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Objective: The purpose of this study was to describe type A behavior pattern and trait anger in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) and compare them with patients with coronary heart disease and healthy controls. Type A behavior pattern and anger have been linked to coronary heart disease in previous studies. This is the first study to assess type A behavior pattern and trait anger in MINOCA patients., Methods: One hundred MINOCA patients, consecutively recruited during 2007-2011 at 5 coronary care units in Stockholm, were matched for sex and age to 100 coronary heart disease patients and 100 healthy controls. All participants completed the Bortner Rating Scale to quantify type A behavior pattern and the Spielberger Trait Anger Scale to quantify anger 3 months after the acute event., Results: MINOCA patients' Bortner Rating Scale score was 70.9 ± 10.8 (mean ± SD) and Spielberger Trait Anger Scale score was 14 (12-17) (median; interquartile range). Coronary heart disease patients' Bortner Rating Scale score was 70.5 ± 10.2 and Spielberger Trait Anger Scale score was 14 (12-17). Healthy controls' Bortner Rating Scale score was 71.9 ± 9.1 and Spielberger Trait Anger Scale score was 13 (11-16)., Conclusion: We found no significant differences in Bortner Rating Scale score and Spielberger Trait Anger Scale score among MINOCA, coronary heart disease patients, and healthy controls, regardless of whether total scores, subscales, or cutoffs were used to classify type A behavior pattern and trait anger. However, we cannot exclude the existence of an occasional episode of anger or mental stress in relation to the coronary event. This is the first study to assess type A behavior pattern and trait anger in patients with MINOCA, and future studies need to confirm the current findings before any firm conclusions can be made., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Depression is associated with increased mortality in stable coronary heart disease. Cardiac rehabilitation and exercise training has been shown to decrease depression, psychological stress, and mortality after a coronary heart disease event. The presence of depression at completion of cardiac rehabilitation and exercise training is associated with increased mortality. However, it is unknown if depression with comorbid psychological risk factors such as anxiety or hostility confers an additional mortality disadvantage. We evaluated the mortality effect of anxiety and hostility on depression after cardiac rehabilitation and exercise training., Patients and Methods: We studied 1150 patients with coronary heart disease following major coronary heart disease events who had completed formal cardiac rehabilitation and exercise training. Using Kellner questionnaires, stress levels were measured in 1 of 3 domains: anxiety, hostility, and depression (with an aggregated overall psychological stress score) and divided into 3 groups: nondepressed (n = 1072), depression alone (n = 18), and depression with anxiety or hostility (n = 60). Subjects were analyzed for all-cause mortality over 161 months of follow-up (mean 6.4 years) by National Death Index., Results: Depression after cardiac rehabilitation was not common (6.8%; mortality 20.8%) but when present, frequently associated with either anxiety or hostility (77% of depressed patients; mortality 22.0%). After adjustment for age, sex, ejection fraction, and baseline peak oxygen consumption, depression alone (hazard ratio [HR] 1.73, P = .04), as well as depression with comorbid psychological stress, was associated with higher mortality (HR 1.98, P = .03). Furthermore, our data showed an increased mortality when both anxiety and hostility were present in addition to depression after cardiac rehabilitation (HR 2.41, P = .04)., Conclusions: After cardiac rehabilitation, depression, when present, is usually associated with other forms of psychological stress, which confers additional mortality. More measures are needed to address psychological stress after cardiac rehabilitation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Higher hemoglobin A1c (HbA1c) is associated with lower cognitive function in type 2 diabetes. To determine whether associations persist at lower levels of dysglycemia in patients who have established cardiovascular disease, cognitive performance was assessed in the Targeting INflammation Using SALsalate in CardioVascular Disease (TINSAL-CVD) trial., Methods: The age-adjusted relationships between HbA1c and cognitive performance measured by the Mini-Mental State Examination, Digit Symbol Substitution Test, Rey Auditory Verbal Learning Test, Trail Making Test, and Categorical Verbal Fluency were assessed in 226 men with metabolic syndrome and established stable coronary artery disease., Results: Of the participants, 61.5% had normoglycemia, 20.8% had impaired fasting glucose, and 17.7% had type 2 diabetes. HbA1c was associated with cognitive function tests of Digit Symbol Substitution Test, Rey Auditory Verbal Learning Test, Trail Making Test, and Categorical Verbal Fluency (all P < .02), but not the Mini-Mental State Examination. In an age-adjusted model, a 1% (11 mmol/mol) higher HbA1c value was associated with a 5.9 lower Digit Symbol Substitution Test score (95% confidence interval [CI], -9.58 to -2.21; P < .0001); a 2.44 lower Rey Auditory Verbal Learning Test score (95% CI, -4.00 to -0.87; P < .0001); a 15.6 higher Trail Making Test score (95% CI, 5.73 to 25.6; P < .0001); and a 3.71 lower Categorical Verbal Fluency score (95% CI, -6.41 to -1.01; P < .02). In a multivariate model adjusting for age, education, and cardiovascular covariates, HbA1c remained associated with cognitive function tests of Rey Auditory Verbal Learning Test (R(2) = 0.27, P < .0001), Trail Making Test (R(2) = 0.18, P < .0001), and Categorical Verbal Fluency (R(2) = 0.20, P < .0001), although association with the Digit Symbol Substitution Test was reduced., Conclusions: Higher HbA1c is associated with lower cognitive function performance scores across multiple domain tests in men with metabolic syndrome and coronary artery disease. Future studies may demonstrate whether glucose lowering within the normative range improves cognitive health., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Many studies have demonstrated the prevalence of depression in patients with coronary artery disease (CAD), but few have examined this relation in those with chest pain who do not have obstructive CAD on angiography. The aim of this study was to compare the prevalence of depression amongst patients with chest pain in the presence or absence of obstructive CAD and a healthy control group without chest pain. This prospectively designed, observational cohort study used 2 independent data sets: (1) The Queen Elizabeth Hospital Coronary Angiogram Database (n = 1,144), consisting of 819 patients with obstructive CAD and 325 patients with nonobstructive CAD (NoCAD), all of whom had chest pain and (2) the North West Adelaide Health Study (NWAHS; n = 3,168), a population-based biomedical cohort, from which patients with chest pain were excluded. The presence of depression was determined by a previously validated method using the Short Form 36. The prevalence of depression differed among the 3 groups, with 63% in those with NoCAD, 53% in those with CAD, and only 24% in the healthy NWAHS cohort. Analysis of the angiography cohort revealed age, gender, antidepressant medication, previous myocardial infarction, previous airway disease, Short Form 36 physical summary score, Seattle Angina Questionnaire physical limitation score, and NoCAD on angiography to be independent predictors of depression. In conclusion, these findings highlight the importance of screening for depression in patients with NoCAD., (Crown Copyright © 2013. Published by Elsevier Inc. All rights reserved.)

