Psychosocial and physical long-term outcome in patients with a history of takotsubo cardiomyopathy or myocardial infarction - a multi-centered case control study.

Physical long-term impacts of Takotsubo Cardiomyopathy (TTC) remain controversial and an underestimation of their severity becomes increasingly evident. Even less is known about mental long-term impacts of TTC. This study aims at a better understanding of the physical and mental long-term effects of TTC in comparison to myocardial infarctions (MI). On average 5 years after disease onset, 68 TTC patients and 68 age- and sex-matched MI patients were assessed for disease-related quality of life, depression, anxiety, chronic stress, social support, resilience, and life events prior to disease onset. Scores of TTC and MI patients were compared to each other and to normative references values. Regression analyses were used to evaluate the predictive value of the number of life events prior to disease onset for physical and mental long-term outcomes. Both groups displayed higher scores in depression and anxiety, higher levels of chronic stress, and lower scores in physical and mental quality of life in comparison to norm samples, while social support did not differ from norms. No differences between the two patient groups were observed. Within both groups, the majority of patients (TTC: 69.1%; MI: 60.3%) reported stressful life events prior to disease onset. In TTCs and MIs, the number of events had a significant impact on long-term mental health and chronic stress. Notably, both patient collectives scored higher in resilience than healthy controls. Results suggest negative long-term impacts of TTC on mental and physical wellbeing, comparable to those of MI. Besides a good somatic-medical care, psychotherapeutic support, including the development of functional coping strategies, might be warranted for TTC patients. The long-term impact of TTC should be taken as serious as that of MI.

Impact of generalized anxiety disorder (GAD) on prehospital delay of acute myocardial infarction patients. Findings from the multicenter MEDEA study.

BACKGROUND: Anxiety has been identified as a cardiac risk factor. However, less is known about the impact of generalized anxiety disorder (GAD) on prehospital delay during an acute myocardial infarction (AMI). This study assessed the impact of GAD on prehospital delay and delay related cognition and behavior. METHODS: Data were from the cross-sectional Munich examination of delay in patients experiencing acute myocardial infarction (MEDEA) study with a total of 619 ST-elevated myocardial infarction (STEMI) patients. Data on socio-demographic, clinical and psycho-behavioral characteristics were collected at bedside. The outcome was assessed with the Generalized Anxiety Disorder scale (GAD-7). A GAD-7 score greater than or equal to 10 indicates general anxiety disorder. RESULTS: A total of 11.47% (n = 71) MI patients suffered from GAD. GAD was associated with decreased odds of delay compared to patients without GAD (OR 0.58, 95% CI 0.35-0.96), which was more significant in women (112 vs. 238 min, p = 0.02) than in men (150 vs. 198 min, p = 0.38). GAD was highly correlated with acute anxiety (p = 0.004) and fear of death (p = 0.005). Nevertheless, the effect remained significant after controlling for these two covariates. GAD patients were more likely to perceive a higher cardiovascular risk (OR 2.56, 95% CI 1.37-4.76) in 6 months before MI, which leads to the higher likelihood of making self-decision to go to the hospital (OR 2.68, 95% CI 1.48-4.85) in the acute phase. However, GAD was also highly associated with impaired psychological well-being, stress and fatigue (p < 0.0001). CONCLUSIONS: In AMI patients, GAD was independently associated with less prehospital delay, but led to an impaired psychological state.

Is denial a maladaptive coping mechanism which prolongs pre-hospital delay in patients with ST-segment elevation myocardial infarction?

