Patients with stroke and psychiatric comorbidities have lower carotid revascularization rates

Differences in TAVR Utilization in Aortic Stenosis Among Patients With and Without Psychiatric Comorbidities

Background

Transcatheter aortic valve replacement (TAVR) is one of the primary treatment modalities for aortic stenosis (AS). Disparities affecting certain groups could result in lower utilization of this life-saving procedure. This study aims to investigate the effects of associated psychiatric conditions on the likelihood of TAVR in hospitalized AS patients.

Methods

Our retrospective observational study used the National Inpatient Sample to identify hospitalized patients with AS. Using the International Classification of Diseases, 10th Revision, Clinical Modification patients were stratified into those without psychiatric comorbidities, and those with psychiatric comorbidities. The primary outcome was comparing the odds of TAVR between AS patients with and without psychiatric comorbidities. The secondary outcome assessed the association between TAVR and specific psychiatric comorbidities, using multivariable logistic regression while adjusting for prespecified covariates.

Results

The study included 1,549,785 AS patients, of which 26% had psychiatric comorbidities. Patients with any psychiatric comorbidity had a significantly reduced likelihood of TAVR (adjusted odds ratio [aOR], 0.76; P < .001). For 2 psychiatric comorbidities, (aOR, 0.80; P < .001), and for more than 2 comorbid mental disorders (aOR, 0.46; P < .001). Lower TAVR odds were observed in patients with depression (aOR, 0.79), anxiety (aOR, 0.79), bipolar disorder (aOR, 0.74), substance use (aOR, 0.73), and psychotic disorders (aOR, 0.61), with P values < .001. There was no significant difference in the odds of surgical aortic valve replacement between those with and without psychiatric comorbidities.

Conclusions

AS patients with psychiatric conditions face reduced TAVR likelihood. Further research is needed to confirm, explore, and address factors contributing to this disparity.

Advanced imaging use and delays among inpatients with psychiatric comorbidity

OBJECTIVE

To determine whether presence of a psychiatric comorbidity impacts use of inpatient imaging tests and subsequent wait times.

METHODS

This was a retrospective cohort study of all patients admitted to General Internal Medicine (GIM) at five academic hospitals in Toronto, Ontario from 2010 to 2019. Exposure was presence of a coded psychiatric comorbidity on admission. Primary outcome was time to test, as calculated from the time of test ordering to time of test completion, for computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or peripherally inserted central catheter (PICC) insertion. Multilevel mixed-effects models were used to identify predictors of time to test, and marginal effects were used to calculate differences in absolute units (h). Secondary outcome was the rate of each type of test included. Subgroup analyses were performed according to type of psychiatric comorbidity: psychotic, mood/anxiety, or substance use disorder.

RESULTS

There were 196,819 GIM admissions from 2010to 2019. In 77,562 admissions, ≥1 advanced imaging test was performed. After adjusting for all covariates, presence of any psychiatric comorbidity was associated with increased time to test for MRI (adjusted difference: 5.3 h, 95% confidence interval [CI]: 3.9-6.8), PICC (adjusted difference: 3.7 h, 95% CI: 1.6-5.8), and ultrasound (adjusted difference: 3.0 h, 95% CI: 2.3-3.8), but not for CT (adjusted difference: 0.1 h, 95% CI: -0.3 to 0.5). Presence of any psychiatric comorbidity was associated with lower rate of ordering for all test types (adjusted difference: -17.2 tests per 100 days hospitalization, interquartile range: -18.0 to -16.3).

CONCLUSIONS

There was a lower rate of ordering of advanced imaging among patients with psychiatric comorbidity. Once ordered, time to test completion was longer for MRI, ultrasound, and PICC. Further exploration, such as quantifying rates of cancelled tests and qualitative studies evaluating hospital, provider, and patient barriers to timely advanced imaging, will be helpful in elucidating causes for these disparities.

