Depression and long-term mortality risk in patients with coronary artery disease

Gender differences in the association between cardiovascular diseases and major depressive disorder among older adults in India

Background

Despite the global disease burden associated with the co-occurrence of cardiovascular diseases (CVDs) and depression, depression remains underdiagnosed and undertreated in the CVD population, especially among older adults in India. As such, this study examines (1) the association between single and multiple CVDs and major depressive disorder among older Indians; (2) whether this association is mediated by older adults' self-rated health and functional limitations; and (3) whether these associations vary for older men and women.

Methods

Data come from the 2017-18 wave 1 of the Longitudinal Ageing Study in India. Multivariable logistic regression is used to explore the association between CVDs and major depressive disorder among older men and women. The Karlson-Holm-Breen (KHB) method is used to examine the mediation effects of self-rated health and functional difficulties in the observed associations.

Results

Overall, 5.08% of the older adults had multiple CVDs. Older women (9.71%) had a higher prevalence of major depressive disorder compared to men (7.50%). Multiple CVDs were associated with greater odds of major depressive disorder after adjusting the potential covariates (adjusted odds ratio [AOR]: 1.49; 95% confidence interval [CI]: 1.10-2.00). Older men with multiple CVDs had a greater risk of major depressive disorder (AOR: 1.64; 95% CI: 1.05-2.57) relative to women with CVDs (AOR: 1.39; 95% CI: 0.93-2.08). The association between multiple CVDs and depression was mediated by self-rated health (34.03% for men vs. 34.55% for women), ADL difficulty (22.25% vs. 15.42%), and IADL difficulty (22.90% vs. 19.10%).

Conclusions

One in five older Indians with multiple CVDs reports major depressive disorder, which is three times more common than the prevalence of depressive disorder in older adults without CVDs. This association is attenuated by self-rated health and functional limitations. Moreover, these associations are more pronounced in older men relative to older women. These findings depart from prior inferences that men with CVDs are less psychologically distressed than their female counterparts. Moreover, the findings underscore the importance of gender-specific approaches to interventions and therapeutics for CVD-related mental health.

Self-reported cataract surgery and 10-year all-cause and cause-specific mortality: findings from the National Health and Nutrition Examination Survey

PURPOSE

To investigate the association of self-reported cataract surgery with all-cause and cause-specific mortality using a large-scale population-based sample.

METHODS

Data from the 1999-2008 cycles of the National Health and Nutrition Examination Survey were used. A self-reported history of cataract surgery was considered a surrogate for the presence of clinically significant cataract surgery. Mortality data were ascertained from National Death Index records. Hazard ratios (HRs) and 95% confidence intervals (CIs) for survival were estimated using Cox proportional hazards regression models.

RESULTS

A total of 14 918 participants were included in the analysis. During a median follow-up of 10.8 (Interquartile range, IQR, 8.25-13.7) years, 3966 (19.1%) participants died. Participants with self-reported cataract surgery were more likely to die from all causes and specific causes (vascular disease, cancer, accident, Alzheimer's disease, respiratory disease, renal disease and others) compared with those without (all Ps <0.05). The association between self-reported cataract surgery and all-cause mortality remained significant after multiple adjustments (HR=1.13; 95% CI 1.01 to 1.26). For cause-specific mortality, multivariable Cox models showed that self-reported cataract surgery predicted a 36% higher risk of vascular-related mortality (HR=1.36; 95% CI 1.01 to 1.82). The association with other specific causes of mortality did not reach statistical significance after multiple adjustments.

CONCLUSIONS

This study found significant associations of self-reported cataract surgery with all-cause and vascular mortalities. Our findings provide potential insights into the pathogenic pathways underlying cataract.

Depression and cardiovascular diseases

Depression is a well-known risk factor for adverse cardiovascular outcomes in patients with cardiovascular diseases. The prevalence of depression in patients with cardiovascular diseases has been reported to be approximately 20 %. A two-step depression screening protocol using the 2-item Patient Health Questionnaire (PHQ-2) and the 9-item Patient Health Questionnaire (PHQ-9) is recommended for patients with cardiovascular diseases. Cardiovascular diseases and depression share a common pathology, including increased activity of the sympathetic nervous system, hyperactivity of hypothalamic-pituitary-adrenal axis, and inflammation. Psychosocial and environmental factors are also associated with depression and cardiovascular outcomes. Randomized controlled trials of antidepressant treatment for patients with depression and cardiovascular diseases have shown no advantage regarding cardiovascular outcomes. However, improvement in depressive symptoms, regardless of the method, may lead to a reduction in subsequent cardiovascular events. A collaborative approach between cardiologists and psychiatrists is recommended to manage depression in patients with cardiovascular diseases. Future research should identify more specific targets for treating patients with cardiovascular diseases, involve collaboration with professionals across fields, and establish community support systems.

Association between cardio-metabolic risks and depressive symptoms among US adults (NHANES 2013-2018)

OBJECTIVES

To elucidate the association between cardio-metabolic risk factors and depressive symptoms among US adults.

METHODS

Data on 9,477 adults ≥ age 18 from the US National Health and Nutrition Examination Survey (NHANES) 2013-2018 were used. Number of cardio-metabolic risk (CMR) factors, from 0 to 5, was based on BMI, blood pressure, fasting blood glucose, and lipid levels. Depressive symptoms by Patient Health Questionnaire (PHQ-9) scores were categorized "no to mild symptoms" (0-9) and "clinically-significant depressive (CSD) symptoms" (10-27). Logistic regression analysis tested associations between CMR factors and CSD symptoms, adjusted for age, gender, education, income, race/ethnicity and smoking status.

RESULTS

CSD symptoms were significantly associated with low HDL, abdominal obesity, and high triglycerides. Increased numbers of CMR factors were associated with increased odds of CSD symptoms, from 1.45 times for 1 CMR to 2.55 times for 5 CMRs. The cross-sectional nature of the present study has resulted in some limitations like the inability to determine the direction and causality of the effects between depression and CMR. The study data was subject to response bias and recall errors as the participants self-reported the use of medications.

CONCLUSIONS

In US adults, cardio-metabolic risk factors were associated with clinically-significant depressive symptoms. Public health and clinical programs should include screening for both health issues, intervention for modifiable risk factors, and support for social determinants of health.

Cortical–Hypothalamic Integration of Autonomic and Endocrine Stress Responses

The prevalence and severity of cardiovascular disease (CVD) are exacerbated by chronic stress exposure. While stress-induced sympathetic activity and elevated glucocorticoid secretion impair cardiovascular health, the mechanisms by which stress-responsive brain regions integrate autonomic and endocrine stress responses remain unclear. This review covers emerging literature on how specific cortical and hypothalamic nuclei regulate cardiovascular and neuroendocrine stress responses. We will also discuss the current understanding of the cellular and circuit mechanisms mediating physiological stress responses. Altogether, the reviewed literature highlights the current state of stress integration research, as well unanswered questions about the brain basis of CVD risk.