Most studies examining potential associations between psychological factors and cardiovascular outcomes have focused on depression or anxiety. The effect of perceived stress on incident coronary heart disease (CHD) has yet to be reviewed systematically. We conducted a systematic review and meta-analysis of the association between perceived stress and incident CHD. Ovid, MEDLINE, and PsycINFO were searched as data sources. Prospective observational cohort studies were selected that measured self-reported perceived stress and assessed incident CHD at ≥6 months. We extracted study characteristics and estimates of the risk of incident CHD associated with high perceived stress versus low perceived stress. We identified 23 potentially relevant articles, of which 6 met our criteria (n = 118,696). Included studies measured perceived stress with validated measurements and nonvalidated simple self-report surveys. Incident CHD was defined as new diagnosis of, hospitalization for, or mortality secondary to CHD. Meta-analysis yielded an aggregate risk ratio of 1.27 (95% confidence interval 1.12 to 1.45) for the magnitude of the relation between high perceived stress and incident CHD. In conclusion, this meta-analysis suggests that high perceived stress is associated with a moderately increased risk of incident CHD., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Mental stress increases cardiovascular morbidity and mortality. Although laboratory mental stress often causes less myocardial ischemia than exercise stress (ES), it is unclear whether mental stress is intrinsically different or differences are due to less hemodynamic stress with mental stress. We sought to evaluate the hemodynamic and ischemic response to intense realistic mental stress created by modern flight simulators and compare this response to that of exercise treadmill testing and conventional laboratory mental stress (CMS) testing in pilots with coronary disease. Sixteen airline pilots with angiographically documented coronary disease and documented myocardial ischemia during ES were studied using maximal treadmill ES, CMS, and aviation mental stress (AMS) testing. AMS testing was done in a sophisticated simulator using multiple system failures as stressors. Treadmill ES testing resulted in the highest heart rate, but AMS caused a higher blood pressure response than CMS. Maximal rate-pressure product was not significantly different between ES and AMS (25,646 vs 23,347, p = 0.08), although these were higher than CMS (16,336, p <0.0001). Despite similar hemodynamic stress induced by ES and AMS, AMS resulted in significantly less ST-segment depression and nuclear ischemia than ES. Differences in induction of ischemia by mental stress compared to ES do not appear to be due to the creation of less hemodynamic stress. In conclusion, even with equivalent hemodynamic stress, intense realistic mental stress induced by flight simulators results in significantly less myocardial ischemia than ES as measured by ST-segment depression and nuclear ischemia., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Coronary heart disease is the leading cause of death in the United States. The American Heart Association has proposed improving overall cardiovascular health by promoting 7 components of ideal cardiovascular health, including health behaviors (not smoking, regular exercise, and healthy diet) and health factors (ideal body mass index, cholesterol, blood pressure, and blood glucose). The patients' knowledge of these 7 components is unknown. We performed a cross-sectional survey of patients at 4 primary care and 1 cardiology clinic. The survey measured demographic data, personal behaviors/health factors, cardiovascular disease history, and knowledge about these 7 components. A multivariate model was developed to assess patient characteristics associated with high knowledge scores. Of the 2,200 surveys distributed, 1,702 (77%) were returned with sufficient responses for analysis. Of these, 49% correctly identified heart disease as the leading cause of death, and 37% (95% confidence interval [CI] 35% to 39%) correctly identified all 7 components. The average respondent identified 4.9 components (95% CI 4.7 to 5.0). The lowest recognition rates were for exercise (57%), fruit/vegetable consumption (58%), and diabetes (63%). In a multivariate model, knowledge of all 7 components was positively associated with high school education or greater (odds ratio 2.43, 95% CI 1.68 to 3.52) and white ethnicity (odds ratio 1.78, 95% CI 1.27 to 2.50), and negatively associated with attending an urban neighborhood clinic (odds ratio 0.60, 95% CI 0.44 to 0.82). In conclusion, just >1/3 of patients could identify all 7 components of ideal cardiovascular health. Educational efforts should target patients in low socioeconomic strata and focus on improving knowledge about healthy diet and regular exercise. Although patients with diabetes were more likely than those without diabetes to recognize their risk, 1 in 5 were not aware that diabetes is a risk factor for cardiovascular disease., (Copyright © 2011 Elsevier Inc. All rights reserved.)

The occurrence of depression in patients with coronary heart disease (CHD) substantially increases the likelihood of a poorer cardiovascular prognosis. Although antidepressants are generally effective in decreasing depression, their use in patients with CHD is controversial. We carried out a meta-analysis to evaluate the health effects of selective serotonin reuptake inhibitors (SSRIs) versus placebo or no antidepressants in patients with CHD and depression. Observational studies and randomized controlled trials (RCTs) were searched in MEDLINE, EMBASE, PsycINFO, Cochrane Controlled Clinical Trial Register and other trial registries, and references of relevant articles. Primary outcomes were readmission for CHD (including myocardial infarction, unstable angina, and stroke) and all-cause mortality; the secondary outcome was severity of depression symptoms. Seven articles on 6 RCTs involving 2,461 participants were included. One study incorrectly randomized participants, and another was a reanalysis of RCT data. These were considered observational and analyzed separately. When only properly randomized trials were considered (n = 734 patients), patients on SSRIs showed no significant differences in mortality (risk ratio 0.39, 95% confidence interval 0.08 to 2.01) or CHD readmission rates (0.74, 0.44 to 1.23) compared to controls. Conversely, when all studies were included, SSRI use was associated with a significant decrease in CHD readmission (0.63, 0.46 to 0.86) and mortality rates (0.56, 0.35 to 0.88). A significantly greater improvement in depression symptoms was always apparent in patients on SSRIs with all selected indicators. In conclusion, in patients with CHD and depression, SSRI medication decreases depression symptoms and may improve CHD prognosis., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

Our understanding of how depression alters the origin and course of coronary heart disease is derived from subjective methodologies. Many psychiatric instruments were not tested for reliability and validity in subjects with comorbid medical illness, particularly coronary heart disease. They largely use scales of categoric or ordinal variables. Instruments used to assess coronary heart disease are considerably more objective and often use interval variables. By searching the websites of Circulation and the Journal of the American College of Cardiology, we entered the word "depression" on August 28, 2009. We ignored articles using "depression" in the context of cardiovascular concepts such as "ST-segment depression." By searching articles dating back to 1995, we selected publications that studied the prognostic association of depression and coronary heart disease. There were 5 relevant publications: 3 from Circulation and 2 from the Journal of the American College of Cardiology. The methods used to assess coronary heart disease (specifically, myocardial infarction) are largely homogenous across the studies, but the methods used to assess depression are heterogeneous. Parameters used to diagnose myocardial infarction and determine its severity are precise, objective, and reliable, whereas those used to assess depression and its severity exhibit less precision and lack comparable objectivity and reliability. This mismatch may compromise our understanding of the link between coronary heart disease and depression in depressed patients with comorbid coronary heart disease. We propose using precise instruments to identify and quantitate coronary heart disease as outcome variables to assess psychiatric interventions and to better define depression in depressed patients with comorbid coronary heart disease. This should lead to a better understanding of the link between depression and comorbid coronary heart disease., (Copyright 2010 Elsevier Inc. All rights reserved.)

