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Die gesundheitsbezogene Lebensqualitat (LQ) von Brustkrebspatientinnen wird wesentlich durch ihre psychische Befindlichkeit bestimmt. Bei 103 Brustkrebspatientinnen wurde die LQ in der Akutbehandlungsphase mittels EORTC-QLQ-C30, psychischer Distress durch die HADS und der psychoonkologische Versorgungswunsch an­hand einer Checkliste erhoben. ICD-10-F-Diagnosen wurden nach klinischem Interview gestellt. Sowohl Patientinnen mit erhohtem HADS-Wert (> 13) als auch solche mit einer ICD-F-Diagnose geben in den EORTC-Skalen niedrige LQ an. Die Ergebnisse bestatigen, dass das Vorhandensein psychischer Auffalligkeiten negativ mit der LQ assoziiert ist. In einer multivariaten Varianzanalyse erwies sich das Vorliegen auffalliger HADS-Scores, nicht aber das Vorhandensein einer ICD-F-Diagnose, als unabhangig signifikanter Pradiktor der LQ. Bei der Bewertung von Screeninginstrumenten sollte nicht nur deren Trefferquote hinsichtlich Diagnosen, sondern auch ihre Relevanz fur die LQ berucksichtigt werden.

THE PROBLEM The body-mind dualism of somatic medicine is resolved through the concept of psychosomatic medicine. More unspecific descriptions such as "integrative medicine" (which does not clarify what should be integrated) or the "holistic approach" (which comes close to esoterics) suggest the unity of mind, body and soul, although the term "psycho-somatic" still reflects dualistic thinking. PAST APPROACHES The American Psychosomatic Society has been considering a name change for years, partially to rid itself of the dualistic label, but so far these efforts have not resulted in a viable alternative. Engel's concept of biopsychosocial medicine supposes a triangular array of the body, mind, and social environment, setting body and mind into a relationship with each other and with a third party. Based on the physician-patient relationship (Balint), psychosomatic medicine can be understood in a broader sense as "relationship medicine," covering not only the use of the interpersonal relationship as a medical agent, but also a science of medicine that puts mind, body, and social environment into a theoretical framework of interrelations, with the perspective of integrating the different system levels. The translation processes among the system levels are, for example, addressed by biosemiotics (v. Uexkull). CONSEQUENCES Both clinical medicine and medical research, if they intend to be psychosomatic, need to take these theoretical concepts into account and utilize them practically for (team)work with patients. Together with a clear differentiation from other cultures of (para)medicine, this can serve to develop a "psychosomatic identity."

Die gesundheitsbezogene Lebensqualitat (LQ) von Brustkrebspatientinnen wird wesentlich durch ihre psychische Befindlichkeit bestimmt. Bei 103 Brustkrebspatientinnen wurde die LQ in der Akutbehandlungsphase mittels EORTC-QLQ-C30, psychischer Distress durch die HADS und der psychoonkologische Versorgungswunsch an­hand einer Checkliste erhoben. ICD-10-F-Diag­nosen wurden nach klinischem Interview gestellt. Sowohl Patientinnen mit erhohtem HADS-Wert (>13) als auch solche mit einer ICD-F-­Diagnose geben in den EORTC-Skalen niedrige LQ an. Die Ergebnisse bestatigen, dass das Vorhandensein psychischer Auffalligkeiten negativ mit der LQ assoziiert ist. In einer multivariaten Varianzanalyse erwies sich das Vorliegen auffalliger HADS-Scores, nicht aber das Vorhandensein einer ICD-F-Diagnose, als unabhangig signifikanter Pradiktor der LQ. Bei der Bewertung von Screeninginstrumenten sollte nicht nur deren Trefferquote hinsichtlich Diagnosen, sondern auch ihre Relevanz fur die LQ berucksichtigt werden.