Exploring the Association between Schizophrenia and Cardiovascular Diseases: Insights into the Role of Sigma 1 Receptor

Contemporary society is characterized by rapid changes. Various epidemiological, political and economic crises represent a burden to mental health of nowadays population, which may at least partially explain the increasing incidence of mental disorders, including schizophrenia. Schizophrenia is associated with premature mortality by at least 13-15 years. The leading cause of premature mortality in schizophrenia patients is high incidence of cardiovascular diseases. The specific-cause mortality risk for cardiovascular diseases in schizophrenia patients is more than twice higher as compared to the general population. Several factors are discussed as the factor of cardiovascular diseases development. Intensive efforts to identify possible link between schizophrenia and cardiovascular diseases are made. It seems that sigma 1 receptor may represent such link. By modulation of the activity of several neurotransmitter systems, including dopamine, glutamate, and GABA, sigma 1 receptor might play a role in pathophysiology of schizophrenia. Moreover, significant roles of sigma 1 receptor in cardiovascular system have been repeatedly reported. The detailed role of sigma 1 receptor in both schizophrenia and cardiovascular disorders development however remains unclear. The article presents an overview of current knowledge about the association between schizophrenia and cardiovascular diseases and proposes possible explanations with special emphasis on the role of the sigma 1 receptor.

Predictive model, miRNA-TF network, related subgroup identification and drug prediction of ischemic stroke complicated with mental disorders based on genes related to gut microbiome

Background

Patients with comorbid schizophrenia, depression, drug use, and multiple psychiatric diagnoses have a greater risk of carotid revascularization following stroke. The gut microbiome (GM) plays a crucial role in the attack of mental illness and IS, which may become an index for the diagnosis of IS. A genomic study of the genetic commonalities between SC and IS, as well as its mediated pathways and immune infiltration, will be conducted to determine how schizophrenia contributes to the high prevalence of IS. According to our study, this could be an indicator of ischemic stroke development.

Methods

We selected two datasets of IS from the Gene Expression Omnibus (GEO), one for training and the other for the verification group. Five genes related to mental disorders and GM were extracted from Gene cards and other databases. Linear models for microarray data (Limma) analysis was utilized to identify differentially expressed genes (DEGs) and perform functional enrichment analysis. It was also used to conduct machine learning exercises such as random forest and regression to identify the best candidate for immune-related central genes. Protein-protein interaction (PPI) network and artificial neural network (ANN) were established for verification. The receiver operating characteristic (ROC) curve was drawn for the diagnosis of IS, and the diagnostic model was verified by qRT-PCR. Further immune cell infiltration analysis was performed to study the IS immune cell imbalance. We also performed consensus clustering (CC) to analyze the expression of candidate models under different subtypes. Finally, miRNA, transcription factors (TFs), and drugs related to candidate genes were collected through the Network analyst online platform.

Results

Through comprehensive analysis, a diagnostic prediction model with good effect was obtained. Both the training group (AUC 0.82, CI 0.93-0.71) and the verification group (AUC 0.81, CI 0.90-0.72) had a good phenotype in the qRT-PCR test. And in verification group 2 we validated between the two groups with and without carotid-related ischemic cerebrovascular events (AUC 0.87, CI 1-0.64). Furthermore, we investigated cytokines in both GSEA and immune infiltration and verified cytokine-related responses by flow cytometry, particularly IL-6, which played an important role in IS occurrence and progression. Therefore, we speculate that mental illness may affect the development of IS in B cells and IL-6 in T cells. MiRNA (hsa-mir-129-2-3p, has-mir-335-5p, and has-mir-16-5p) and TFs (CREB1, FOXL1), which may be related to IS, were obtained.

Conclusion

Through comprehensive analysis, a diagnostic prediction model with good effect was obtained. Both the training group (AUC 0.82, CI 0.93-0.71) and the verification group (AUC 0.81, CI 0.90-0.72) had a good phenotype in the qRT-PCR test. And in verification group 2 we validated between the two groups with and without carotid-related ischemic cerebrovascular events (AUC 0.87, CI 1-0.64). MiRNA (hsa-mir-129-2-3p, has-mir-335-5p, and has-mir-16-5p) and TFs (CREB1, FOXL1), which may be related to IS, were obtained.

Symptoms of Anxiety and Depression and Sense of Coherence in Patients Undergoing Carotid Artery Stenting

BACKGROUND

The sense of coherence is lower in patients with somatic diseases and psychiatric disorders.

PURPOSE

The purpose of this study was to evaluate the intensity of depression and anxiety symptoms and their relationship with the sense of coherence and to try to determine the relationship between the strength of sense of coherence and symptoms of depression and anxiety with the presence of symptoms of carotid atherosclerosis in a group of patients undergoing carotid artery stenting.

METHODS

35 patients, including 13 with symptomatic atherosclerosis in the carotid arteries, completed self-report tests: Hospital Scale of Depression and Anxiety (HADS) and the SOC-29 Life Orientation Questionnaire (SOC-29), 22 of whom also rated their subjective feelings of anxiety and depression on a scale included in the author's questionnaire.