Postoperative cognitive decrease (POCD) represents the most frequent complication in modern cardiac surgery. The application of easily assessable surrogate parameters that predict long-term POCD at early time points is tempting. The aim of the present study was to analyze the predictive value of cerebral biomarkers, diffusion-weighted magnetic resonance imaging (DWI), and cognitive bedside testing after coronary artery bypass grafting (CABG). From 106 patients who underwent elective CABG, blood samples were drawn for the measurement of protein S100B and neuron-specific enolase release at baseline, at the end of surgery, and 48 hours afterward. Cerebral DWI was carried out before and 2 to 4 days after surgery. Cognitive functioning was assessed before, 2 to 4 days (bedside testing) after, and 3 months after CABG. On DWI, lesions were detected in 15.1% of patients. Biomarker levels and the presence of acute ischemic lesions on DWI were not associated with long-term POCD. Early POCD was correlated with 3-month POCD (r = 0.46, p <0.001). Ninety-one percent of patients who had shown moderate to severe POCD (<-1.5 z scores) in the early phase still had decreased memory functioning at 3 months compared to baseline (likelihood ratio 5.23). Early POCD was asserted as the only predictor for long-term POCD in a stepwise multiple linear regression model (R(2) = 0.20, p <0.001), excluding age, length of surgery, aortic clamping and cardiopulmonary bypass duration, the number of anastomoses, and postoperative neuron-specific enolase and S100B levels. In conclusion, the results show that in contrast to biomarkers, DWI, age, or intraoperative variables, early neuropsychological bedside testing predicts long-term POCD after CABG with acceptable accuracy., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Exercise training reduces mortality in patients with coronary artery disease. Behavioral characteristics, including depression, hostility, and overall psychosocial stress, have been shown to be independent risk factors for recurrent myocardial infarction and death in these patients. Exercise training can reduce these high-risk behaviors, but it remains uncertain as to what extent the health benefits of exercise training can be attributed to improving these behaviors., Methods: We evaluated the impact of exercise training during cardiac rehabilitation on mortality in 53 patients with coronary artery disease with high levels of psychosocial stress and in 469 patients with coronary artery disease with low levels of psychosocial stress and compared them with 27 control patients with high psychosocial stress who did not undergo formal cardiac rehabilitation and exercise training., Results: Mortality was approximately 4-fold greater in patients with high psychosocial stress than in those with low psychosocial stress (22% vs 5%; P = .003). Exercise training decreased the prevalence of psychosocial stress from 10% to 4% (P<.0001) and similarly improved peak oxygen uptake in patients with high and low psychosocial stress. Mortality in patients who improved exercise capacity by>or=10% (high exercise change) was 60% lower than in patients who had<10% improvement in exercise capacity (low exercise change) (P=.009). Mortality was lower in patients with high psychosocial stress with high exercise change compared with patients with high psychosocial stress with low exercise change (0% vs 19%; P=.009). In contrast, there was no significant improvement in mortality in patients with high versus low exercise change with low psychosocial stress (4% vs 8%; P=.14)., Conclusion: Psychosocial stress is an independent risk factor for mortality in patients with coronary artery disease, and exercise training can effectively reduce its prevalence. Exercise training reduces mortality in patients with coronary artery disease, and this effect seems to be mediated in part because of the salutary effects of exercise on psychosocial stress.

A rapidly growing body of evidence supports a relationship between psychosocial factors and cardiovascular disease. In this article, a review of the epidemiologic and clinical research investigating this relationship concludes that psychosocial stressors can be both a cause and a consequence of cardiovascular disease events. Furthermore, recent data have shown that stress management might reduce future cardiac events in patients with cardiovascular disease. Unfortunately, the influence of psychosocial risk factors on cardiovascular disease remains underrecognized compared with traditional cardiac risk factors. Physicians and their associates should screen for psychosocial stressors and recognize potential symptoms. Consideration should be given to developing improved liaison relationships with psychologic or behavioral specialists to facilitate more specialized interventions when appropriate. A variety of interventions conducted by appropriately trained mental health professionals have successfully improved stress in patients with cardiovascular disease and other chronic diseases. The time has come for physicians to recognize the impact of psychosocial stressors on cardiovascular disease.

Approximately 20% of patients with coronary heart disease (CHD) have major depression and 20% have minor depression at any given point in the course of their illness. Depression causes significant psychological and social morbidity, and is a risk factor for further cardiac morbidity and mortality. Although there are many possible biological and behavioral mechanisms, the causal pathways through which depression increases the risk for cardiac events and death are not well understood. Despite the morbidity associated with depression, and the devastating impact it has on the quality of life of patients with CHD, it is underdiagnosed and often left untreated. This article describes screening techniques for use in primary care and cardiology settings, and discusses the safety and efficacy of available treatments for depression in patients with CHD.

Purpose: Depression following major cardiac events is associated with higher mortality, but little is known about whether this can be reduced through treatment including cardiac rehabilitation and exercise training. We evaluated the impact of cardiac rehabilitation on depression and its associated mortality in coronary patients., Patients and Methods: We evaluated 522 consecutive coronary patients (381 men, 141 women; aged 64+/-10 years) enrolled in cardiac rehabilitation from January 2000 to July 2005 and a control group of 179 patients not completing rehabilitation. Depressive symptoms were assessed by questionnaire at baseline and following rehabilitation, and mortality was evaluated after a mean follow-up of 1296+/-551 days., Results: Prevalence of depressive symptoms decreased 63% following rehabilitation, from 17% to 6% (P <.0001). Depressed patients following rehabilitation had an over 4-fold higher mortality than nondepressed patients (22% vs 5%, P=.0004). Depressed patients who completed rehabilitation had a 73% lower mortality (8% vs 30%; P=.0005) compared with control depressed subjects who did not complete rehabilitation. Reductions in depressive symptoms and its associated mortality were related to improvements in fitness; however, similar reductions were noted in those with either modest or marked increases in exercise capacity., Conclusion: In patients following major coronary events, cardiac rehabilitation is associated with both reductions in depressive symptoms and the excess mortality associated with it. Moreover, only mild improvements in levels of fitness appear to be needed to produce these benefits on depressive symptoms and its associated mortality.