Background Depression is associated with a negative prognosis in coronary heart disease and heart failure patients. Type D personality has been shown to predict the persistence of depressive symptoms over 12 months. Data on longer follow-up periods and on the effectiveness of Type D as a screening tool compared to established measures of depressive symptoms are missing. Methods Type D personality and depressive mood were assessed with the DS14 and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) in 679 consecutive cardiac patients (22.2% female, mean age 62.4 ± 10.2 years) over a period of 6 years. Latent class and growth mixture models with Type D, comorbidity, age, and sex as covariates were used to model individual depression trajectory classes and to predict trajectories and class membership. Estimates of specificity and sensitivity were calculated for Type D and the HADS-D baseline cut-off point. Results In a model with four latent classes (mild symptoms, moderate and increasing symptoms, significant but decreasing symptoms, and significant and increasing symptoms), Type D predicted the membership in the class with significant and increasing symptoms (OR = 10.94, 4.93, and 3.15). Sensitivity and specificity were 59% and 78% for Type D and 47% and 80% for the HADS-D. Limitations Some possible confounders might be missing. With just two measurement points only linear trajectories could be modeled. Conclusions Type D personality is a stronger predictor for persistent depressive symptoms than the baseline HADS-D score, but the predictive power seems low for clinical practice.

Objective The aim of the study was to systematically analyze the stability of Type-D personality over a time span of several years in a clinical sample. Methods In a prospective cohort study, cardiac patients from different medical settings in Germany were assessed using the DS14 questionnaire at baseline (n = 1240) and at a mean follow-up time of six years (n = 679). Different types of stability were examined and compared with the stability of the Hospital Anxiety and Depression Scale (HADS). Results Rank-order stability was moderate (r = .61 for Negative Affectivity [NA] and r = .60 for Social Inhibition [SI]) and didn't differ from the rank-order stability of the HADS. Whereas the mean level of SI didn't change over time, the mean level of NA increased (d = 0.08). On an individual level, approximately one quarter of the participants showed a significant increase or decrease. The factorial structure of the DS14 was stable over time. Finally, the agreement of Type-D classification between the two measurement points was moderate (κ = .42) with 22% of the participants changing their Type-D classification over time. Conclusion The stability of NA and SI didn't differ from the stability of measures of emotional distress that are generally considered to be less stable. In particular, the only moderate stability of the dichotomous Type-D classification raises some questions.

Objectives We sought to determine whether structured exercise training (ET) improves maximal exercise capacity, left ventricular diastolic function, and quality of life (QoL) in patients with heart failure with preserved ejection fraction (HFpEF). Background Nearly one-half of patients with heart failure experience HFpEF, but effective therapeutic strategies are sparse. Methods A total of 64 patients (age 65 ± 7 years, 56% female) with HFpEF were prospectively randomized (2:1) to supervised endurance/resistance training in addition to usual care (ET, n = 44) or to usual care alone (UC) (n = 20). The primary endpoint was the change in peak Vo2 after 3 months. Secondary endpoints included effects on cardiac structure, diastolic function, and QoL. Results Peak Vo2 increased (16.1 ± 4.9 ml/min/kg to 18.7 ± 5.4 ml/min/kg; p Conclusions Exercise training improves exercise capacity and physical dimensions of QoL in HFpEF. This benefit is associated with atrial reverse remodeling and improved left ventricular diastolic function. (Exercise Training in Diastolic Heart Failure–Pilot Study: A Prospective, Randomised, Controlled Study to Determine the Effects of Physical Training on Exercise Capacity and Quality of Life [Ex-DHF-P]; ISRCTN42524037)