RESULTS

Both symptomatic and asymptomatic patients did not differ significantly in the severity of depression, but they differed in anxiety levels as assessed by the HADS scale. There were no differences in the overall strength of sense of coherence and its individual components. Nearly 12% of those undergoing carotid artery stenting have pronounced anxiety symptoms, and just over 14% have pronounced depression symptoms. A higher overall sense of coherence and its components are associated with lower severity of depression symptoms. Lower severity of anxiety correlates negatively with a higher sense of understanding, meaningfulness, and holistic Sense of Coherence (SOC). Manageability appeared higher in men.

CONCLUSIONS

SOC is an important health-promoting factor that is preferably related to mental health parameters of patients with carotid atherosclerosis.

Association of severe mental illness with stroke outcomes and process-of-care quality indicators: nationwide cohort study

BACKGROUND

Severe mental illness (SMI) is associated with increased stroke risk, but little is known about how SMI relates to stroke prognosis and receipt of acute care.

AIMS

To determine the association between SMI and stroke outcomes and receipt of process-of-care quality indicators (such as timely admission to stroke unit).

METHOD

We conducted a cohort study using routinely collected linked data-sets, including adults with a first hospital admission for stroke in Scotland during 1991-2014, with process-of-care quality indicator data available from 2010. We identified pre-existing schizophrenia, bipolar disorder and major depression from hospital records. We used logistic regression to evaluate 30-day, 1-year and 5-year mortality and receipt of process-of-care quality indicators by pre-existing SMI, adjusting for sociodemographic and clinical factors. We used Cox regression to evaluate further stroke and vascular events (stroke and myocardial infarction).

RESULTS

Among 228 699 patients who had had a stroke, 1186 (0.5%), 859 (0.4%), 7308 (3.2%) had schizophrenia, bipolar disorder and major depression, respectively. Overall, median follow-up was 2.6 years. Compared with adults without a record of mental illness, 30-day mortality was higher for schizophrenia (adjusted odds ratio (aOR) = 1.33, 95% CI 1.16-1.52), bipolar disorder (aOR = 1.37, 95% CI 1.18-1.60) and major depression (aOR = 1.11, 95% CI 1.05-1.18). Each disorder was also associated with marked increased risk of 1-year and 5-year mortality and further stroke and vascular events. There were no clear differences in receipt of process-of-care quality indicators.

CONCLUSIONS

Pre-existing SMI was associated with higher risks of mortality and further vascular events. Urgent action is needed to better understand and address the reasons for these disparities.

Stroke care and case fatality in people with and without schizophrenia: a retrospective cohort study

BACKGROUND

Schizophrenia is associated with an increased risk of death following stroke; however, the magnitude and underlying reasons for this are not well understood.

OBJECTIVE

To determine the association between schizophrenia and stroke case fatality, adjusting for baseline characteristics, stroke severity and processes of care.

DESIGN

Retrospective cohort study used linked clinical and administrative databases.

SETTING

All acute care institutions (N=152) in the province of Ontario, Canada.

PARTICIPANTS

All patients (N=52 473) hospitalised with stroke between 1 April 2002 and 31 March 2013 and included in the Ontario Stroke Registry. Those with schizophrenia (n=612) were identified using validated algorithms.

MAIN OUTCOMES AND MEASURES

We compared acute stroke care in those with and without schizophrenia and used Cox proportional hazards models to examine the association between schizophrenia and mortality, adjusting for demographics, comorbidity, stroke severity and processes of care.

RESULTS

Compared with those without schizophrenia, people with schizophrenia were less likely to undergo thrombolysis (10.1% vs 13.4%), carotid imaging (66.3% vs 74.0%), rehabilitation (36.6% vs 46.6% among those with disability at discharge) or be treated with antihypertensive, lipid-lowering or anticoagulant therapies. After adjustment for age and other factors, schizophrenia was associated with death from any cause at 1 year (adjusted HR (aHR) 1.33, 95% CI 1.14 to 1.54). This was mainly attributable to early deaths from stroke (aHR 1.47, 95% CI 1.20 to 1.80, with survival curves separating in the first 30 days), and the survival disadvantage was particularly marked in those aged over 70 years (1-year mortality 46.9% vs 35.0%).