Association of Cardiovascular Disease and Military Veteran Status With Impairments in Physical and Psychological Functioning: Retrospective Cross-Sectional Analysis of US National Survey Data

INTRODUCTION

The Veterans Health Administration (VHA) provides multidisciplinary team-based care with peer-to-peer support for diabetes and obesity, but not for most heart diseases.

OBJECTIVE

To inform disease-care models, assess physical and psychological functioning in veterans with, or at high risk of, heart disease.

METHODS

Retrospective, cross-sectional cohort analysis of data from the National Survey on Drug Use and Health, 2015-2019, based on standard measures of functioning: self-rated health, serious psychological distress, and high-risk substance use. Cohorts were veterans with respondent-reported heart disease, or at high risk of cardiovascular disease based on age/comorbidity combinations (HD/risk); nonveterans with HD/risk; and veterans without HD/risk. Ordinal logistic regression models adjusted for demographics, social determinants of health, and chronic conditions. A priori alpha was set to 0.01 because of large sample size (N = 28,314).

RESULTS

Among those with HD/risk, veterans (n = 3,483) and nonveterans (n = 16,438) had similar physical impairments, but distress trended higher among veterans (adjusted odds ratio = 1.36, 99% confidence interval [CI] = 0.99-1.86). Among those with comorbid HD/risk and behavioral health problems, regression-adjusted treatment rates were similar for veterans and nonveterans with psychological symptoms (55.9% vs. 55.2%, respectively, P = 0.531) or high-risk substance use (18.7% vs. 19.4%, P = .547); veterans were more likely to receive outpatient mental health treatment (36.1% [CI = 34.4%-37.8%] vs. 28.9% [CI = 28.2%-29.6%]).

CONCLUSION

An upward trend in distress among veterans compared with nonveterans with HD/risk was not explained by differences in behavioral health treatment utilization. Further research should test multidisciplinary team-based care for veterans with HD/risk, similar to that used for other chronic diseases.

Depression and anxiety following acute myocardial infarction in women

Cardiovascular disease is the leading global cause of mortality, with ischemic heart disease causing the majority of cardiovascular deaths. Despite this, diagnostic delay commonly occurs in women experiencing acute myocardial infarction (AMI) who have a higher associated in-hospital mortality. Several studies have demonstrated that women are significantly more likely than men to experience depression and anxiety following AMI which is linked with increased morbidity, rehospitalization, and mortality, as well as decreased quality of life. Thus, it is imperative that future work aims to understand the factors that put women at higher risk for depression and anxiety following AMI, informing prevention and intervention. This narrative review will summarize the current literature on the association between AMI and mental health in women, including the impact on morbidity, mortality, and quality of life.

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.

Effectiveness of e-Health cardiac rehabilitation program on quality of life associated with symptoms of anxiety and depression in moderate-risk patients

Exploring new models of medical care requires evaluating the impact of new care strategies not only on physiological parameters but also on the quality of life of the patient. On the other hand the presence of anxiety together with depression requires further consideration when planning appropriate management strategies. The aim of this study was to examine the effectiveness of a home-based cardiac rehabilitation program incorporating an e-Health technology on health-related quality of life associated with symptoms of anxiety and depression in moderate-risk patients. A multicenter, randomized controlled clinical trial was designed to compare a traditional hospital based cardiac rehabilitation program (n = 38, 35 male) with a mixed home surveillance program where patients exercised at home with a remote electrocardiographic monitoring device (n = 33, 31 male). The Short Form-36 (SF-36) Health Survey and the Goldberg questionnaire were used to evaluate quality of life and the presence of symptoms of anxiety and depression respectively. The results of this study show that the type of cardiac rehabilitation program did not influence the improvement in quality of life (p = 0.854), but the presence of symptoms of anxiety and depression did (p = 0.001). Although both programs achieved a decrease in anxiety and depression symptoms and improved functional capacity (p ≤ 0.001), a significant interaction effect was found between the group with or without anxiety and depression symptoms and the type of program in the bodily pain dimension (p = 0.021). Trial registration: Retrospectively registered NCT02796404 (10/06/2016) in clinialtrials.gov.

Relationship Between Kihon Checklist Score and Anxiety Levels in Elderly Patients Undergoing Early Phase II Cardiac Rehabilitation

Background

The frailty state consists of not only physical but also psycho-emotional problems, such as cognitive dysfunction and depression as well as social problems. However, few reports have examined the relationship between frailty and anxiety levels in elderly patients undergoing cardiac rehabilitation (CR).

Methods

We analyzed 255 patients (mean age: 74.9 ± 5.8 years, 67% male) who participated in early phase II CR at Juntendo University Hospital. At the beginning of CR, patients carried out self-assessments based on the Kihon Checklist (KCL) and the State Trait Anxiety Inventory Form (STAI). Patients were divided into three groups: frailty group (n = 99, 39%), pre-frailty group (n = 81, 32%), and non-frailty group (n = 75, 29%) according to the KCL. We assessed results from the KCL scores and its relationship with anxiety levels.

Results

Among the three groups, there were no significant differences in age, underlying illnesses, or the prevalence of coronary risk factors. Depressive mood domains of the KCL were significantly higher in the frailty and pre-frailty groups than in the non-frailty groups (3.0 ± 1.5 vs. 1.4 ± 1.2 vs. 0.4 ± 0.6; P < 0.01). The state anxiety level was significantly higher in the frailty group than in the non-frailty group (41.6 ± 0.9 vs. 34.9 ± 1.0; P < 0.01). The trait anxiety levels were significantly higher in the frailty group and pre-frailty group than in the non-frailty group (45.5 ± 0.9 vs. 39.2 ± 1.0 vs. 35.1 ± 1.1; P < 0.01). State anxiety and trait anxiety also showed a significantly positive correlations with the KCL scores (r = 0.32 vs. 0.41, P < 0.01).

Conclusions

Frailty scores were positively correlated not only with physical function but also with depression mood and anxiety levels in elderly patients undergoing early phase II CR. These results suggest that assessment of depressive mood and anxiety is also important in elderly patients undergoing early phase II CR.