Objective Depressive symptoms are highly relevant for the quality of life, health behavior, and prognosis in patients with coronary artery disease (CAD). However, previous psychotherapy trials in depressed CAD patients produced small to moderate effects on depression, and null effects on cardiac events. In this multicentre psychotherapy trial, symptoms of depression are treated together with the Type D pattern (negative affectivity and social inhibition) in a stepwise approach. Methods Men and women (N=569, age 18–75 years) with any manifestation of CAD and depression scores ≥ 8 on the Hospital Anxiety and Depression Scale (HADS), will be randomized (allocation ratio 1:1) into the intervention or control group. Patients with severe heart failure, acutely life-threatening conditions, chronic inflammatory disease, severe depressive episodes or other severe mental illness are excluded. Both groups receive usual medical care. Patients in the intervention group receive three initial sessions of supportive individual psychotherapy. After re-evaluation of depression (weeks 4–8), patients with persisting symptoms receive an additional 25 sessions of combined psychodynamic and cognitive–behavioral group therapy. The control group receives one psychosocial counseling session. Primary efficacy variable is the change of depressive symptoms (HADS) from baseline to 18 months. Secondary endpoints include cardiac events, remission of depressive disorder (SCID) and Type D pattern, health-related quality of life, cardiovascular risk profile, neuroendocrine and immunological activation, heart rate variability, and health care utilization, up to 24 months of follow-up (ISRCTN: 76240576; NCT00705965). Funded by the German Research Foundation.

Objective Type D personality has been established as a predictor of adverse clinical events in patients with cardiovascular diseases. To date, all studies except one have been conducted by a single research group. Thus, the aim of our study was to provide an independent replication of the results regarding the prognostic validity of Type D personality in a German sample of cardiac patients. Methods Cardiac patients (n = 1040) were recruited from cardiac rehabilitation centers (n = 484), an outpatient clinic (n = 249), and a university hospital (n = 307). Main analyses were based on the combined data from these three subsamples. Cardiac health status, medical risk factors, sociodemographic characteristics, psychological symptoms, and Type D personality were assessed at baseline. The primary end point was all-cause mortality. The Cox proportional hazards regression model was used to estimate the relative risk of death. Results Vital status was known for 977 patients (22.5% women; mean [standard deviation] = 63.3 [10.7] years). Within the follow-up time (mean [standard deviation] = 71.5 [3.6] months), 172 patients died. Type D personality was found in 25.2% of survivors and in 22.2% of nonsurvivors (χ²= 0.78, p = .38). Depressive symptoms (p = .13) and anxiety (p = .27) were also not predictive of mortality. In the multivariate analyses, neither Type D (p = .95) nor negative affectivity (p = .71) and social inhibition (p = .59), as well as their interaction (p = .88), were associated with all-cause mortality. Conclusions In the present study, Type D personality and its constituents are not associated with increased mortality in patients with heart disease. The discrepancies with previous results deserve further investigation.

It is currently unknown whether elevated cytokine levels in depression are confined to any specific subgroup of depressive patients. In this study, medical out-patients presenting with cardiovascular risk factors (N = 356) were assessed for both cognitive-affective and physical symptoms of depression using the Hospital Anxiety and Depression Scale (HADS) and the Maastricht questionnaire (MQ), respectively. In study participants assigned to the highest (≥21) and lowest (≤5) quartile for the MQ score, serum levels of cytokines were measured. We found highly significant associations between cognitive-affective symptoms of depression and elevated serum levels of interleukin-6 (IL-6; ρ = .231; p = .002) and interleukin-10 (IL-10; ρ = .370; p.001), respectively. In multiple regression models elevated IL-10 serum concentration was independently related to cognitive-affective symptoms of depression (ρ = .165; p = .002). When all cytokines were included in one model, elevated IL-10 serum concentrations remained a significant predictor for depressive mood (ρ = .157; p = .009). In patients with cardiovascular risk factors and extreme scores for vital exhaustion, elevated serum IL-6 and even more IL-10 concentrations are linked to the presence of depressive mood. Future studies will have to test whether the so far unreported association of IL-10 with depressive mood represents a causal pathway involved in the pathogenesis or in the prognostic effect of depressive mood in cardiac patients.