CONCLUSIONS

Schizophrenia is associated with increased stroke case fatality, which is not fully explained by stroke severity, measurable comorbid conditions or processes of care. Future work should focus on understanding this mortality gap and on improving acute stroke and secondary preventive care in people with schizophrenia.

Cardiovascular disease in patients with severe mental illness

Individuals diagnosed with schizophrenia or bipolar disorder have a life expectancy 15-20 years shorter than that in the general population. The rate of unnatural deaths, such as suicide and accidents, is high for these patients. Despite this increased proportion of unnatural deaths, physical conditions account for approximately 70% of deaths in patients with either schizophrenia or bipolar disorder, with cardiovascular disease contributing 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively. Risk factors for cardiovascular disease, such as smoking, unhealthy diet and lack of exercise, are common in these patients, and lifestyle interventions have been shown to have small effects. Pharmacological interventions to reduce risk factors for cardiovascular disease have been proven to be effective. Treatment with antipsychotic drugs is associated with reduced mortality but also with an increased risk of weight gain, dyslipidaemia and diabetes mellitus. These patients have higher risks of both myocardial infarction and stroke but a lower risk of undergoing interventional procedures compared with the general population. Data indicate a negative attitude from clinicians working outside the mental health fields towards patients with severe mental illness. Education might be a possible method to decrease the negative attitudes towards these patients, thereby improving their rates of diagnosis and treatment.

Neuropsychiatric issues after stroke: Clinical significance and therapeutic implications

A spectrum of neuropsychiatric disorders is a common complication from stroke. Neuropsychiatric disorders after stroke have negative effects on functional recovery, increasing the rate of mortality and disability of stroke survivors. Given the vital significance of maintaining physical and mental health in stroke patients, neuropsychiatric issues after stroke have raised concerns by clinicians and researchers. This mini-review focuses on the most common non-cognitive functional neuropsychiatric disorders seen after stroke, including depressive disorders, anxiety disorders, post-traumatic stress disorder, psychosis, and psychotic disorders. For each condition, the clinical performance, epidemiology, identification of the therapeutic implication, and strategies are reviewed and discussed; the main opinions and perspectives presented here are based on the latest controlled studies, meta-analysis, or updated systematic reviews. In the absence of data from controlled studies, consensus recommendations were provided accordingly.

Reduced rate of revascularization in schizophrenic patients with acute myocardial infarction: A systematic review and meta-analysis

IMPORTANCE

It has been suggested that patients with schizophrenia have higher than expected mortality following acute coronary events. However, the in-hospital revascularization rate in patients with schizophrenia and acute myocardial infarction (AMI) compared to mentally healthy patients remains unknown.

OBJECTIVE

To evaluate the revascularization rate in schizophrenic patients after AMI with a meta-analysis of observational studies.

DATA SOURCES

PubMed and Embase electronical databases.

STUDY SELECTION

Observational studies that evaluate the likelihood of revascularization in AMI patients with schizophrenia compared to those without schizophrenia, after adjustment for potential influencing factors.

DATA EXTRACTION AND SYNTHESIS

Data regarding study design, characteristics of the AMI patients and schizophrenic patients, and strategies of revascularization were extracted. Results were pooled and analyzed with a random effect model to incorporate the potential heterogeneity.

MAIN OUTCOME AND MEASURES

The likelihood of revascularization in AMI patients with schizophrenia compared to those without schizophrenia, after adjustment for potential influencing factors.

RESULTS

Overall, 3,260,754 hospitalized AMI patients from six follow-up studies were included, of which 17,875 patients had a prior diagnosis of schizophrenia. Results of this meta-analysis suggest that revascularization was significantly lower in AMI patients with schizophrenia compared to those without schizophrenia (odds ratio [OR]: 0.48, 95% confidence interval [CI]: 0.38 to 0.62, p < .001; I² = 93%), after adjustment for demographic characteristics, comorbidities, and hospital and regional factors. Specifically, AMI patients with schizophrenia had significantly fewer percutaneous coronary interventions (OR: 0.48, 95% CI: 0.41 to 0.56, p < .001; I² = 49%) and coronary artery bypass grafts (OR: 0.61, 95% CI: 0.53 to 0.70, p < .001; I² = 20%) compared to those without schizophrenia.

CONCLUSIONS AND RELEVANCE

Patients with schizophrenia and AMI have a lower rate of coronary revascularization as compared with patients without schizophrenia, which is an important cause of higher-than-expected mortality rate in this population.