Impact of sex and depressed mood on the central regulation of cardiac autonomic function

Cardiac autonomic dysregulation has been implicated in the comorbidity of major psychiatric disorders and cardiovascular disease, potentially through dysregulation of physiological responses to negative stressful stimuli (here, shortened to stress response). Further, sex differences in these comorbidities are substantial. Here, we tested the hypothesis that mood- and sex-dependent alterations in brain circuitry implicated in the regulation of the stress response are associated with reduced peripheral parasympathetic activity during negative emotional arousal. Fifty subjects (28 females) including healthy controls and individuals with major depression, bipolar psychosis and schizophrenia were evaluated. Functional magnetic resonance imaging and physiology (cardiac pulse) data were acquired during a mild visual stress reactivity challenge. Associations between changes in activity and functional connectivity of the stress response circuitry and variations in cardiovagal activity [normalized high frequency power of heart rate variability (HFn)] were evaluated using GLM analyses, including interactions with depressed mood and sex across disorders. Our results revealed that in women with high depressed mood, lower cardiovagal activity in response to negative affective stimuli was associated with greater activation of hypothalamus and right amygdala and reduced connectivity between hypothalamus and right orbitofrontal cortex, amygdala, and hippocampus. No significant associations were observed in women with low levels of depressed mood or men. Our results revealed mood- and sex-dependent interactions in the central regulation of cardiac autonomic activity in response to negative affective stimuli. These findings provide a potential pathophysiological mechanism for previously observed sex differences in the comorbidity of major depression and cardiovascular disease.

Advances in understanding mechanisms and therapeutic targets to treat comorbid depression and cardiovascular disease

Chronic or repeated social stress exposure often precipitates the onset of depression and cardiovascular disease (CVD). Despite a clear clinical association between CVD and depression, the pathophysiology underlying these comorbid conditions is unclear. Chronic exposure to social stress can lead to immune system dysregulation, mitochondrial dysfunction, and vagal withdrawal. Further, regular physical exercise is well-known to exert cardioprotective effects, and accumulating evidence demonstrates the antidepressant effect of exercise. This review explores the contribution of inflammation, mitochondrial dysfunction, and vagal withdrawal to stress-induced depression and CVD. Evidence for therapeutic benefits of exercise, anti-inflammatory therapies, and vagus nerve stimulation are also reviewed. Benefits of targeted therapeutics of mitochondrial agents, anti-inflammatory therapies, and vagus nerve stimulation are discussed. Importantly, the ability of exercise to impact each of these factors is also reviewed. The current findings described here implicate a new direction for research, targeting the shared mechanisms underlying comorbid depression-CVD. This will guide the development of novel therapeutic strategies for the prevention and treatment of these stress-related pathologies, particularly within treatment-resistant populations.

Depression in the medically ill

BACKGROUND

Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill.

METHODS

Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary.

RESULTS

Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation.

LIMITATIONS

Non-systematic review of the literature.

CONCLUSION

Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.

Prevalence and socio-demographic correlates of major depressive disorder in older adults in Hebei province, China

BACKGROUND

Major depressive disorder (MDD) is common among older adults. The epidemiology of MDD is greatly influenced by sociocultural and economic factors. This study examined the 1-month and lifetime prevalence of MDD and its socio-demographic correlates in older adults living in Hebei province, an agricultural area of China.

METHODS

Multistage, stratified, random sampling was administered between April and August 2016. The diagnosis of MDD was established with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) Axis I Disorders.

RESULTS

A total of 3911 participants were enrolled. The 1-month and lifetime prevalence of MDD in older adults was 2.0% (95%CI: 1.6-2.4%) and 3.4% (95%CI: 2.8-4.0%), respectively. Multivariable logistic regression analyses revealed that female gender [P < 0.001, adjusted odds ratio (aOR) = 2.6, 95%CI: 1.53-4.53], presence of comorbid major medical conditions (P < 0.001, aOR = 4.8, 95%CI: 2.17-10.39) and family history of psychiatric disorders (P = 0.013, aOR = 3.4, 95%CI: 1.30-8.96) were independently and significantly associated with higher odds of MDD.

CONCLUSION

The prevalence of MDD in older adults in Hebei province, China, was lower than most findings in China and other countries. Nevertheless, continued surveillance of elderly depression in China along with the development of primary, secondary and tertiary preventative interventions for the elderly with MDD is indicated.

Prefrontal Cortex Regulates Chronic Stress-Induced Cardiovascular Susceptibility

Background The medial prefrontal cortex is necessary for appropriate appraisal of stressful information, as well as coordinating visceral and behavioral processes. However, prolonged stress impairs medial prefrontal cortex function and prefrontal-dependent behaviors. Additionally, chronic stress induces sympathetic predominance, contributing to health detriments associated with autonomic imbalance. Previous studies identified a subregion of rodent prefrontal cortex, infralimbic cortex (IL), as a key regulator of neuroendocrine-autonomic integration after chronic stress, suggesting that IL output may prevent chronic stress-induced autonomic imbalance. In the current study, we tested the hypothesis that the IL regulates hemodynamic, vascular, and cardiac responses to chronic stress. Methods and Results A viral-packaged small interfering RNA construct was used to knockdown vesicular glutamate transporter 1 (vGluT1) and reduce glutamate packaging and release from IL projection neurons. Male rats were injected with a vGluT1 small interfering RNA-expressing construct or GFP (green fluorescent protein) control into the IL and then remained as unstressed controls or were exposed to chronic variable stress. IL vGluT1 knockdown increased heart rate and mean arterial pressure reactivity, while chronic variable stress increased chronic mean arterial pressure only in small interfering RNA-treated rats. In another cohort, chronic variable stress and vGluT1 knockdown interacted to impair both endothelial-dependent and endothelial-independent vasoreactivity ex vivo. Furthermore, vGluT1 knockdown and chronic variable stress increased histological markers of fibrosis and hypertrophy. Conclusions Knockdown of glutamate release from IL projection neurons indicates that these cells are necessary to prevent the enhanced physiological responses to stress that promote susceptibility to cardiovascular pathophysiology. Ultimately, these findings provide evidence for a neurobiological mechanism mediating the relationship between stress and poor cardiovascular health outcomes.

Depression Prevalence, Antidepressant Treatment Status, and Association with Sustained HIV Viral Suppression Among Adults Living with HIV in Care in the United States, 2009-2014

Previous research indicates a high burden of depression among adults living with HIV and an association between depression and poor HIV clinical outcomes. National estimates of diagnosed depression, depression treatment status, and association with HIV clinical outcomes are lacking. We used 2009-2014 data from the Medical Monitoring Project to estimate diagnosed depression, antidepressant treatment status, and associations with sustained viral suppression (all viral loads in past year < 200 copies/mL). Data were obtained through interview and medical record abstraction and were weighted to account for unequal selection probabilities and non-response. Of adults receiving HIV medical care in the U.S. and prescribed ART, 27% (95% confidence interval [CI] 25-29%) had diagnosed depression during the surveillance period; the majority (65%) were prescribed antidepressants. The percentage with sustained viral suppression was highest among those without depression (72%, CI 71-73%) and lowest among those with untreated depression (66%, CI 64-69%). Compared to those without depression, those with a depression diagnosis were less likely to achieve sustained viral suppression (aPR 0.95, CI 0.93-0.97); this association held for persons with treated depression compared to no depression (aPR 0.96, CI 0.94-0.99) and untreated depression compared to no depression (aPR 0.92, CI 0.89-0.96). The burden of depression among adults living with HIV in care is high. While in our study depression was only minimally associated with a lower prevalence of sustained viral suppression, diagnosing and treating depression in persons living with HIV remains crucial in order to improve mental health and avoid other poor health outcomes.