Background Quality of life (QoL) is impaired in diastolic heart failure. Little is known about QoL in diastolic dysfunction (DD) without heart failure. Methods In the DIAST-CHF observational study, outpatients with risk factors for or a history of heart failure were included. In a cross-sectional analysis, we classified patients with preserved systolic function as having normal diastolic function (N, n = 264) or DD without (DD−, n = 957) or with (DD+, n = 321) elevated filling pressures according to echocardiography. Quality of life was evaluated by the Short Form 36 (SF-36) questionnaire. Results Short Form 36 physical function (SF-36-PF) was worse in DD+ (mean ± SD 67.2 ± 25.6) than in DD− (76.2 ± 22.7, P Conclusions Physical dimensions of QoL are reduced in DD. Impaired SF-36-PF is only weakly associated with DD per se but rather seems to be contingent on the presence of elevated filling pressures. Biomarkers are more strongly and independently associated with SF-36-PF and may be more adequate surrogate markers of QoL in DD than echocardiographic measurements.

Eine depressive Symptomatik hat bei Patienten mit einer koronaren Herzerkrankung (KHK) Einfluss auf die Lebensqualitat, das Gesundheitsverhalten und die Prognose. Die bisher in kontrollierten randomisierten Studien hinsichtlich ihrer Wirksamkeit gepruften psychotherapeutischen Interventionen zeigten nur geringe Effekte. In einer deutschen Multizenterstudie soll ein gestuftes Angebot aus einzel- und gruppenpsychotherapeutischen Interventionen auf seine Wirksamkeit untersucht werden. Der vorliegende Beitrag beschreibt das therapeutische Vorgehen in 2 Einzelgesprachen und einem Paargesprach anhand von Fallbeispielen. Hauptfokusse sind die depressive Symptomatik und die damit im Zusammenhang stehenden maladaptiven Personlichkeitszuge wie negative Affektivitat und soziale Gehemmtheit (Typ-D-Muster). Depressive Stimmung, Enttauschungen und Krankungen im beruflichen sowie privaten Bereich und bei den bisherigen Behandlungserfahrungen werden verbalisiert. Dysfunktionale Beziehungsmuster und maladaptives Krankheitsverhalten werden vom Psychotherapeuten aufgegriffen und alternative Verhaltensweisen erarbeitet. Ziele des Paargesprachs sind die Starkung der partnerschaftlichen Ressourcen sowie der Abbau von Angsten und Befurchtungen im Zusammenhang mit der KHK. Das psychotherapeutische Vorgehen ist psychodynamisch orientiert, beinhaltet aber auch kognitiv-behaviorale und interaktionelle Behandlungsansatze.

To test the possibility of predicting psychotherapy outcome by measures of cardiovascular adaptability to stress at the beginning of treatment we used a prospective, within-subject design with experimental induction of short-term stress. Cardiovascular data during induced stress (mental arithmetic, anger recall) and relaxation were assessed in 21 patients with a main diagnosis of depression at the beginning of their 12-week inpatient psychotherapy treatment. Lower change scores in blood pressure during induced stress at the beginning of therapy were significantly related to better treatment outcome, accounting for 41% of variance, even after controlling for several covariates. Furthermore, there was evidence for the impact of negative affect. Using cardiovascular stress testing as an additional area of information seems a feasible method of incorporating biological parameters in psychotherapy evaluation.

Aims Increasing evidence suggests that enhanced aldosterone signalling plays a key role in the onset and progression of diastolic heart failure (DHF). Aldo-DHF will test the hypothesis that aldosterone receptor blockade by spironolactone will improve exercise capacity and diastolic function in patients with DHF. Methods Aldo-DHF is a randomized, placebo-controlled, double-blinded, two-armed, multicentre, parallel group study. Four hundred and twenty patients with DHF will be randomly assigned to receive spironolactone 25 mg per day or placebo. The main inclusion criteria are: age ≥ 50 years, New York Heart Association II/III, preserved left ventricular ejection fraction (≥50%), and echocardiographic evidence of diastolic dysfunction. The two primary endpoints are changes in exercise capacity (peak VO2, spiroergometry) and in diastolic function (E/e, echocardiography) after 12 months. Secondary endpoints include effects of spironolactone on additional parameters of exercise performance and diastolic as well as systolic function, neurohumoral activation, and quality of life. Morbidity and mortality as well as safety aspects will also be assessed. Conclusion Aldo-DHF is the first large-scale clinical trial to evaluate the effects of aldosterone receptor blockade on exercise capacity and diastolic function in patients with DHF. Aldo-DHF will provide important information about the clinical course of this condition and may have significant impact on treatment strategies and future trials in these patients.