OBJECTIVE: During an acute myocardial infarction, patients often use denial as a coping mechanism which may provide positive mood regulating effects but may also prolong prehospital delay time (PHD). However, empirical evidences are still sparse. METHODS: This cross-sectional study included 533 ST-elevated myocardial infarction (STEMI) patients from the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Data on sociodemographic, clinical and psycho-behavioral characteristics were collected at bedside. The outcome was assessed using the Cardiac Denial of Impact Scale (CDIS) with the median split as cutoff point. A total of 206 (41.8%) STEMI patients were thus classified as deniers. RESULTS: Deniers were less likely to suffer from major depression (p=0.04), anxiety (p=0.01) and suboptimal well-being (p=0.01) compared to non-deniers during the last six months prior to STEMI. During STEMI, they were less likely to perceive severe pain strength (p=0.04) and racing heart (p=0.02). Male deniers were also less likely to perceive shortness of breath (p=0.03) and vomiting (p=0.01). Denial was not associated with overall delay time. However, in the time window of 3 to 24h, denial accounted for roughly 40min extra delay (356 vs. 316.5min p=0.02 n=196). CONCLUSIONS: Denial not only contributes to less suffering from acute heart related symptoms and negative affectivity but also leads to a clinically significant delay in the prevalent group.

Patients' knowledge about symptoms and adequate behaviour during acute myocardial infarction and its impact on delay time: Findings from the multicentre MEDEA Study.

OBJECTIVE: We aimed to assess whether patients' knowledge about acute myocardial infarction (AMI) has an impact on the prehospital delay-time. METHODS: This investigation was based on 486 AMI patients who participated in the cross-sectional Munich-Examination-of-Delay-in-Patients-Experiencing-Acute-Myocardial-Infarction (MEDEA) study. A modified German-version of the ACS-Response-Index Questionnaire was used. Multivariate logistic-regression models were used to identify factors associated with knowledge-level as well as the impact of knowledge-level on delay-time. RESULTS: High AMI-knowledge shortened median delay-time in men (168[92-509] vs. 276[117-1519] mins, p=0.0069), and in women (189[101-601] vs. 262[107-951]mins, p=0.34). Almost half-of-patients (n=284,58%) demonstrated high AMI-knowledge. High-knowledge were independently associated with male-gender (OR=1.47[1.17-1.85]) and General-Practitioner as a knowledge-source (OR=1.42[1.14-1.77]). Old-age (OR=0.87[0.86-0.89]) and previous AMI-history/stent-placement (OR=0.65[0.46-0.93]) were significantly associated with lower-knowledge. Although the majority (476,98%) correctly recognized at least one AMI-symptom, 69(14.2%) patients correctly identified all AMI-symptoms. Additionally, one-in-three believed that heart-attack is always accompanied with severe chest-pain. Elderly-patients and women were more likely to be less-knowledgeable about atypical-symptoms (p=0.006), present with atypical AMI-presentation (p<0.001) and subsequently experience protracted delay-times (p<0.001). CONCLUSIONS: Knowledge of AMI-symptoms remains to be substandard, especially knowledge of atypical-symptoms. Knowledge is essential to reduce delay-times, but it is not a panacea, since it is not sufficient alone to optimize prehospital delay-times.

Frequency and covariates of fear of death during myocardial infarction and its impact on prehospital delay: findings from the multicentre MEDEA Study.

BACKGROUND: Fear of death (FoD) is an exceptionally stressful symptom of ST-elevation myocardial infarction (STEMI), which received little scientific attention in recent years. We aimed to describe the prevalence and factors contributing to FoD among STEMI patients and assess the impact of FoD on prehospital delay. METHODS: This investigation was based on 592 STEMI patients who participated in the Munich Examination of Delay in Patients Experiencing Acute Myocardial Infarction (MEDEA) study. Data on sociodemographic, clinical and psycho-behavioral characteristics were collected at bedside. Multivariate logistic regression models were used to identify factors associated with FoD. RESULTS: A total of 15% of STEMI patients reported FoD (n = 88), no significant gender difference was found. STEMI pain strength [OR = 2.3 (1.4-3.9)], STEMI symptom severity [OR = 3.7 (2-6.8)], risk perception pre-STEMI [OR = 1.9 (1.2-3.2)] and negative affectivity [OR = 1.9 (1.2-3.1)] were independently associated with FoD. The median delay for those who experienced FoD was 139 min compared to 218 min for those who did not (p = 0.005). Male patients with FoD were significantly more likely to delay less than 120 min [OR = 2.11(1.25-3.57); p = 0.005], whereas in women, this association was not significant. Additionally, a clear dose-response relationship between fear severity and delay was observed. Male FoD patients significantly more often used emergency services to reach the hospital (p = 0.003). CONCLUSIONS: FoD is experienced by a clinically meaningful minority of vulnerable STEMI patients and is strongly associated with shorter delay times in men but not in women. Patients' uses of emergency services play an important role in reducing the delay in male FoD patients.