Background: Depression is an unfavorable state that is difficult to recognize in patients with coronary heart disease (CHD). Little is known about the characteristics of depressed female CHD patients., Objective: The purpose of this study was to investigate the occurrence of depressive symptoms in women entering a cardiac rehabilitation program, and furthermore, to examine whether women who have CHD and depressive symptoms display any unfavorable physical or psychological characteristics that could be helpful in identifying female CHD patients at increased risk of depression., Methods: In a Swedish cross-sectional survey of Swedish women entering a randomized, female cardiac rehabilitation trial, patients with a Beck Depression Inventory (BDI) score indicating depression were compared with patients without depressive symptoms., Results: Of the 121 women with CHD who participated in the study, 23.1% had BDI scores consistent with moderate to severe depression (BDI > or =19). Scores of > or =19 were strongly correlated to established angina pectoris (P = 0.007) and higher rates of anxiety on the Beck Anxiety Inventory (P < 0.001). Depressed women also were more likely to have a family history of heart disease (P = 0.036) and were less likely to care for their health in the future (P = 0.005)., Conclusions: This study suggests a strong relationship between depression and angina pectoris in women with CHD. The study also confirms previous findings that depressive symptoms are common in women with CHD. Findings of more pronounced cardiac symptoms in depressed women with CHD suggest that depressive symptoms may present differently or alter cardiac symptoms in female CHD patients. Consequently, the occurrence of increased cardiac symptoms indicates the need to screen for depression, whether depressive symptoms are apparent or not. The higher scores for anxiety in depressed women with CHD and their poorer health care practices, in combination with their more pessimistic beliefs about lifestyle changes, highlight the need to identify depression to enhance adherence to treatment regimens in the cardiac rehabilitation process.

Depression and coronary heart disease are common conditions that often occur together. Evidence shows that the co-occurrence of these illnesses is not random but driven by depression as a risk factor for the occurrence and progression of coronary heart disease. This link is due, in part, to the impact that depression has on neuroendocrine pathways leading to increased platelet activation, cortisol and catecholamine excess, and altered autonomic nervous system function that influence the pathogenesis and progression of coronary atherosclerosis and subsequent heart disease. We know that treating depression in patients with coronary heart disease improves the symptoms and signs of depression. Evidence is less compelling that treating depression improves the morbidity and mortality of coronary heart disease. However, early findings suggest that some antidepressants may improve the course of coronary heart disease and improve patient compliance with various cardiac interventions. We outline a practical approach to the treatment of depression in patients with coronary heart disease. This approach includes education, counseling, antidepressant drugs, and referral when appropriate.

Psychological stress and type D personality have been associated with adverse cardiac prognosis, but little is known about their relative effect on the pathogenesis of coronary heart disease (CHD). "Type D" refers to the tendency to experience negative emotions and to inhibit the expression of these emotions in social interactions. We investigated the relative effect of stress and type D personality on prognosis at 5-year follow-up. At baseline, 337 patients with CHD who participated in cardiac rehabilitation filled in the General Health Questionnaire (psychological stress) and the Type D personality scale. Patients were followed for 5 years. The end point was major adverse cardiac events, which were defined as a composite of cardiac death, myocardial infarction, and cardiac revascularization (coronary artery bypass grafting/percutaneous coronary intervention). There were 46 major adverse cardiac events at follow-up, including 4 deaths and 8 myocardial infarctions. Type D patients had an increased risk of death/infarction (odds ratio 4.84, 95% confidence interval 1.42 to 16.52, p = 0.01) compared with non-type D patients, independent of disease severity. Stress (p = 0.011) and type D (p = 0.001) were related to an increased risk of developing a major adverse cardiac event after adjusting for gender, age, and biomedical risk factors. Multivariate analysis yielded left ventricular ejection fraction < or =40%, no treatment with coronary artery bypass grafting, and type D personality (odds ratio 2.90, 95% confidence interval 1.42 to 5.92, p = 0.003) as independent predictors of major adverse cardiac events, whereas psychological stress was marginally significant (odds ratio 2.01, 95% confidence interval 0.99 to 4.11, p = 0.054). In conclusion, type D personality is a psychological factor that may optimize risk stratification in patients with CHD. Type D reflects more than temporary changes in general stress level because it predicted cardiac events after controlling for concurrent symptoms of stress.

The lack of social integration has predicted coronary heart disease morbidity and mortality in prospective observational studies; however, the biologic mechanisms by which this may occur are not well understood. The objective of this study was to determine whether social integration is associated with inflammatory risk factors for coronary heart disease, specifically C-reactive protein (CRP) and interleukin-6. The study participants (aged 70 to 79 years; 380 men and 425 women) were from the MacArthur Successful Aging Study, a longitudinal study of 3 community-based cohorts in the United States of older adults with relatively high physical and cognitive functioning at baseline (1988 to 1989). The plasma concentrations of interleukin-6 and CRP were assessed using a high-sensitivity enzyme-linked immunosorbent assay. Cross-sectional logistic regression analyses were performed. Multivariate adjusted analyses indicated that social integration was significantly inversely associated with CRP concentration in men after adjusting for age, race/ethnicity, smoking, alcohol consumption, physical activity, body mass index, cardiovascular disease, other major or chronic conditions, physical functioning, socioeconomic status, and depression (odds ratio 2.23, 95% confidence interval 1.05 to 4.76, for elevated CRP [>3.19 mg/L] in the least socially integrated quartile vs the most socially integrated quartile). No significant associations were found between social integration and interleukin-6 in men or either inflammatory marker in women. In conclusion, social integration was negatively associated with the plasma CRP concentration in men. These findings suggest a potential biologic mechanism for the observed associations between social integration and coronary heart disease in prospective studies. Differences may exist between women and men in the biologic pathways associated with social integration.

Experiencing an acute coronary syndrome (ACS) may provoke a range of negative emotional responses, including acute distress and fear of dying. The frequency of these emotional states has rarely been assessed. This study examined the presence and severity of the fear of dying and acute distress in 184 patients with ACS and analyzed its correlates and consequences. Intense distress and fear of dying was reported by 40 patients (21.7%) and moderate fear and distress by 95 patients (51.6%). Intense distress and fear was associated with female gender (odds ratio [OR] 2.49, 95% confidence interval [CI] 1.07 to 2.49), lower levels of education (OR 2.44, 95% CI 1.02 to 5.87), greater chest pain (OR 5.33, 95% CI 1.40 to 20.4), and emotional upset in the 2 hours before onset of ACS (OR 2.70, 95% CI 1.13 to 6.45). Having no acute distress or fear was more common in patients who exercised regularly (OR 3.32, 95% CI 1.35 to 8.18) and who did not initially attribute the chest pain to cardiac causes (OR 2.67, 95% CI 1.10 to 6.47). No association was found with cardiovascular disease history, objective measures of clinical severity, or with clinical presentation of ACS. Acute distress and fear of dying predicted greater depression and anxiety 1 week after ACS (p=0.006), and elevated levels of depression at 3 months (p=0.009), after adjustment for age, gender, and negative affect. In conclusion, distress and fear during the initial stages of an ACS may trigger subsequent depression and anxiety, thereby promoting poorer prognosis and greater morbidity with time.