The DS14 ( Denollet, 2005 ) is the most accepted and widely used diagnostic instrument for the assessment of the type-D pattern, which has been established as a predictor of adverse clinical events and cardiac prognosis in patients with heart disease. Despite an increasing number of applications of the DS14 in non-cardiac and healthy samples, psychometric properties of the DS14 item and subscale scores have not been tested explicitly for non-cardiac samples, and population-based norms have been missing until now. The present study aimed to analyse the psychometric properties of the item and subscale scores and the factorial structure of the DS14, as well as to examine prevalence rates and to provide population-based norms for the German general population from a population-based representative sample of 2495 subjects. The analyses document sound psychometric properties. A confirmatory factor analysis demonstrated the best fit for a two-factor structure. The prevalence of the type-D personality in the German population was 31%. In comparison, most studies report lower prevalence rates in cardiac patients. The present findings support the use of the DS14 to assess the traits of negative affectivity and social inhibition and to classify type-D personality in epidemiologic research and individual diagnostics as well.

Background Vital exhaustion, a psychological state characterized by unusual fatigue, irritability, and feelings of demoralization, has been identified as a risk factor for cardiovascular diseases and linked to elevated levels of pro-inflammatory cytokines. Objective The purpose of this study was to investigate the relationship between vital exhaustion and cytokine levels in patients with cardiovascular risk factors. Method The entire cohort consisted of 356 primary-care patients with cardiovascular risk factors who participated in a study of early recognition of heart failure. All participants completed the Maastricht questionnaire (MQ) for assessing vital exhaustion. Cytokine serum levels were measured in all those subjects (N = 178) who were assigned to the highest and lowest quartiles of the MQ, respectively. Results Elevated serum concentrations of interleukin-6 and tumor necrosis factorα, but not other cytokines, were associated with high MQ scores indicative of vital exhaustion. Conclusion The subjective state of vital exhaustion is linked to a substantial alteration in the pattern of secreted cytokines. Data suggest that a disturbance in the levels of both pro-inflammatory and anti-inflammatory mediators, rather than isolated stimulation by pro-inflammatory cytokines, is associated with the mental and physical changes of vital exhaustion.

To identify moderators that influence the relationship of anxiety and long-term prognosis in patients with coronary heart disease (CHD). It has been an ongoing source of controversy what the long-term effects of anxiety are on mortality in patients with CHD, suggesting heterogeneity in prognostic parameters.The prognostic role of anxiety was examined in a large sample of patients (n = 4864), who completed the Hospital Anxiety and Depression Scale (HADS) before routine exercise testing. At 5-year follow-up, survival data were obtained and mortality was assessed by means of Cox proportional hazard models.In the whole sample, higher anxiety scores were associated with reduced mortality (adjusted hazard ratio [HR] = 0.77; 95% confidence interval (CI) = 0.67-0.88; p.001). Similar findings were obtained in the subgroup of patients without clinical evidence of CHD (n = 2514; HR = 0.74; 95% CI = 0.59-0.93; p = .01). In patients with CHD but without a history of myocardial infarction (MI), anxiety remained a significant predictor of better survival (HR = 0.70; 95% CI = 0.51-0.97; p = .031). In post-MI patients, no beneficial effect of anxiety was observed. In the subgroup of post-MI patients with reduced ejection fraction, anxiety was associated with increased mortality (n = 536; HR = 1.32; CI = 1.07-1.65; p = .011).Anxiety exhibits opposite effects on survival in patients with stable cardiac conditions versus post-MI patients with reduced systolic left ventricular (LV) function. We found that a noninvasive physical risk index and the degree of LV dysfunction seem to modulate the prognostic significance of anxiety. These data suggest that the combined screening for anxiety symptoms and LV dysfunction may improve risk stratification in patients with CHD.