Heart and Brain Interaction of Psychiatric Illness: A Review Focused on Heart Rate Variability, Cognitive Function, and Quantitative Electroencephalography

Heart rate variability (HRV) reflects beat-to-beat variability in the heart rate due to the dynamic interplay of the sympathetic and parasympathetic nervous systems. HRV is considered an index of the functional status of the autonomic nervous system. A decrease in HRV is thus observed in individuals with autonomic dysfunction. Abnormal HRV has been reported in a range of mental disorders. In this review, we give an overview of HRV in patients with major depressive disorder (MDD), schizophrenia, and posttraumatic stress disorder (PTSD), one of whose core symptoms is cognitive dysfunction. The association between HRV and cognitive function is highlighted in this review. This review consists of three main sections. In the first section, we examine how HRV in patients with MDD, schizophrenia, and PTSD is characterized, and how it is different when compared to that in healthy controls. In the second section, beyond the heart itself, we discuss the intimate connection between the heart and the brain, focusing on how HRV interacts with quantitative electroencephalography (qEEG) in the context of physiological changes in the sleep cycle. Lastly, we finish the review with the examination of the association between HRV and cognitive function. The overall findings indicate that the reduction in HRV is one of main manifestations in MDD, schizophrenia, and PTSD, and also more generally HRV is closely linked to the change in qEEG and also to individual differences in cognitive performance.

The Influence of Sex on Cardiac Physiology and Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of death world-wide. Most of treatment strategies were based on studies conducted on male patients. Studies have shown that significant differences exist between the two sexes in the development of CVD. There are certain differences between men and women in the structure and physiological functions of the heart such as left ventricular mass index, resting heart rate, and contractile function. Accordingly, the pathological features of the heart such as the extend of hypertrophy, fibrosis, and remodeling are also different. In addition, different genders also affect clinical symptoms, responses to treatment and prognosis in the development of CVD. Therefore, it is important to take these differences into consideration when design treatment options for men and women.

Depression-like behavior corresponds with cardiac changes in a rodent model of spinal cord injury

In previous studies we have shown that approximately 1/3 of male Sprague Dawley rats develop symptoms of depression following a spinal cord injury (SCI). Using established behavioral tests to measure depression in rodents, we found that after SCI, subjects characterized as depressed had decreased sucrose preference, open field activity, social exploration, and burrowing behavior. As some of these tests of depression could be affected by the compromised motor function inherent to the SCI condition, the current study examined whether non-subjective, physiological differences in heart rate and heart rate variability were also associated with depression, as seen in humans. Male Sprague Dawley rats were implanted with radiotelemetry devices and either received a moderate contusion injury or remained intact. The implanted telemetry devices recorded home cage activity, body temperature, heart rate, and heart rate variability for 5 min/h throughout a 30-day post-injury assessment period. Depression behavior was evaluated using a battery of tests conducted on days 9-10 and 19-20 post-injury. Locomotor recovery and pain reactivity were also examined. Hierarchical clustering, based on the behavioral scores collected on the tests of depression, revealed that 28% of the SCI subjects displayed symptoms of depression, relative to the remaining 72% of SCI subjects. The subjects characterized as depressed had significantly lower social interaction and burrowing activity than the group that was not depressed. Interestingly, the subjects behaviorally characterized as depressed also had significantly lower heart rate variability than the not-depressed intact group. There was no difference between not-depressed SCI and intact rats on this measure. Therefore, in addition to behavior, depressed and not-depressed rats differ on measures of physiological function that are associated with depression in humans. These physiological differences further validate the rodent model of depression after SCI.

Sex differences in major depression and comorbidity of cardiometabolic disorders: impact of prenatal stress and immune exposures

Major depressive disorder topped ischemic heart disease as the number one cause of disability worldwide in 2012, and women have twice the risk of men. Further, the comorbidity of depression and cardiometabolic disorders will be one of the primary causes of disability worldwide by 2020, with women at twice the risk. Thus, understanding the sex-dependent comorbidities has public health consequences worldwide. We propose here that sex differences in MDD-cardiometabolic comorbidity originate, in part, from pathogenic processes initiated in fetal development that involve sex differences in shared pathophysiology between the brain, the vascular system, the CNS control of the heart and associated hormonal, immune, and metabolic physiology. Pathways implicate neurotrophic and angiogenic growth factors, gonadal hormone receptors, and neurotransmitters such as gamma amino butyric acid (GABA) on neuronal and vascular development of HPA axis regions, such as the paraventricular nucleus (PVN), in addition to blood pressure, in part through the renin-angiotensin system, and insulin and glucose metabolism. We show that the same prenatal exposures have consequences for sex differences across multiple organ systems that, in part, share common pathophysiology. Thus, we believe that applying a sex differences lens to understanding shared biologic substrates underlying these comorbidities will provide novel insights into the development of sex-dependent therapeutics. Further, taking a lifespan perspective beginning in fetal development provides the opportunity to target abnormalities early in the natural history of these disorders in a sex-dependent way.

Compromised Dynamic Cerebral Autoregulation in Patients With Depression

Background: Patients with depression tend to have various comorbid neurological symptoms, but the mechanisms remain unclear. The purpose of this study was to analyze the characteristics of dynamic cerebral autoregulation in depressed patients. Methods: Patients (aged ≥ 18 years) who were diagnosed with depression [17-item Hamilton Depression Rating Scale (HAMD) > 17] or suspected of depression (HAMD > 7) were enrolled in this study. Medically healthy volunteers were recruited as controls. The subjects also received the 7-item HAMD. We simultaneously recorded noninvasive continuous arterial blood pressure and bilateral middle cerebral artery blood flow velocity from each subject. Cerebral autoregulation was assessed by analyzing the phase difference using transfer function analysis. Results: This study enrolled 54 patients with suspected depression, 45 patients with depression, and 48 healthy volunteers. The mean phase difference values were significantly lower in the patients with depression (F = 9.071, P < 0.001). In the multiple regression analysis, depression was negatively correlated with the phase difference values. Conclusions: Dynamic cerebral autoregulation was compromised in patients with depression and negatively correlated with the depression score. Improving dynamic cerebral autoregulation may be a potential therapeutic method for treating the neurological symptoms of depression.

A case-vignette based assessment of patient's perspective on coronary revascularization strategies, the OPINION study

BACKGROUND AND AIMS

Significant left main (LM) stem disease is potentially life-threatening and mandates revascularization. This study aimed to assess how patients rate the importance of particular features of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), how this determines their preference for a particular treatment strategy, and whether particular personality characteristics influence this preference.