Previous research has established a relation between depression at the time of cardiac hospitalization and patient mortality. The objective of this study was to examine the role of depressive history and symptomatology during hospitalization on 5-year all-cause mortality after admission for an acute coronary syndrome. We recruited 750 patients who had unstable angina pectoris and myocardial infarction from 12 coronary care units between 1997 and 1999. Measurements included sociodemographic and clinic data and the Beck Depression Inventory (BDI). Data were linked to an administrative database to determine 5-year all-cause mortality. Survival data were adjusted using a Cox's proportional hazards model. One hundred seventy-four participants (23.2%) self-reported a history of depressed mood for >2 weeks, 235 (31.3%) had elevated BDI scores at index hospitalization, with 105 (14.0%) reporting persistent depressive symptomatology. One hundred fifteen participants (15.3%) died by 5 years after hospitalization. After adjusting for prognostic indicators, such as cardiac disease severity, medical history, and smoking, depressive symptomatology during hospitalization was significantly predictive of mortality, but depressive history was not. Hazard ratios associated with BDI scores <10 versus those > or =10 at hospitalization ranged from 1.90 (95% confidence interval 1.12 to 3.24) at 2 years to 1.53 (95% confidence interval 1.04 to 2.24) at 5 years. In conclusion, the significance of depressive symptomatology at the time of, but not before, hospitalization underlines the need for early identification of increased distress and renews calls to identify treatments that not only improve quality of life but also decrease the risk of mortality.

Major depression is associated with adverse outcomes in patients who have coronary heart disease. How best to identify depression in busy cardiology practices is unknown. We compared the test characteristics of 4 depression screening instruments with an interview diagnosis of depression (Diagnostic Interview Schedule) in 1,024 outpatients who had coronary heart disease. Screening instruments were the 10-item Center for Epidemiologic Studies Depression Scale-10, the Patient Health Questionnaire-9, the Patient Health Questionnaire-2, and a simple 2-item instrument that asks (1) "During the past month, have you often been bothered by feeling down, depressed, or hopeless?" and (2) "During the past month, have you often been bothered by little interest or pleasure in doing things?" Of the 1,024 participants, 224 (22%) had major depression based on the Diagnostic Interview Schedule. Areas under the receiver-operating characteristic curves were similar for all instruments (range 0.84 to 0.87). In conclusion, a positive response to 1 of the 2 items was 90% sensitive and 69% specific for depression, with a negative likelihood ratio of 0.14. Thus, negative responses to the 2 items effectively ruled out depression. A score > or =10 on the Patient Health Questionnaire-9 was 54% sensitive and 90% specific, with a positive likelihood ratio of 5.4. Thus, a cutpoint > or =10 was virtually diagnostic for depression.

Inflammatory biomarkers and depression have been proposed as novel coronary heart disease (CHD) risk markers. However, prospective studies have rarely assessed these 2 candidate CHD risk markers simultaneously in predicting incident CHD events. Therefore, although depression and elevated inflammatory biomarkers frequently covary, it is unclear how these risk markers relate to each other and to CHD event onset. The elucidation of these causal pathways has important clinical implications for patients who are depressed and/or have elevated inflammatory biomarkers. In this review, the publications examining the relations among depression, inflammation, and CHD events are discussed.

Purpose: We hypothesized that obese adults with coronary heart disease, obstructive lung disease, or depression would report greater impairments in health-related quality of life owing to their angina, dyspnea, or depressive symptoms as compared with persons with normal body weight., Methods: We analyzed cross-sectional data from the Ambulatory Care Quality Improvement Project, a multicenter study of veterans enrolled in general internal medicine clinics. Health-related quality of life was assessed using the Medical Outcomes Study Short Form-36, the Seattle Angina Questionnaire, the Seattle Obstructive Lung Disease Questionnaire, and the Hopkins Symptom Checklist for Depression., Results: Compared with patients of normal weight (body mass index: 18.5 to 24.9 kg/m2), underweight patients (body mass index <18.5 kg/m2) reported health-related quality-of-life scores that were at least 5% lower (worse) in all 15 quality-of-life domains examined. Patients with class III obesity (body mass index > or =40 kg/m2) reported quality-of-life scores that were at least 5% lower than those of normal weight patients in eight domains. Scores of overweight patients (body mass index: 25 to 29.9 kg/m2) were higher (better) than those of normal weight patients in 11 domains., Conclusion: Body mass index was strongly associated with generic- and condition-specific health-related quality of life. Our results suggest that, when considering health-related quality-of-life outcomes among veterans, the optimal body mass index may be above the "normal" range. Further research should test the validity of the 1998 National Institutes of Health body mass index categories as predictors of health outcomes among veterans.

Major depressive disorders complicate recovery from acute coronary syndrome in approximately 1 in 5 patients, and have been found to be associated with significant impairments of quality of life and functioning. The aim of the present analysis was to evaluate the efficacy of sertraline in improving quality of life and functioning in patients diagnosed with major depression who had recently been hospitalized for acute coronary syndrome. Three hundred sixty-nine patients hospitalized in the previous month for acute coronary syndrome (myocardial infarction, 74%; unstable angina, 26%) who also met criteria for major depressive disorder were randomized to 24 weeks of double-blind treatment with sertraline (50 to 200 mg/day) or placebo. Quality-of-life and functional status were assessed using the Quality of Life, Enjoyment, and Satisfaction scale (Q-LES-Q) and the Medical Outcomes Study SF-36. Data from the total sample, and the recurrent depression subgroup, were analyzed. Severe baseline impairment was found in the Q-LES-Q and all subscales of the SF-36. A multivariate regression analysis identified depression as the strongest predictor of baseline quality-of-life impairment (partial r, -0.37, p = 0.001). In the recurrent depression group, treatment with sertraline resulted in significantly greater improvement than placebo in the Q-LES-Q total score and SF-36 mental component summary score, as well as the SF-36 role limitations, emotional, and mental health factors. Depression has a substantial negative impact on quality of life and functioning in patients hospitalized for acute coronary syndrome. Sertraline was associated with clinically meaningful improvement in multiple quality-of-life domains in patients with acute coronary syndrome and recurrent depression.