What prevents old people living alone from feeling lonely? Findings from the KORA-Age-study.

OBJECTIVES: Living alone in later life is an important risk factor of loneliness for elderly people unless they have resources to compensate for that. The aim of this investigation was to identify these resources. METHOD: Data were drawn from the population-based KORA-Age-study (KOoperativen Gesundheitsforschung in der Region Augsburg) conducted in the Region of Augsburg, Germany in 2008/2009 with 1079 elderly men and women (64-94 years). Loneliness was measured by the short version of the UCLA-Loneliness-Scale in a face-to-face interview. Multiple logistic regression analyses were conducted to identify associations between loneliness and potential protecting resources. RESULTS: A total of 346 (32%) subjects reported to be living alone, among them 70% (n = 241) expressed no feelings of loneliness. Participants with a stable social network had a fourfold higher chance (OR 4.08, 95% CI 1.20-13.88, p = 0.025) and with the absence of depression a threefold higher chance (OR 3.04, 95% CI 1.59-5.78, p-value < 0.001) of not feeling lonely. Physical or mental resources were not correlated with lower levels of loneliness. CONCLUSION: Absence of depression and a functioning social network are the most important protecting resources against loneliness for elderly people living alone, while income, level of education and age-related limitations have no impact. These findings should be considered when supporting the elderly in successful aging.

[Treatment of non-specific, functional and somatoform bodily complaints]. / Umgang mit Patienten mit nicht-spezifischen, funktionellen und somatoformen Körperbeschwerden.

In primary and secondary medicine "non-specific, functional, and somatoform bodily complaints" are common and often take a chronic course, with the patients' quality of life usually markedly impaired, and give rise to high direct and indirect costs. They are challenging as they can deteriorate in case of inappropriate behavior on the physician's part. Coordinated by both German professional associations of Psychosomatic Medicine a new evidence based guideline was developed, aiming to transfer relevant diagnostic and therapeutic knowledge to all physicians who are in charge of these patients. After establishing a stable therapeutic alliance a symptom- and coping-oriented attitude could be demonstrated to be helpful. A biopsychosocial diagnostic evaluation combines a thorough assessment of bodily complaints and early introduces a sensitive discussion of signs of psychosocial stress, which can be extended carefully in case problems of this type are present. In less severe courses, physical/social activation is recommended and the patient's explanatory disease model should be extended towards a psychological dimension. More severe and complicated courses require a more structured approach consisting of regular appointments (as opposed to ad-hoc appointments whenever the patient feels worse) and an active cooperation of the patient. A coordinated, multimodal management includes additional measures as graded activation, psychotherapy, relaxation training or--if indicated--temporary medication.

[Frequency of cardiac arrhythmia in patients with liver cirrhoses and evaluation of associated factors]. / Häufigkeit von Herzrhythmusstörungen bei Patienten mit Leberzirrhose sowie Evaluierung assoziierter Faktoren.

