Psychological Aspects of Heart Failure.

Psychological conditions such as depression can have a greater impact on morbidity and mortality outcomes than traditional risk factors for these outcomes. Despite their importance, it is rare for clinicians to assess patients for these conditions and rarer still for them to consistently and adequately manage them. Illumination of the phenomena of comorbid psychological conditions in heart failure may increase awareness of the problem, resulting in improved assessment and management.

The association of co-morbid symptoms of depression and anxiety with all-cause mortality and cardiac rehospitalization in patients with heart failure.

BACKGROUND: Patients with heart failure (HF) experience multiple psychologic symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown. OBJECTIVE: To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. METHOD: A total of 1260 patients with HF participated in this study. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous-level variables, then as categorical variables using standard published cut points. Patients were then divided into 4 groups based on the presence of anxiety and depression symptoms. RESULTS: When entered as a continuous variable, the interaction between anxiety and depression (hazard ratio = 1.02; 95% CI: 1.01-1.03; p = 0.002) was a significant predictor of all-cause mortality in patients with HF. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (vs no symptoms or symptoms of anxiety or depression alone) independently predicted all-cause mortality (hazard ratio = 2.59; 95% CI: 1.49-4.49; p = 0.001). None of the psychologic variables was a predictor of cardiac rehospitalization in patients with HF whether using the continuous or categorical level of measurement. CONCLUSION: To improve mortality outcomes in patients with HF, attention must be paid by health care providers to the assessment and management of co-morbid symptoms of depression and anxiety.

The Association of Persistent Symptoms of Depression and Anxiety with Recurrent Acute Coronary Syndrome Events: A Prospective Observational Study.

The purpose of this study was to examine the role of persistent symptoms of depression and anxiety in a second acute coronary syndrome (ACS) event. Data presented in this study were from an RCT study. A follow-up for 24 months after baseline to detect a second ACS event among 1162 patients from five hospitals. Hierarchal Cox regression analyses were used. The results showed that persistent depression only (HR 2.27; 95% CI: 1.35-3.81; p = 0.002), and comorbid persistent depression and anxiety (HR 2.03; 95% CI: 1.03-3.98; p = 0.040) were the significant predictors of a second ACS event. Secondary education level compared to primary educational level (HR 0.63; 95% CI: 0.43-0.93; p = 0.020) and college or more education level compared to primary educational level (HR 0.47; 95% CI: 0.27-0.84; p = 0.011) were the only demographic variables that were significant predictors of a second event. The study reveals that attention must be paid by healthcare providers to assess and manage persistent depression; particularly when it is co-morbid with anxiety.

High Dietary Sodium Intake is Associated with Shorter Event-Free Survival in Patients with Heart Failure and Comorbid Diabetes.

The aim was to determine whether 24-hour urine sodium excretion predicted event-free survival of patients with heart failure (HF) and diabetes mellitus (DM). Twenty-four hour urine sodium, as an indicator of dietary sodium, was collected from 107 patients with HF and comorbid DM. Patients were followed for a median period of 337 days to determine time to the first event of either all-cause hospitalization or cardiac-related mortality. There were 44 patients (41%) who had an event of death or hospitalization. Cox regression showed that higher urine sodium (>3.8 gm/day) was associated with 2.8 times greater risk for an event than lower urine sodium after controlling for age, gender, New York Heart Association class (I/II vs. III/IV), left ventricular ejection fraction, and body mass index. These data suggest that dietary sodium restriction may be beneficial for patients with HF and DM.

Perceptions related to cardiovascular disease and physical activity behavior in Arab men: A qualitative study.

OBJECTIVES: To describe the daily physical activity of Arab men living in the United States and to understand how perceptions of cardiovascular disease (CVD) risk influence their inclusion of physical activity into their daily routine. METHODS: A qualitative descriptive method using a semi-structured face-to-face interview with each participant was conducted. Twenty young college males (age 26 ± 4 years) were recruited from Arab American community centers. RESULTS: The qualitative inductive content analysis revealed three main themes: impact of perceived CVD risk on physical activity behavior and perceived barriers and motivators to be physically active. Arab men primarily perceived gaining weight as the most important CVD risk factor that could promote their physical activity behavior. CONCLUSIONS: These findings demonstrate that unawareness about CVD risk and barriers to regular physical activity must be considered in any intervention to engage Arab men in regular physical activity.

