activation marker D-dimer throughout the first year after myocardial infarction (MI).

METHODS

Patients with acute MI (mean age 60 years, 85% men) were investigated at hospital admission (n = 190), 3 months (n = 154) and 12 months (n = 106). Random linear mixed regression models were used to evaluate the relation between cognitive depressive symptoms, assessed with the Beck depression inventory (BDI), and changes in plasma D-dimer levels. Demographics, cardiac disease severity, medical comorbidity, depression history, medication, health behaviors, and stress hormones were considered for analyses.

RESULTS

The prevalence of clinical depressive symptoms (13-item BDI score ≥ 6) was 13.2% at admission and stable across time. Both continuous (p < .05) and categorical (p < .010) cognitive depressive symptoms were related to higher D-dimer levels over time, independent of covariates. Indicating clinical relevance, D-dimer was 73 ng/ml higher in patients with a BDI score ≥ 6 versus those with a score < 6. There was a cognitive depressive symptom-by-cortisol interaction (p < .05) with a positive association between cognitive depressive symptoms and D-dimer when cortisol levels were high (p < .010), but not when cortisol levels were low (p > .05). Fluctuations (up and down) of cognitive depressive symptoms and D-dimer from one investigation to the next showed also significant associations (p < .05).

CONCLUSIONS

Cognitive depressive symptoms were independently associated with hypercoagulability in patients up to 1 year after MI. Hypothalamic-pituitary-adrenal axis could potentially modify this effect.

The self in context: brain systems linking mental and physical health

Increasing evidence suggests that mental health and physical health are linked by neural systems that jointly regulate somatic physiology and high-level cognition. Key systems include the ventromedial prefrontal cortex and the related default-mode network. These systems help to construct models of the 'self-in-context', compressing information across time and sensory modalities into conceptions of the underlying causes of experience. Self-in-context models endow events with personal meaning and allow predictive control over behaviour and peripheral physiology, including autonomic, neuroendocrine and immune function. They guide learning from experience and the formation of narratives about the self and one's world. Disorders of mental and physical health, especially those with high co-occurrence and convergent alterations in the functionality of the ventromedial prefrontal cortex and the default-mode network, could benefit from interventions focused on understanding and shaping mindsets and beliefs about the self, illness and treatment.

Investigating the relationship between emotional granularity and cardiorespiratory physiological activity in daily life

Emotional granularity describes the ability to create emotional experiences that are precise and context-specific. Despite growing evidence of a link between emotional granularity and mental health, the physiological correlates of granularity have been under-investigated. This study explored the relationship between granularity and cardiorespiratory physiological activity in everyday life, with particular reference to the role of respiratory sinus arrhythmia (RSA), an estimate of vagal influence on the heart often associated with positive mental and physical health outcomes. Participants completed a physiologically triggered experience-sampling protocol including ambulatory recording of electrocardiogram, impedance cardiogram, movement, and posture. At each prompt, participants generated emotion labels to describe their current experience. In an end-of-day survey, participants elaborated on each prompt by rating the intensity of their experience on a standard set of emotion adjectives. Consistent with our hypotheses, individuals with higher granularity exhibited a larger number of distinct patterns of physiological activity during seated rest, and more situationally precise patterns of activity during emotional events: granularity was positively correlated with the number of clusters of cardiorespiratory physiological activity discovered in seated rest data, as well as with the performance of classifiers trained on event-related changes in physiological activity. Granularity was also positively associated with RSA during seated rest periods, although this relationship did not reach significance in this sample. These findings are consistent with constructionist accounts of emotion that propose concepts as a key mechanism underlying individual differences in emotional experience, physiological regulation, and physical health.