METHODS AND RESULTS

In total, 1145 patients who visited the outpatient clinic of the Erasmus Medical Center for stable coronary artery disease were asked to complete a case vignette-questionnaire on a hypothetical significant LM stenosis amenable to PCI or CABG. To assess the individual's personality disposition and general distress level, each patient had to complete a set of 3 standardized, validated questionnaires with satisfactory psychometric properties. Overall 89% of patients preferred PCI to CABG. PCI was the preferred strategy despite a higher risk for repeat revascularization and need for more medication. Remarkably, the fact that a risk for repeat revascularization is more common in the PCI group is less important for the patients who opt for PCI. Risk for stroke and bleeding were the most important arguments to opt for PCI over CABG. Type D personality, depression, and anxiety were all associated with a relatively higher preference for CABG as revascularization strategy.

CONCLUSION

Overall, when given the choice patients seem to have a clear preference for PCI over CABG and consider stroke and bleeding important procedure-related complications. Patients with Type D personality, depression, or anxiety favor CABG.

Chronic Blockade of Brain Endothelin Receptor Type-A (ETA) Reduces Blood Pressure and Prevents Catecholaminergic Overactivity in the Right Olfactory Bulb of DOCA-Salt Hypertensive Rats

Overactivity of the sympathetic nervous system and central endothelins (ETs) are involved in the development of hypertension. Besides the well-known brain structures involved in the regulation of blood pressure like the hypothalamus or locus coeruleus, evidence suggests that the olfactory bulb (OB) also modulates cardiovascular function. In the present study, we evaluated the interaction between the endothelinergic and catecholaminergic systems in the OB of deoxycorticosterone acetate (DOCA)-salt hypertensive rats. Following brain ET receptor type A (ET_A) blockade by BQ610 (selective antagonist), transcriptional, traductional, and post-traductional changes in tyrosine hydroxylase (TH) were assessed in the OB of normotensive and DOCA-salt hypertensive rats. Time course variations in systolic blood pressure and heart rate were also registered. Results showed that ET_A blockade dose dependently reduced blood pressure in hypertensive rats, but it did not change heart rate. It also prevented the increase in TH activity and expression (mRNA and protein) in the right OB of hypertensive animals. However, ET_A blockade did not affect hemodynamics or TH in normotensive animals. Present results support that brain ET_A are not involved in blood pressure regulation in normal rats, but they significantly contribute to chronic blood pressure elevation in hypertensive animals. Changes in TH activity and expression were observed in the right but not in the left OB, supporting functional asymmetry, in line with previous studies regarding cardiovascular regulation. Present findings provide further evidence on the role of ETs in the regulation of catecholaminergic activity and the contribution of the right OB to DOCA-salt hypertension.

Recent Approaches to Improve Medication Adherence in Patients with Coronary Heart Disease: Progress Towards a Learning Healthcare System

PURPOSE OF REVIEW

Non-adherence to medications for the secondary prevention of myocardial infarction (MI) is a major contributor to morbidity and mortality in these patients. This review describes recent advances in promoting adherence to therapies for coronary artery disease (CAD).

RECENT FINDINGS

Two large randomized controlled trials to "incentivize" adherence were somewhat disappointing; neither financial incentives nor "peer pressure" successfully increased rates of adherence in the post-MI population. Patient education and provider engagement appear to be critical aspects of improving adherence to CAD therapies, where the provider is a physician, pharmacist, or nurse and follow-up is performed in person or by telephone. Fixed-dose combinations of CAD medications, formulated as a so-called "polypill," have shown some early efficacy in increasing adherence. Technological advances that automate monitoring and/or encouragement of adherence are promising but seem universally dependent on patient engagement. For example, medication reminders via text message perform better if patients are required to respond. Multifaceted interventions, in which these and other interventions are combined together, appear to be most effective. There are several available types of proven interventions through which providers, and the health system at large, can advance patient adherence to CAD therapies. No single intervention to promote adherence will be successful in all patients. Further study of multifaceted interventions and the interactions between different interventions will be important to advancing the field. The goal is a learning healthcare system in which a network of interventions responds and adapts to patients' needs over time.

The predictive value of positive affect and Type D personality for adverse cardiovascular clinical outcomes in patients with non-obstructive coronary artery disease

BACKGROUND

Patients with non-obstructive coronary artery disease (NOCAD) continue to experience disabling symptoms. Positive affect (PA) has shown a cardioprotective potential. Type D personality has previously been shown to have a deleterious effect on adverse outcomes in diverse cardiac populations. Little is known about the predictive value of PA and Type D personality for long-term outcomes in NOCAD patients. The aim was to investigate the effect of PA and Type D personality on clinical outcomes.

METHODS

547 patients (mean age 61 years±9, 48% male) who underwent a coronary angiography or CT-scan between January 2009 and February 2013 answered questionnaires concerning PA (GMS) and Type D personality (DS14). Cox proportional hazards analyses were performed.

RESULTS

When analyzed dichotomously, PA was a significant predictor of need for repeat cardiac testing (HR=0.64, 95% CI: 0.41-0.99), but not emergency department (ED) admissions (HR=0.83, 95% CI: 0.52-1.32) after adjustment for age, sex, education, diagnosis by group, BMI and hypertension. Analyzed continuously, the predictive value of PA was non-significant for both repeat testing (HR=0.85, 95% CI: 0.69-1.06) and ED admissions (HR=0.98, 95% CI: 0.77-1.23). Type D personality, both continuously and dichotomously, was not significantly associated with the outcomes. Findings were also examined for men and women separately.

CONCLUSION

Although Type D personality was not predictive of adverse events in this sample, PA is an interesting and important variable to take into account in NOCAD patients. Research on psychosocial factors in NOCAD patients should consider the importance of choices of endpoint, given the heterogeneity of NOCAD patients.

The prevalence of depressive symptoms among older patients with hypertension in rural China

OBJECTIVE

The comorbidity of depression and hypertension (HTN) is common and complicates the management of both conditions. This study investigated the prevalence of depressive symptoms among older patients with HTN in rural China and explored the relationship between the two conditions.

METHODS

The baseline data of older patients diagnosed with HTN included in the depression/HTN in Chinese Older Adults-Collaborations for Health Study were used for the analysis. The Chinese Older Adults-Collaborations for Health Study was conducted in rural villages of Tonglu County, Zhejiang Province, China. In all, 10 389 older village residents had HTN (57.2% female, mean age 71.5 ± 8.1 years). Blood pressure was measured by using a calibrated manual sphygmomanometer and stethoscope. Depressive symptom was measured by using the Chinese version of the nine-item Patient Health Questionnaire.

RESULTS

Among 10 389 patients with HTN, 12.8% had significant depressive symptoms (nine-item Patient Health Questionnaire ≥ 10). Rates of significant depressive symptoms were 5.3% and 32.8% among patients with controlled and uncontrolled HTN (systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90), respectively (χ²  = 8.701, p < 0.001). Logistic regression analysis indicated that those in older age group (≥70 years) and with uncontrolled HTN have higher rates of significant depressive symptoms than those who are younger (age 60 to <70) and with controlled HTN.