Social position and psychosocial factors are associated with coronary disease, but the underlying pathophysiologic mechanisms remain unclear. In a sample of 283 nonsmokers, we found that social position was inversely associated with interleukin-6 and C-reactive protein and that participants with mild depression had impaired endothelial function.

Anxiety and depression have significant and widespread effects on daily function and symptoms of patients with coronary artery disease over a 5-year period. This may partially explain why results of treadmill stress testing and angiography poorly predict the daily functioning of patients with coronary artery disease.

Social support and depression have been shown to affect the prognosis of coronary patients, and social support has been found to influence depression in community and patient samples. We investigated the characteristics of coronary patients whose depressive symptomatology was most likely to improve with social support. We predicted that social support would be most beneficial for the most severely depressed, the old, the poor, the most severely ill, and those with poor functional status. Patients (n = 590) with documented coronary artery disease were assessed for depressive symptoms, social support, and functional status while in hospital. They were reassessed for depression 1 month later during a home visit. Depression scores were lower at follow-up (p = 0.001), and improvement was more marked among those reporting more support (p <0.001). The social support effect was strongest among those with high levels of depression at baseline (p <0.001) and those with lower income (p = 0.01). Unexpectedly, social support was more strongly associated with improvement in younger patients (p = 0.01). Social support did not interact with gender, disease severity, or functional status. These findings are partially consistent with the notion that social support is most effective for those who are most vulnerable and/or have few coping resources. These findings also have implications for the design and interpretation of psychosocial interventions.

The conditions of depression, erectile dysfunction (ED), and cardiovascular disease may seem at a superficial level as independent medical problems managed by 3 separate and unrelated healthcare disciplines. Various studies, however, have revealed significant associations between depression and cardiovascular disease, ED and cardiovascular disease, and depression and ED. The purpose of this research was to identify whether the 3 medical conditions share mutually reinforcing associations and predictors. Population-based epidemiologic studies were utilized where possible. Variables including age, heart disease, hypertension, sedentary behavior, related medications, cigarette smoking, and abnormal lipids have been found to be highly associated with depressive symptoms, cardiovascular disease, and ED. It was concluded that all 3 medical conditions share many of the same risk factors and etiologic associations and may be best modeled in a 3-way holistic, mutually reinforcing relation. Of particular relevance, patients with sexual dysfunction have a likely comorbidity of cardiovascular disease and depression, as well as the potential increased risk for cardiac morbidity and mortality.

Despite the growing amount of reseach on cardiac disease and sexual dysfunction, few empirical studies have been published on the overlap of these 2 areas. In particular, previous research has noted that the overall attainment of social and occupational adjustment for patients with cardiac disease remains a challenge. Emotional distress of sufficient intensity to receive a psychiatric diagnosis has been estimated to be as high as 37-58% in patients after myocardial infarction (MI). In fact, numerous studies have concluded that failure to adjust socially or to return to normal activity levels is more strongly related to psychological distress than to the extent of the organic disease itself. These factors, either pre-existing or after onset of psychological morbidity, are highly likely to influence sexual adjustment of the cardiac patient. This article reviews the role of anxiety as a risk factor for the development of cardiac disease, as a comorbid condition, and the role anxiety may play in the development of sexual difficulties. The complicated association between psychological distress, previous sexual adjustment, organic factors, and existing family supports should be considered in cardiac rehabilitation.

There is a well-documented association between depression, ischemic heart disease, and cardiovascular mortality. This association has a number of dimensions including: (1) depressed patients have a higher than expected rate of sudden cardiovascular death; (2) over the course of a lifetime, patients with depression develop symptomatic and fatal ischemic heart disease at a higher rate compared with a nondepressed group; and (3) depression after myocardial infarction (MI) is associated with increased cardiac mortality. Depression is also associated with sexual dysfunction, particularly erectile dysfunction. If depression is the primary illness, then erectile dysfunction can be considered a symptom of the depressive illness. However, if the erectile dysfunction is primary, men may develop a depressive syndrome in reaction to the loss of sexual function. Regardless of whether erectile dysfunction is a symptom of depression or depression is a consequence of erectile dysfunction, these conditions are frequently comorbid. Thus, the patient with ischemic heart disease who is depressed is more likely to have erectile difficulties. An attempt by this patient to engage in sexual activity is therefore more likely to be unsuccessful and, given the increase in cardiac mortality associated with depression, it may result in a serious cardiac event.

The purpose of this study was to examine the prospective relation between dominance, as assessed by a Minnesota Multiphasic Personality Inventory (MMPI-2)-derived dominance scale, and incidence of coronary heart disease (CHD), independent of participants' anger level. The study was performed in the VA Normative Aging Study, an ongoing cohort of older (mean age 61 years) men. A total of 1,225 men who were free of CHD in 1986 completed the MMPI-2. A factor analysis of selected MMPI items provided the basis for the construction of a dominance scale and an anger scale. During an average of 8 years of follow-up, 158 cases of incident CHD occurred, including 29 cases of fatal CHD, 69 cases of nonfatal myocardial infarction (MI), and 60 cases of angina pectoris (AP). Compared with men reporting the lowest levels of dominance (lower tertile), the multivariate-adjusted relative risk among men reporting the highest levels of dominance (upper tertile) was 1.80 (95% confidence interval [CI] 1.21 to 3.24) for combined nonfatal MI and fatal CHD. Additional adjustment for anger scores did not significantly alter this relation. There was no significant relation between dominance and AP. Our data suggest that dominance is an independent risk factor for CHD in older men.

Vital exhaustion, defined as a combination of fatigue, lack of energy, feelings of hopelessness, loss of libido, and increased irritability, has been proposed as a risk indicator for the development of coronary heart disease (CHD). It is unclear if the association between vital exhaustion and CHD is independent of sleep behavior, depression, and physical activity. We ascertained sense of exhaustion among 5,053 male college alumni who were free of cardiovascular disease, cancer, and chronic obstructive pulmonary disease by asking, "How often do you experience sense of exhaustion (except after exercise)?" on a health survey in 1980. Eight hundred fifteen men died during 12 years of follow-up, 25% due to CHD. After adjustment for age, body mass index, smoking status, and history of physician-diagnosed diabetes and hypertension, frequent sense of exhaustion was associated with a twofold increase in CHD mortality (rate ratio 2.07; 95% confidence interval 1.08 to 3.96). After additional adjustment for insomnia, sleep duration, use of sleeping pills and tranquilizers, physical activity, history of physician-diagnosed depression, and alcohol intake, the rate ratio was not appreciably altered; however, the association now was of borderline significance (rate ratio 2.06; 95% confidence interval: 0.98 to 4.36) because there were only 10 deaths from CHD among men who were frequently exhausted. In a prospective observational study, frequent sense of exhaustion appeared to be independently associated with increased risk of CHD mortality in men.