INTRODUCTION: Studies analysing the frequency of rhythm disorders in patients with cirrhosis are rare. Nevertheless, factors triggering rhythm disorders occur frequently in cirrhosis. Therefore, a retrospective case control study was performed investigating the frequency of cardiac arrhythmia in a population of patients with cirrhosis while evaluating several associated factors. METHODS: The files of patients with cirrhosis (n  =  293) in the period 2004 - 2008 were analysed retrospectively regarding cardiac arrhythmia. The frequency of cardiac arrhythmia in the presence of relevant risk factors was analysed using χ ²tests and logistic regression models. RESULTS: 61.1  % of all patients were male (mean age 61.7 years) and 38.9  % female (mean age 62.8 years). The severity of cirrhosis according to the Child-Pugh score (CP) was as follows: CP A 43.3  %, CP B 32.8  % and CP C 23.9  %. Altogether, rhythm disorders were diagnosed in 16.4  % (48/293) of the study population, most frequently atrial fibrillation (68.8  %) and atrial flutter (6.7  %). An advanced age and comorbidities such as arteriosclerotic diseases, hypercholesterinemia (p  <  0.001, each) and diabetes mellitus (p  =  0.013) correlated significantly with the frequency of rhythm disorders which occurred more often in males than in females (p  = 0.066). Ongoing alcohol abuse, the severity of cirrhosis and arterial hypertension were not associated significantly with the onset of rhythm disorders. 84.4  % of all patients with cardiac arrhythmia were treated by diuretics. Decreased (<  3.5 mmol/L) and elevated (>  5 mmol/L) potassium values were observed in 60.6  % of the study collective. Rhythm disorders were more often observed in patients with hyperkalemia (especially atrioventricular block, p  < 0.01). CONCLUSION: Compared to the average population, the prevalence of atrial fibrillation was increased in our cirrhotic cohort. The occurrence of rhythm disorders was significantly associated with arteriosclerotic diseases, hypercholesterinaemia and diabetes mellitus. Additionally, cardiac arrhythmia must be considered under diuretic therapy and in the presence of electrolyte disturbances.

Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial.

BACKGROUND: Multisomatoform disorder is characterised by severe and disabling bodily symptoms, and pain is one of the most common and impairing of these. Furthermore, these bodily symptoms cannot be explained by an underlying organic disorder. Patients with multisomatoform disorder are commonly found at all levels of healthcare and are typically difficult to treat for physicians as well as for mental health specialists. AIMS: To test whether brief psychodynamic interpersonal therapy (PIT) effectively improves the physical quality of life in patients who have had multisomatoform disorder for at least 2 years. METHOD: We recruited 211 patients (from six German academic outpatient centres) who met the criteria for multisomatoform disorder for a randomised, controlled, 12-week, parallelgroup trial from 1 July 2006 to 1 January 2009 (International Standard Randomised Controlled Trial Number ISRCTN23215121). We randomly assigned the patients to receive either 12 weekly sessions of PIT (n = 107) or three sessions of enhanced medical care (EMC, n = 104). The physical component summary of the Short Form Health Survey (SF-36) was the pre-specified primary outcome at a 9-month follow-up. RESULTS: Psychodynamic interpersonal therapy improved patients' physical quality of life at follow-up better than EMC (mean improvement in SF-36 score: PIT 5.3, EMC 2.2), with a small to medium between-group effect size (d = 0.42, 95% CI 0.15-0.69, P = 0.001). We also observed a significant improvement in somatisation but not in depression, health anxiety or healthcare utilisation. CONCLUSIONS: This trial documents the long-term efficacy of brief PIT for improving the physical quality of life in patients with multiple, difficult-to-treat, medically unexplained symptoms.

[Treating ICD patients at the end of their lives: attitudes, knowledge, and behavior of doctors and patients. A critical literature analysis]. / Umgang mit ICD-Patienten an ihrem Lebensende: Einstellungen, Wissen und Verhalten von Ärzten und Patienten. Eine kritische Literaturanalyse.