CONCLUSION

Our findings show high rates of depressive symptoms among patients with HTN in rural China and higher rates of depressive symptoms among patients with uncontrolled HTN. These support the development and dissemination of integrative care approaches for older adults with HTN and depression in rural China. Copyright © 2016 John Wiley & Sons, Ltd.

Psychological sequelae of myocardial infarction

Patient with myocardial infarction (MI) are often affected by psychological disorders such as depression, anxiety, and post-traumatic stress disorder. Psychological disorders are disabling and have a negative influence on recovery, reduce the quality of life and causes high mortality rate in MI patients. Despite tremendous advancement in technologies, screening scales, and treatment strategies, psychological sequelae of MI are currently understudied, underestimated, underdiagnosed, and undertreated. Depression is highly prevalent in MI patients followed by anxiety and post-traumatic stress disorder. Pathophysiological factors involved in psychopathologies observed in patients with MI are sympathetic over-activity, hypothalamic-pituitary-adrenal axis dysfunction, and inflammation. Numerous preclinical and clinical studies evidenced a positive association between MI and psychopathologies with a common molecular pathophysiology. This review provides an update on diagnostic feature, prevalence, pathophysiology, clinical outcomes, and management strategies of psychopathologies associated with MI. Moreover, preclinical research findings on molecular mechanisms involved in post-MI psychopathologies and future therapeutic strategies have been outlined in the review.

Enhanced External Counterpulsation Therapy: Past, Present, and Future

External counterpulsation therapy was first developed over half a century ago as a resuscitative tool to support the failing heart and was based on hemodynamic principles of the intraaortic balloon pump. Over the course of last few decades, it has evolved into the modern enhanced external counterpulsation (EECP) therapy, which has proven to be a safe, effective, and low-cost noninvasive treatment for patients with debilitating angina and chronic heart failure who are poor candidates for revascularization procedures and have suboptimal results from other therapies. Numerous studies have shown EECP to be efficacious in patients with chronic angina, with its effects lasting for several years after completion of therapy. Besides being safe in patients with coexisting left ventricular dysfunction, there is emerging evidence that EECP therapy may result in improvement in exercise capacity and oxygen consumption in heart failure patients. Several mechanisms have been postulated to explain the therapeutic effects of EECP, including improvement in endothelial function, promotion of angiogenesis and new collaterals, reduction in atherosclerotic burden, improvement in ventricular function, and peripheral training effects analogous to that of exercise. With greater understanding of these complex mechanisms, possible applications of EECP have broadened in recent years, with its use being studied in conditions like hepatorenal syndrome, erectile dysfunction, and restless leg syndrome. This review article offers a historical perspective on the origins of EECP, an overview of our current understanding of its physiological effects, and a glimpse at its future utilization in clinical practice.

Clinical Impact of Subsequent Depression in Patients With a New Diagnosis of Stable Angina: A Population-Based Study

BACKGROUND

Depression is prevalent among patients with myocardial infarction and is associated with a worse prognosis. However, little is known about its importance in patients with chronic stable angina. We conducted a retrospective population-based cohort study to determine the occurrence and predictors of developing depression in patients with a new diagnosis of chronic stable angina. In addition, we sought to understand its impact on subsequent clinical outcomes.

METHODS AND RESULTS

Our cohort included patients in Ontario, Canada, with stable angina based on obstructive coronary artery disease found on angiogram. Depression was ascertained by physician billing codes and hospital admissions diagnostic codes. We first developed multivariable Cox proportional hazards models to determine predictors of developing depression. Clinical outcomes of interest included all-cause mortality, admission for myocardial infarction, and subsequent revascularization. Using hierarchical multivariable Cox proportional hazards models with occurrence of depression as a time-varying variable to control for potential immortal time bias, we evaluated the impact of depression on clinical outcomes. Our cohort consisted of 22 917 patients. The occurrence of depression after diagnosis of stable chronic angina was 18.8% over a mean follow-up of 1084 days. Predictors of depression included remote history of depression, female sex, and more symptomatic angina based on Canadian Cardiovascular Society class. Patients who developed depression had a higher risk of death (hazard ratio 1.83, 95% confidence interval 1.62-2.07) and admission for myocardial infarction (hazard ratio 1.36, 95% confidence interval 1.10-1.67) compared with nondepressed patients.

CONCLUSIONS

Depression is common in patients with chronic stable angina and is associated with increased morbidity and mortality.

Association of anger proneness, depression and low social support with peripheral arterial disease: the Atherosclerosis Risk in Communities Study

There is mounting evidence to suggest that psychosocial factors, including anger proneness, depression and social isolation, are risk factors for cardiovascular disease. Nevertheless, evidence relating these factors to peripheral arterial disease (PAD) and intermittent claudication remains sparse. Using data from the Atherosclerosis Risk in Communities Study, we analyzed the relationship of psychosocial variables (Spielberger anger score, depression score from the Maastricht questionnaire, and a perceived social support scale) at study visit 2 with incident PAD (ankle-brachial index ≤0.9; a hospital discharge diagnosis of PAD, leg amputation, or leg revascularization procedures; or intermittent claudication). In 12 965 middle-aged adults with no prior history of PAD, 854 developed PAD over a mean follow-up time of 9.7 years, yielding an incidence rate of 6.8 per 1000 person years. A modest, monotonic dose-response, positive association between anger proneness and incident PAD was observed in a multivariable model: relative risk (RR) = 1.15 (95% confidence interval (CI) 0.99-1.38) in the moderate anger group and RR = 1.38 (95% CI 1.08-1.76) in the high anger group, compared with the low anger group. When compared with a low level of depressive symptoms, moderate and high levels of depressive symptoms were also associated with greater incident PAD, with multivariable RRs of 1.20 (95% CI 0.99-1.45) and 1.44 (95% CI 1.19-1.74) respectively. There was no association of perceived level of social support with the occurrence of PAD. Anger proneness and depressive symptoms may be associated with the occur-rence of PAD, as for other atherosclerotic syndromes. These findings may warrant confirmation in further studies and, if causal, could serve as a unique target for a PAD prevention trial.