Depression is prevalent in women with coronary artery disease, and increases morbidity and mortality following major coronary events. We demonstrated that women with depression had markedly abnormal overall cardiovascular risk profiles and have marked benefits in exercise capacity, obesity indexes, behavioral characteristics (including depression), and quality of life following formal, outpatient phase II cardiac rehabilitation and exercise training programs.

This cross-sectional study investigated the association of hostility and social support to coronary heart disease (CHD) in 2 groups of men and women: those with a familial predisposition for CHD (high-risk sample) and a randomly selected group. The hypothesis was that hostility and low social support would be associated with CHD, and would have a greater effect in the high-risk group. The random sample contained 2,447 individuals (47.1% male) from 576 families, and the high-risk sample consisted of 2,300 people (45.5% male) from 542 families. Odds ratios (OR) and their 95% confidence intervals were calculated using generalized estimating equations (GEE) for logistic regression. Family was specified as the clustering variable, and robust SEEs were obtained to account for dependence of the data within families. After controlling for age, education, body mass index, exercise, smoking history, drinking history, and drinking >5 drinks a day, hostility was associated with a history of coronary bypass surgery or coronary angioplasty in high-risk men (OR 1.21) and a history of myocardial infarction in high-risk women (OR 1.39). High-risk women with high social support had reduced odds of a previous myocardial infarction (OR 0.76), whereas women with high network adequacy in the random sample had reduced risk of myocardial infarction (OR 0.41) and angina (OR 0.49). A ratio of high hostility to low social support was associated with past myocardial infarction in high-risk women (OR 2.47) and a history of angina (OR 2.02) in the random sample men. These results suggest that high hostility and low social support are associated with some manifestations of CHD after controlling for adverse health behaviors.

Increasing evidence supports an association between symptomatic depression and the risk of coronary heart disease (CHD), although no single study has compared multiple depression scales. We hypothesized that higher levels of symptomatic depression assessed from different depression scales were associated with the risk of CHD. We examined this relation in the Normative Aging Study, a prospective cohort of older men. A total of 1,305 men free of diagnosed CHD in 1986 completed the revised Minnesota Multiphasic Personality Inventory (MMPI-2). We categorized scores for the MMPI-2 D, MMPI-2 DEP, and Symptom Checklist-90 (SCL-90) depression scales. During an average 7.0 years of follow-up, 110 cases of incident CHD occurred, including 30 cases of nonfatal myocardial infarction, 20 cases of fatal CHD, and 60 cases of angina pectoris. Compared with men reporting the lowest level of depression, men in the highest level of depression had multivariate-adjusted relative risks of incident CHD (total CHD and angina) of 1.46 (95% confidence interval 0.83 to 2.57), 2.07 (95% confidence interval 1.13 to 3.81), and 1.73 (95% confidence interval 0.97 to 3.10) for the MMPI-2 D, MMPI-2 DEP, and SCL-90 scales, respectively. Similar RRs were obtained for each CHD subtype according to each depression scale. We found strong dose-response relations between level of depression measured by the MMPI-2 DEP scale and incidence of both angina pectoris (p value for trend, 0.039) and CHD (p value for trend, 0.016). Among older men, symptomatic depression measured by any of 3 depression scales may be positively associated with the risk of CHD.

Depression is a prevalent condition in coronary patients and is associated with increased morbidity and mortality following major coronary events. We measured the prevalence of depressive symptoms in 268 elderly coronary patients 4 to 6 weeks following a major coronary event and assessed its modulation by outpatient cardiac rehabilitation and found that cardiac rehabilitation resulted in a significant reduction in the prevalence and severity of this disorder.

Purpose: Although coronary disease is the second most common cause of work and functional disability, little is known about the relative contributions of biomedical and psychosocial factors to this disability. This study was conducted to determine the associations of depression and anxiety with self-reported physical function and activity interference in patients with coronary artery disease., Methods: This was a 1-year prospective cohort study of 198 HMO members who had elective cardiac catheterization for coronary artery disease in 1992. Measures included: severity of coronary artery stenosis from cardiac catheterization reports; anxiety and depression severity using interviewer-administered Hamilton Anxiety and Depression Rating Scales; and self-reported physical function and activity interference., Results: At the time of catheterization, patients' self-reported physical function differed significantly by number of main coronary vessels stenosed >70% (P <0.03), by anxiety quartiles (P = 0.001), and by depression quartiles (P = 0.001). At 1 year, physical function was no longer associated with the number of main coronary vessels stenosed at baseline, but still was significantly associated with baseline anxiety (P <0.001) and depression quartiles (P = 0.01). Moreover, change in physical function scores from baseline to 12 months was associated with baseline anxiety (P <0.001) or depression (P <0.001) quartiles, but not with baseline number of occluded coronaries. Results for activity interference were similar to those for physical function. These associations were largely unchanged when corrected for age, sex, education, social class, medical versus surgical management of CAD, and degree of medical comorbidity., Conclusion: Anxiety and depression have a significant and persistent effect on physical function in patients with coronary artery disease. Although current treatment methods appear to neutralize the influence of coronary stenosis on physical function during the year following catheterization, this is not true for anxiety and depression.

Cardiac rehabilitation programs have not consistently been shown to improve the psychological well being of their patients. In our study of 38 cardiac patients (29 men and 9 women), a variety of quality-of-life parameters were assessed before and after they completed either 12 weeks of high-intensity strength training or flexibility training added to their outpatient cardiac rehabilitation aerobic exercise program. The strength-trained patients increased their self-efficacy scores for lifting (29% vs 4%, p <0.05), push-ups (65% vs. 17%, p <0.01), climbing (36% vs 0%, p <0.001), and jogging (100% vs -9%, p <0.001), when compared with the flexibility-trained patients. The strength group also had greater improvements in Profile of Mood States dimensions: total mood disturbance (123% vs 18%, p <0.05), depression/dejection (73% vs 15%, p <0.05), and fatigue/inertia (42% vs 3% p <0.05), than did the flexibility group. The Medical Outcome Survey Short Form 36 role emotional health domain scores were significantly improved in the strength group when compared with the flexibility group (64% vs 0%, p <0.05), and the role limitation scores improved in both groups. Increases in strength were associated with enhanced self efficacy and improved mood and well-being scores (n = 34, r = 0.30 to 0.53, p <0.05). High-intensity strength training added to a cardiac rehabilitation program of selected patients leads to improvements in quality-of-life parameters. These data, in conjunction with improvements in strength, strongly support the value of adding high-intensity strength training to cardiac rehabilitation programs.

