Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial.

CONTEXT: Depressive symptoms commonly follow coronary artery bypass graft (CABG) surgery and are associated with less positive clinical outcomes. OBJECTIVE: To test the effectiveness of telephone-delivered collaborative care for post-CABG depression vs usual physician care. DESIGN, SETTING, AND PARTICIPANTS: Single-blind effectiveness trial at 7 university-based and community hospitals in or near Pittsburgh, Pennsylvania. Participants were 302 post-CABG patients with depression (150, intervention; 152, usual care) and a comparison group of 151 randomly sampled post-CABG patients without depression recruited between March 2004 and September 2007 and observed as outpatients until June 2008. INTERVENTION: Eight months of telephone-delivered collaborative care provided by nurses working with patients' primary care physicians and supervised by a psychiatrist and primary care physician from this study. MAIN OUTCOME MEASURES: Mental health-related quality of life (HRQL) measured by the Short Form-36 Mental Component Summary (SF-36 MCS) at 8-month follow-up; secondary outcome measures included assessment of mood symptoms (Hamilton Rating Scale for Depression [HRS-D]), physical HRQL (SF-36 PCS), and functional status (Duke Activity Status Index [DASI]); and hospital readmissions. RESULTS: The intervention patients reported greater improvements in mental HRQL (all P < or = .02) (SF-36 MCS: Delta, 3.2 points; 95% confidence interval [CI], 0.5-6.0), physical functioning (DASI: Delta, 4.6 points; 95% CI, 1.9-7.3), and mood symptoms (HRS-D: Delta, 3.1 points; 95% CI, 1.3-4.9); and were more likely to report a 50% or greater decline in HRS-D score from baseline (50.0% vs 29.6%; number needed to treat, 4.9 [95% CI, 3.2-10.4]) than usual care patients (P < .001). Men with depression were particularly likely to benefit from the intervention (SF-36 MCS: Delta, 5.7 points; 95% CI, 2.2-9.2; P = .001). However, the mean HRQL and physical functioning of intervention patients did not reach that of the nondepressed comparison group. CONCLUSION: Compared with usual care, telephone-delivered collaborative care for treatment of post-CABG depression resulted in improved HRQL, physical functioning, and mood symptoms at 8-month follow-up. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00091962.

Positive effect of darbepoetin on peri-infarction remodeling in a porcine model of myocardial ischemia-reperfusion.

Erythropoietin (Epo) has anti-apoptotic and pro-angiogenic effects in rodent models of myocardial infarction (MI). We tested the hypothesis that a long-acting Epo derivative (darbepoetin) has a beneficial effect on infarct size and peri-infarct remodeling in a clinically relevant large animal model of ischemia-reperfusion. A human acute MI scenario was simulated in 16 domestic pigs by inflating an angioplasty balloon in the proximal left circumflex (LCx) artery for 60 min. The animals were randomized to darbepoetin 30 microg/kg i.v. or placebo (saline) at the time of reperfusion. Treatment with darbepoetin did not lead to a reduction in the infarct size at 2 weeks as assessed by histology (30.3+/-1.8% of the volume at risk for placebo vs. 33.2+/-2.5% for darbepoetin). However, significant effects were seen in the peri-infarct region. Histological evaluation revealed decreased interstitial fibrosis (6.8+/-0.7% of myocardial sections area vs. 9.6+/-0.7%, p=0.02) and increased average capillary area (106+/-3% of the non-infarcted myocardium vs. 89+/-4%, p=0.003) in the treatment arm in the absence of significant cardiac hypertrophy. This resulted in preserved regional wall motion as assessed by tissue Doppler-derived radial strain (subepicardial radial strain 90.1+/-21.2% for darbepoetin vs. 20.3+/-10.1% for placebo, p<0.05). However, this did not translate to improved wall thickening (126.5+/-6.0% of diastolic thickness for darbepoetin vs. 119.8+/-5.4% for placebo, p=NS). Beneficial effects of darbepoetin to peri-infarct remodeling were observed in a clinically relevant model of ischemia-reperfusion. Although the infarct size was not reduced, there was a limited decrease in interstitial fibrosis, increased capillary area and regional functional improvement in darbepoetin-treated animals.

Effect of statin therapy prior to elective percutaneous coronary intervention on frequency of periprocedural myocardial injury.

This study evaluated whether pretreatment with statins was associated with a decreased incidence of periprocedural myocardial injury. Periprocedural myocardial injury occurs after percutaneous coronary intervention (PCI) and is associated with adverse outcomes. The pleiotropic properties of statins stabilize plaque and decrease the inflammatory milieu of atherosclerotic lesions. Accordingly, we hypothesized that preprocedural statin therapy would decrease periprocedural myocardial injury. We enrolled 425 patients who underwent successful PCI. The control arm (n = 150) included patients not on statin therapy at the time of PCI, and the statin arm (n = 275) included patients who were taking statin medication before PCI. All patients had serial enzymes measured, including creatine kinase (CK), CK-MB, and troponin I. The incidence of increased levels of CK and CK-MB >3 times normal and the absolute increase in CK and troponin I were compared between groups. The control arm had significantly higher periprocedural levels of CK. In the control group, 6% of patients had CK increases >3 times the upper limit of normal compared with 1.8% in the statin group (p = 0.02). The control arm had a higher frequency of CK-MB increases >3 times the upper limit of normal (7.3% vs 2.2%, p = 0.01). There was a trend toward higher levels of troponin I in the control group (3.21 vs 1.85 ng/ml, p = 0.06). Thus, statin therapy before elective PCI was associated with lower levels of periprocedural CK.