Relation between Major and Minor Depression and Heart Rate, Heart-Rate Variability, and Clinical Characteristics of Patients with Acute Coronary Syndrome

This study examined the prevalence of major and minor depression in patients with acute coronary syndrome and their relation with heart rate and heart-rate variability, and clinical characteristics. The study group included 297 patients, 200 men and 97 women, between ages of 21 and 70 years ( M age = 57.5 ± 9.6), who were admitted to a coronary care unit with acute coronary syndrome and survived to discharge from the hospital. Major and minor depression were diagnosed using DSM-IV. There were 44.1% patients with acute coronary syndrome without depression, 29.3% with minor depression, and 26.6% with major depression. The prevalence of minor and major depression was more elevated in patients with non-ST-segment elevation myocardial infarction and unstable angina than in patients with ST-segment elevation myocardial infarction. Ventricular fibrillation and atrial fibrillation were more common in patients with major and minor depression than in patients without depression. The 24-hr. duration of heart-beat intervals and heart-rate variability were significantly lower in patients with major and minor depression than in patients without depression. This study implies that clinical depression was significantly comorbid with the acute coronary syndrome and was related to hypertension, diabetes mellitus, age, sex, type of acute coronary syndrome, left ventricular failure, higher heart rate, and lower heart-rate variability.

Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement

Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.

Impact of antidepressants use on risk of myocardial infarction: A systematic review and meta-analysis

Aims:

The aim of the study was to perform a systematic review and meta-analysis to determine the association between antidepressants use and risk of myocardial infarction (MI), and whether this association differs between tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs).

Methods:

A PubMed/MEDLINE search was conducted for studies published up to December 2013. Included studies were evaluated for publication bias and heterogeneity. Depending on the presence of heterogeneity, a random or fixed effects model was used to identify the pooled relative risk (RR) with 95% confidence intervals (CIs). Cumulative meta-analysis, subgroup and sensitivity analyses were also performed. All analyses were performed using comprehensive meta-analysis software.

Results:

Fourteen (five cohort and nine case–control) studies were included. There was heterogeneity among the studies (P_{heterogeneity} = 0.02; I² = 68%) but no publication bias (Begg's P = 0.30 and Egger's P = 0.45). Antidepressants use significantly increases the risk of myocardial infarction (MI) (RR = 2.03; 95% CI = 1.30–3.18; P < 0.01). On subgroup analysis by study design, cohort studies show significant positive association (RR = 2.16; 95% CI = 1.42–3.29; P < 0.01), but not case–control studies (RR = 2.47; 95% CI = 0.69–8.90; P = 0.17). Sensitivity analysis and cumulative meta-analysis confirmed the stability of results. TCAs users are having 36% increased risk of MI after excluding one outlier (RR = 1.36; 95% CI = 1.10–1.67; P < 0.01), but SSRIs showing no association (RR = 0.84; 95% CI = 0.57–1.22; P = 0.35).

Conclusions:

We found evidence that the use of antidepressants was associated with elevated risk of MI. Further research is needed to identify the underlying biological mechanisms.

Mapping inflammation onto mood: Inflammatory mediators of anhedonia

Evidence supports inflammatory involvement in mood and cognitive symptoms across psychiatric, neurological and medical disorders; however, inflammation is not a sensitive or specific characteristic of these diagnoses. The National Institute of Mental Health Research Domain Criteria (RDoC) ask for a shift away from symptom-based diagnoses toward a transdiagnostic neurobiological focus in the study of brain illnesses. The RDoC matrix may provide a useful framework for integrating the effects of inflammation on brain function. Based on preclinical and clinical findings, relevant relationships span negative and positive valence systems, cognitive systems, systems for social processes and arousal/regulatory systems. As an exemplar, we consider the psychopathological domain of anhedonia, conceptualizing the relevance of inflammation (e.g., cellular immunity) and downstream processes (e.g., indoleamine 2,3-dioxygenase activation and oxidative inactivation of tetrahydrobiopterin) across RDoC units of analysis (e.g., catecholamine neurotransmitter molecules, nucleus accumbens medium spiny neuronal cells, dopaminergic mesolimbic and mesocortical reward circuits, animal paradigms, etc.). We discuss implications across illnesses affecting the brain, including infection, major depressive disorder, stroke, Alzheimer's disease and type 2 diabetes.

Acute Stress Decreases but Chronic Stress Increases Myocardial Sensitivity to Ischemic Injury in Rodents

Cardiovascular disease (CVD) is the largest cause of mortality worldwide, and stress is a significant contributor to the development of CVD. The relationship between acute and chronic stress and CVD is well evidenced. Acute stress can lead to arrhythmias and ischemic injury. However, recent evidence in rodent models suggests that acute stress can decrease sensitivity to myocardial ischemia-reperfusion injury (IRI). Conversely, chronic stress is arrhythmogenic and increases sensitivity to myocardial IRI. Few studies have examined the impact of validated animal models of stress-related psychological disorders on the ischemic heart. This review examines the work that has been completed using rat models to study the effects of stress on myocardial sensitivity to ischemic injury. Utilization of animal models of stress-related psychological disorders is critical in the prevention and treatment of cardiovascular disorders in patients experiencing stress-related psychiatric conditions.

Enhanced External Counterpulsation Is an Effective Treatment for Depression in Patients With Refractory Angina Pectoris

OBJECTIVE

To examine the effect of enhanced external counterpulsation (EECP) on depression in patients with refractory angina pectoris (Canadian Cardiovascular Society class 2-4).

METHOD

The study was a prospective observational investigation with a 2-month control period preceding the EECP therapy (to minimize a possible effect of the regression-toward-the-mean phenomenon). The patients were examined 2 months before and just before EECP and just after, 3 months after, and 12 months after EECP. Depression was assessed using the Major Depression Inventory and the ICD-10. During EECP, 3 sets of cuffs were fastened around the lower extremities and were inflated sequentially to a pressure of 260 mm Hg in each diastole for 60 minutes 5 days a week for 7 weeks (35 sessions). The study was conducted at a regional hospital in Denmark from May 2006 to January 2011.

RESULTS

Fifty patients with angina pectoris and an abnormal coronary angiography, with no possibility for revascularization, were included (72% men, mean age of 63 years) between May 2006 and January 2011. The prevalence of depression before EECP was 18%, just after was 2%, 3 months after was 2%, and 12 months after was 4% (P = .013). The depressive state was more severe at a lower age (P = .016). No significant predictors of effect of EECP on depression were found (P > .05), and no association was detected between decline in depressive state and chest pain (P > .05).

CONCLUSIONS

The study indicates that EECP is an effective treatment for depression in patients with refractory angina pectoris, that depression is more severe in younger patients, and that the effect of EECP on depression is not related to the effect on chest pain.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01112163.

Acute coronary syndrome-associated depression: the salience of a sickness response analogy?

Depression emerging in conjunction with acute coronary syndrome (ACS) is thought to constitute a distinct high-risk phenotype with inflammatory determinants. This review critically examines the notion put forward in the literature that ACS-associated depression constitutes a meaningful subtype that is qualitatively different from depressive syndromes observed in psychiatric patients; and evaluates the salience of an analogy to the acute sickness response to infection or injury as an explanatory model. Specific features differentiating ACS-associated depression from other phenotypes are discussed, including differences in depression symptom profiles, timing of the depressive episode in relation to ACS, severity of the cardiac event, and associated immune activation. While an acute sickness response analogy offers a plausible conceptual framework, concrete evidence is lacking for inflammatory activity as the triggering mechanism. It is likely that ACS-associated depression encompasses several causative scenarios.