BACKGROUND: The implantable cardioverter-defibrillator (ICD) is highly effective in the therapy of malign heart rhythm abnormalities. However, the ethical dilemma of harming a dying patient has received little attention. We studied the current state of knowledge and behavior of physicians and the subjective needs of ICD patients with respect to end-of-life issues. METHODS: A literature search of articles published between 8/2010 and 3/2011 in PubMed resulted in the identification of 32 reports, of which 25 met selection criteria. RESULTS: Practically no clinical institution (96% in Europe) offers routine counseling of ICD patients on end-of-life issues. In only about 25% of cases do doctors initiate a discussion on this issue with the ICD patient, of which the majority takes place during the final hours of the patient's life. Knowledge of legal aspects of ICD deactivation is insufficient in about 50% of physicians. Many physicians underestimate the impact of ICD shocks and often have unrealistic expectations about the patient's knowledge on technical aspects of the ICD device. The majority of patients are reluctant to address this topic and prefer to rely on the decision of their attending physician. CONCLUSION: Despite insufficient empirical data, findings point to a low willingness of ICD patients to confront the end-of-life issue and prefer decisions to be made by their physician. Substantial knowledge gaps of physicians may cause barriers in considering the option of deactivating the ICD.

[Psychological comorbidity and quality of life in patients with an implantable cardioverter/defribrillator (ICD)]. / Psychische Komorbidität und Lebensqualität bei Patienten mit implantierbarem Kardioverter/Defibrillator (ICD).

Currently, the method of choice for protection against sudden cardiac death for high-risk patients is ICD treatment. The CIDS study could prove a significant advantage of ICD treatment compared to amiodarone therapy. However, the survival advantages can be affected by the negative side effects of ICD therapy. The therapeutic survival function of the device is, in general, associated with a consciously experienced, at the same time completely unexpected and unprepared intracardial shock experience. Within the first year after implantation, 30-50% of patients with an ICD for secondary preventative indications experience such a shock. The average shock application frequency per year (under normal conditions) is about 2.5 shocks. The experience of one or more ICD shocks is significantly associated with a decrease in quality of life. Particularly the experiencing of five or more intracardial shocks approaches the patient's psychological resilience threshold. Partners and relatives of ICD patients are, on the other hand, often helpless with respect to the demands of and stress associated with the ICD technology. In current clinical practice, the involvement of the partners in the treatment of ICD patients is generally a coincidence and is generally not systematic or target-oriented. Improved involvement of relatives can contribute to an improved prognosis. Cardiologists caring for ICD patients should be aware of the specific psychological aspects of ICD technology, integrate these aspects into the guidance and care of patients, and be able to identify and address pathologically negative affects and crises in ICD patients.

Functional relaxation and guided imagery as complementary therapy in asthma: a randomized controlled clinical trial.

BACKGROUND: Asthma is a frequently disabling and almost invariably distressing disease that has a high overall prevalence. Although relaxation techniques and hypnotherapeutic interventions have proven their effectiveness in numerous trials, relaxation therapies are still not recommended in treatment guidelines due to a lack of methodological quality in many of the trials. Therefore, this study aims to investigate the efficacy of the brief relaxation technique of functional relaxation (FR) and guided imagery (GI) in adult asthmatics in a randomized controlled trial. METHODS: 64 patients with extrinsic bronchial asthma were treated over a 4-week period and assessed at baseline, after treatment and after 4 months, for follow-up. 16 patients completed FR, 14 GI, 15 both FR and GI (FR/GI) and 13 received a placebo relaxation technique as the control intervention (CI). The forced expiratory volume in the first second (FEV(1)) as well as the specific airway resistance (sR(aw)) were employed as primary outcome measures. RESULTS: Participation in FR, GI and FR/GI led to increases in FEV(1) (% predicted) of 7.6 +/- 13.2, 3.3 +/- 9.8, and 8.3 +/- 21.0, respectively, as compared to -1.8 +/- 11.1 in the CI group at the end of the therapy. After follow-up, the increases in FEV(1) were 6.9 +/- 10.3 in the FR group, 4.4 +/- 7.3 in the GI and 4.5 +/- 8.1 in the FR/GI, compared to -2.8 +/- 9.2 in the CI. Improvements in sR(aw) (% predicted) were in keeping with the changes in FEV(1) in all groups. CONCLUSIONS: Our study confirms a positive effect of FR on respiratory parameters and suggests a clinically relevant long-term benefit from FR as a nonpharmacological and complementary therapy treatment option.