Stress, cognitive appraisal, coping, and event free survival in patients with heart failure.

OBJECTIVES: To describe self-reported stress level, cognitive appraisal and coping among patients with heart failure (HF), and to examine the association of cognitive appraisal and coping strategies with event-free survival. METHODS: This was a prospective, longitudinal, descriptive study of patients with chronic HF. Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale, Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event-free survival was defined as cardiac rehospitalization and all-cause death. RESULTS: A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated. Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidant emotional coping (ß = -0.28; 95% CI: -0.21 - 0.02; p = 0.02) and event free survival (HR = 0.53; 95% CI: 0.28 - 1.02; p = 0.05). CONCLUSIONS: The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event-free survival.

The association of comorbid diabetes mellitus and symptoms of depression with all-cause mortality and cardiac rehospitalization in patients with heart failure.

BACKGROUND: More than 22% of individuals with diabetes mellitus have concomitant heart failure (HF), and the prevalence of diabetes in those with HF is nearly triple that of individuals without HF. Comorbid depressive symptoms are common in diabetes and HF. Depressive symptoms are an independent predictor of mortality in individuals with diabetes alone, as well as those with HF alone and are a predictor of rehospitalization in those with HF. However, the association of comorbid HF, diabetes and depressive symptoms with all-cause mortality and rehospitalization for cardiac causes has not been determined. OBJECTIVE: The purpose of this study was to evaluate the association of comorbid HF, diabetes and depression with all-cause mortality and rehospitalization for cardiac cause. METHOD: Patients provided data at baseline about demographic and clinical variables and depressive symptoms; patients were followed for at least 2 years. Participants were divided into four groups based on the presence and absence of diabetes and depressive symptoms. Cox regression analysis was used to determine whether comorbid diabetes and depressive symptoms independently predicted all-cause mortality and cardiac rehospitalization in these patients with HF. RESULTS: Patients (n=663) were primarily male (69%), white (76%), and aged 61±13 years. All-cause mortality was independently predicted by the presence of concomitant diabetes and depressive symptoms (HR 3.71; 95% CI 1.49 to 9.25; p=0.005), and depressive symptoms alone (HR 2.29; 95% CI 0.94 to 5.40; p=0.05). The presence of comorbid diabetes and depressive symptoms was also an independent predictor of cardiac rehospitalization (HR 2.36; 95% CI 1.27 to 4.39; p=0.007). CONCLUSIONS: Comorbid diabetes and depressive symptoms are associated with poorer survival and rehospitalization in patients with HF; effective strategies to regularly evaluate and effectively manage these comorbid conditions are necessary to improve survival and reduce rehospitalization rates.

Examination of the potential association of stress with morbidity and mortality outcomes in patient with heart failure.

OBJECTIVES: The high mortality and morbidity rates associated with heart failure are still not well explained. A few psychosocial factors have been studied and explain some of this risk, but other factors, like stress, remain largely unexplored in heart failure. This study aimed to (1) examine the association of stress with 6-month cardiac event-free survival, (2) examine the relationship of stress with salivary cortisol, and (3) examine the association of salivary cortisol level with 6-month cardiac event-free survival. METHOD: A total of 81 heart failure patients participated. Stress was measured using the brief Perceived Stress Scale. Cortisol was measured from unstimulated whole expectorated saliva. Cox regression analyses were used to determine whether stress predicted event-free survival, and if salivary cortisol predicted event-free survival. Linear and multiple regressions were used to determine the association of stress with salivary cortisol. RESULTS: Stress was not a significant predictor of event-free survival in heart failure (heart rate = 1.06; 95% confidence interval = 0.95-1.81; p = 0.32). Salivary cortisol was a significant predictor of event-free survival in the unadjusted model (heart rate = 2.30; 95% confidence interval = 0.99-5.927; p = 0.05), but not in the adjusted model. Stress (ß 1.06; 95% confidence interval = 0.95-1.18; p = 0.32) was not a significant predictor of salivary cortisol level. CONCLUSION: Stress is a complex phenomenon, and our measure of stress may not have captured it well. Alternatively, the physical stressors acting in heart failure produce levels of neurohormonal activation that mask the effects of psychosocial stressors or an indirect association of stress with outcomes that is mediated through another construct. Future studies are needed to investigate stress in patients with heart failure to provide definitive answers.