The mechanisms by which antidepressants may reduce coronary heart disease risk

BACKGROUND

Depression is known to increase the risk for coronary heart disease (CHD) likely through various pathogenetic actions. Understanding the links between depression and CHD and the effects of mediating these links may prove beneficial in CHD prevention.

METHODS

An integrated model of CHD was used to elucidate pathogenetic pathways of importance between depression and CHD. Using biomarker relative risk data the pathogenetic effects are representable as measurable effects based on changes in biomarkers.

RESULTS

A 'connection graph' presents interactions by illustrating the relationship between depression and the biomarkers of CHD. The use of selective serotonin reuptake inhibitors (SSRIs) is postulated to have potential to decrease CHD risk. Comparing the 'connection graph' of SSRI's to that of depression elucidates the possible actions through which risk reduction may occur.

CONCLUSIONS

The CHD effects of depression appear to be driven by increased inflammation and altered metabolism. These effects might be mediated with the use of SSRI's.

Design and methods of the Gentle Cardiac Rehabilitation Study--A behavioral study of tai chi exercise for patients not attending cardiac rehabilitation

INTRODUCTION

Cardiac rehabilitation (CR) programs reduce overall and cardiovascular mortality in patients with a history of acute coronary events or revascularization procedures, but only 30% of patients enroll in CR and attrition rates reach up to 60%. Tai chi, a mind-body practice based on light/moderate aerobic exercise accompanied by meditative components could be a possible exercise option for patients who do not attend CR.

METHODS/DESIGN

Sixty patients will be randomized to a "LITE" condition (one tai chi session twice weekly for 12 weeks) or to a "PLUS" condition (one tai chi session 3 times weekly for 12 weeks, followed by maintenance classes 1-2 times weekly for an additional 12 weeks). Measurements will be conducted at baseline, 3-, 6-, and 9 months after enrollment. The primary outcome is to determine the feasibility, acceptability and safety of each dose. Secondary outcomes include estimates of effect size of each dose on accelerometry-assessed physical activity; the proportion of patients meeting current recommendations for physical activity; and measures of fitness, quality of life, body weight, and sleep. In addition, we will collect exploratory information on possible mediators (exercise self-efficacy, perceived social support, resilience, mindfulness, and depression).

CONCLUSIONS

Findings from this pilot study will provide preliminary indications about the usefulness of tai chi as an exercise option for patients not attending traditional CR programs. Results will also shed light on the possible mechanisms by which tai chi practice may improve overall physical activity among patients with atherosclerotic coronary heart disease.

Role of Heart and its Diseases in the Etiology of Depression According to Avicenna's Point of View and its Comparison with Views of Classic Medicine

Background:

Depression is one of the most important medical problems in today's world; despite its high prevalence, its causes unfortunately remain not fully known. Among important issues regarding this is its relation with heart diseases. Based on studies this comorbidity increase morbidity and mortality and leads to worst prognosis. However the cause of such high rate of comorbidity is unclear and instead of efforts to understand this correlation has prompted the medical world to consult other medicinal disciplines, not only to find the answer but also to increase the effectiveness of treatment and decrease its cost.

Methods:

We first reviewed the most important ancient causes for depression mentioned by Avicenna and considered those as the key words for our next step. Then, we made a literature search (PubMed and Scopus) with those key words to find out new scientific findings in modern medicine about the Avicenna's suggestions.

Results:

Avicenna does not regard depression as only a mental ailment, but as a disorder resulted by the involvement of brain, heart and blood. He believed that the main causes of depressive events are rooted in heart diseases; in most cases brain is only affected secondary to the heart. Thus he declared that for the treatment of depressive disorders, the underlying cardiovascular diseases should be considered.

Conclusions:

It is worthwhile to consider the Avicenna's recommended causes of depression and to design future scientific studies based on his suggestions.

Somatic, but not cognitive-affective, symptoms are associated with reduced heart rate variability in individuals with dysphoria

Background: Somatic, but not cognitive–affective, symptoms of depression have been associated with reduced heart rate variability (HRV), and with poor prognosis in cardiovascular patients. However, factors concomitant with cardiovascular diseases may confound the relationship between somatic symptoms of depression and reduced HRV. Therefore, this study examined whether reduced HRV was differentially associated with cognitive–affective and somatic symptoms of depression in medically healthy individuals with and without dysphoria.

Methods: Self-reported cognitive–affective and somatic symptoms as measured with the Beck Depression Inventory-II questionnaire and time and frequency domain parameters of HRV were collected in 62 medically healthy individuals, of whom 25 with and 37 without dysphoria.

Results: Somatic, but not cognitive–affective, symptoms of depression were inversely associated with SD of NN intervals (β = -0.476, p < 0.05), number of interval differences of successive NN intervals greater than 50 ms (NN50; β = -0.498, p < 0.03), and HRV total power (β = -0.494, p < 0.04) in the group with dysphoria, after controlling for sex, anxiety, and lifestyle factors. Cognitive–affective and somatic symptoms were not related to any of the HRV parameters in the group without dysphoria (all ps > 0.24).

Conclusion: By showing that the relationship between somatic depressive symptoms and reduced HRV extends to medically healthy individuals with dysphoria, the present findings suggest that this association is independent of factors concomitant with cardiovascular diseases. The present study also suggests that individuals with somatic rather than cognitive–affective subsets of depressive symptoms may be at greater risk for developing cardiovascular diseases.

Detrimental effects of chemotherapeutics and other drugs on the endothelium: A call for endothelial toxicity profiling

The vascular endothelium is a real "maestro of circulation", and endothelial dysfunction leads to atherothrombosis, its cardiovascular complications, as well as to many other diseases. It is surprising that quite a large number of drugs seem to hamper the vasoprotective mechanisms of the endothelium, possibly promoting the development of cardiovascular diseases in patients initially treated for non-cardiological conditions. Toxicity profiling (including cardiac and liver toxicity assessment) is a routine procedure performed during pre-clinical drug development. Unfortunately, endothelium-dependent side effects are not taken into account in standard toxicity profiling protocols, as the "endothelial safety" of drugs is not required in order to enter the clinical phase of drug development. Presumably, this might be one of the reasons why several efficient therapeutics, including rofecoxib (COX-2 inhibitor), torcetrapib (CETP-inhibitor), and bardoxolone (Nrf2 activator), have unexpectedly displayed clinically significant cardiovascular hazard, resulting in their withdrawal from the market or alarming comments, respectively. In this review, we will briefly characterize the endothelial activity profiles of chemotherapeutics, antidepressants and antipsychotics-all drugs prescribed for severe, life-threatening and/or life-long diseases-and will show that at least some of them may display clinically relevant detrimental effects on endothelial function.