Emotional defensiveness, defined by concealment of both negative emotions and personal vulnerability, was substantially and consistently correlated with the magnitude of blood pressure reactions to 2 types of mental stress among coronary patients, independently of clinical status. Given recent studies denoting stress-related blood pressure surges as triggers of dangerous cardiovascular events, exaggerated vasomotor reactions among defensive patients may be of clinical significance.

Elderly women are frequently not referred to cardiac rehabilitation programs. The data provided in this study, which demonstrate the benefits on exercise capacity, obesity indexes, behavioral characteristics, quality of life, and plasma lipids, support the idea that elderly women should be routinely referred to and vigorously encouraged to attend these programs following major coronary artery disease events.

Two groups of patients with coronary artery disease who differed in level of cardiac vagal control were compared in their cardiovascular responses to psychological stress. Patients with lower vagal control manifested increased reactions in diastolic blood pressure and rate-pressure product to mental stress and tended to have greater systemic vasoconstriction.

Purpose: To establish the prevalence of panic disorder in emergency department (ED) chest pain patients; compare psychological distress and recent suicidal ideation in panic and non-panic disorder patients; assess psychiatric and cardiac comorbidity; and examine physician recognition of this disorder., Design: Cross-sectional survey (for psychiatric data). Prospective evaluation of patient discharge diagnoses and physician recognition of panic disorder., Setting: The ambulatory ED of a major teaching hospital specializing in cardiac care located in Montreal, Canada., Subjects: Four hundred and forty-one consenting, consecutive patients consulting the ED with a chief complaint of chest pain., Primary Outcome Measure: Psychiatric diagnoses (AXIS I). Psychological and pain test scores, discharge diagnoses, and cardiac history., Results: Approximately 25% (108/441) of chest pain patients met DSM-III-R criteria for panic disorder. Panic disorder patients displayed significantly higher panic-agoraphobia, anxiety, depression, and pain scores than non-panic disorder patients (P < 0.01). Twenty-five percent of panic disorder patients had thoughts of killing themselves in the week preceding their ED visit compared with 5% of the patients without this disorder (P = 0.0001) even when controlling for co-existing major depression. Fifty-seven percent (62/108) panic disorder patients also met criteria for one or more current AXIS I disorder. Although 44% (47/108) of the panic disorder patients had a prior documented history of coronary artery disease (CAD), 80% had atypical or nonanginal chest pain and 75% were discharged with a "noncardiac pain" diagnosis. Ninety-eight percent of the panic patients were not recognized by attending ED cardiologists., Conclusions: Panic disorder is a significantly distressful condition highly prevalent in ED chest pain patients that is rarely recognized by physicians. Nonrecognition may lead to mismanagement of a significant group of distressed patients with or without coronary artery disease.

Even elderly patients > or = 75 years of age with coronary artery disease have modest improvements in lipid levels and marked improvements in exercise capacity, behavioral characteristics, and quality-of-life parameters after cardiac rehabilitation and exercise training programs. These data support that even very elderly patients with coronary artery disease should be routinely referred to and vigorously encouraged to pursue formal outpatient cardiac rehabilitation and exercise training programs following major coronary events.

Twenty-one patients with documented coronary artery disease were tested at baseline by exercise tolerance testing, and assigned to either stress reduction using the Transcendental Meditation (TM) program or to a wait-list control, After 8 months, the TM group had a 14.7% increase in exercise tolerance, an 11.7% increase in maximal workload, an 18% delay in onset of ST-segment depression, and significant reductions in rate-pressure product at 3 and 6 minutes, and at maximal exercise compared with the control group.

This study examines the effect of anger and vital exhaustion on recurrent events after percutaneous transluminal coronary angioplasty (PTCA). Data came from 149 patients (123 men and 26 women) who underwent successful PTCA. During 18 months of follow-up, there were 37 recurrent events (25%) for which there was objective evidence of new or progression of coronary disease. The 123 male patients with high anger were significantly more likely to have multivessel disease before PTCA (odds ratio 2.42; p = 0.04), after controlling for standard heart disease risk factors. High-anger male patients also had a threefold increased risk for recurrent events after PTCA (RR 2.94; p = 0.01), which remained marginally significant after accounting for other heart disease risk factors and residual stenosis after PTCA (RR 2.33; p = 0.09). Among female patients, these relations were much weaker and not statistically significant. Among male patients, additional adjustment for vital exhaustion did not change the risk for recurrent events associated with high anger. A composite index of psychosocial risk based on anger and vital exhaustion was significantly related (p = 0.02) to events after PTCA after adjustment for standard heart disease risk factors. These findings add to the growing body of research on the role of psychosocial factors on clinical course in patients with coronary artery disease.

This study assessed the relation between hemodynamic data during a standardized mental stressor and ambulatory ischemia to determine if laboratory-induced responses could predict the magnitude of daily life ischemia. Forty-two men and 11 women, aged 46 to 79 years (mean 61), with coronary artery disease and exercise-induced ischemia were studied. All patients underwent 24- to 48-hour ambulatory electrocardiographic (ECG) monitoring (mean 43 +/- 0.8 hours) and laboratory-induced mental stress using a public speaking task. Hemodynamic data were obtained at rest and every minute during mental stress. Thirty-three of 53 patients (62%) had at least 1 ischemic episode during ECG monitoring. In patients who had ambulatory ischemia, there was a mean number of 7.9 +/- 1.8 episodes (mean total duration 79.2 +/- 24.1 minutes/48 hours). Significant positive correlations were found for peak heart rate and changes in heart rate during mental stress and ambulatory ischemia (r = 0.353 to 0.462, p < 0.05) in patients who had ambulatory ischemia. There was no correlation between systolic blood pressure during mental stress and ambulatory ischemia. Results of this study demonstrate that heart rate response during laboratory-induced mental stress correlates with magnitude of ischemia on ambulatory ECG monitoring in patients with coronary artery disease.

Decreased heart rate (HR) variability is an independent risk factor for mortality in cardiac populations. Clinical depression has also been associated with adverse outcomes in patients with coronary artery disease (CAD). This study tests the hypothesis that depressed patients with CAD have decreased HR variability compared with nondepressed CAD patients. Nineteen patients with angiographically documented CAD and either major or minor depression were compared with a sample of nondepressed CAD patients according to age, sex, and smoking status. All patients underwent 24-hour Holter monitoring, and the standard deviation of all normal-to-normal intervals was used as the primary index of HR variability. HR variability was significantly lower in depressed than nondepressed patients (90 +/- 35 vs 117 +/- 26 ms; p < or = 0.01), even after adjusting for relevant covariates. Thus, decreased HR variability may help explain the increased risk for cardiac mortality and morbidity in depressed CAD patients.