Objective To determine the independent effects of positive and negative affect items on mortality in consecutive medical inpatients. Methods Consecutive general medical inpatients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at admission. Prognostic indicators were obtained from patients' records and physicians' ratings. The study end point was mortality from all causes at 1 year. Results The baseline assessment was completed by 575 patients (87.7%). Survival data were available for 572 of these (86 deaths). HADS depression scores and several physical risk indicators predicted mortality. Independent effects could be observed for HADS item 1 (“Can enjoy things as much as before”) adjusted for physicians' ratings of prognosis, a principal diagnosis of hemato-oncological disease and Charlson comorbidity scores. In contrast, HADS depression items 2–7 (Model 1) as well as positive HADS depression scores did not contribute significantly to the prediction of mortality. Conclusion Our present results suggest that one single item on positive affect independently predicts 1-year survival in consecutively admitted medical inpatients. Interestingly, this item has a stronger association with survival status than the presence of depressed mood.

The aim of this health service research study was to investigate the change in the psychological distress of cancer in-patients. According to the structured psychooncological care program Case Management Psychoonkologie (CMP) the patients received psychological treatment during the acute cancer therapy. The CMP was implemented in routine healthcare practice of 6 hospitals. The improvement in the patient's symptoms of anxiety and depression was analyzed as an indication for the effectiveness of the CMP. In order to assess the psychological distress, quality of life, and the functional status the German version of the Hospital Anxiety and Depression Scale (HADS) and a checklist of single-item-scales were administered at hospital admission (t1), 120 days later (t2) and one year after the hospital admission (t3). According to the HADS, the pre-post effect sizes of the psychooncological care program for 258 patients were 0.35 at t2 and 0.46 at t3. The effect sizes of 1.05 at t2 and 1.38 at t3 were calculated for the sub-group of patients with high psychological distress at t1. In 34.4 % of these patients clinical significant improvements in symptoms of anxiety and depression could be identified at t2 and in 45.3 % of the cases at t3. Symptom changes were significantly influenced by the patient's age and the intensity of psychooncological interventions. Symptom improvement was most evident for patients with a high use of psychooncological care. The correlation between HADS and single Item scales is in the moderate to high range. This is an indication of improvement not only in the psychological domain but also in the quality of life and functional status one year after the beginning of cancer treatment. These findings implicate that this study is one of the first to demonstrate the potential effectiveness of structured psychooncological care interventions in routine hospital care.

Wachsende Evidenz fur eine Interaktion zwischen dem Ausbruch und dem Voranschreiten einer Vielzahl von kardialen Erkrankungen mit psychosozialen Faktoren hat die Klinische Kommission der DGK dazu bewogen, ein Positionspapier zu diesem Gegenstandsbereich anzuregen. In einem formalisierten Expertenrating wurden von den 10 teilnehmenden Experten die fur die Fragestellung relevanten Subdisziplinen, in denen gegenwartig eine kritische Masse umsetzungsrelevanten psychokardiologischen Wissens vorhanden ist, ermittelt, die Evidenz zusammengetragen und bewertende Schlussfolgerungen fur die Praxis gezogen. Komorbide psychosoziale Parameter im Kontext der koronaren Herzerkrankung (KHK) erreichten die groste Aufmerksamkeit mit I-A-Empfehlungen fur ein Depressionsscreening im Vorfeld und Verlauf der KHK; der Notwendigkeit zur Einbeziehung psychosozialer Konzepte in Strategien zur Verkurzung der Prahospitalzeit sowie fur die Empfehlung einer routinemasigen (Mit-)Behandlung psychosozialer Belastungsfaktoren in der Sekundarpravention der KHK. Eine weitere I-A-Empfehlung konnte fur die Einbeziehung psychologischer Belastungsfaktoren in die Bewertung von Therapieverlaufen von ICD-Patienten ausgesprochen werden. Weitere relevante Aufgabenfelder beziehen sich auf die Herzinsuffizienz und das Verhalten bei Herzoperationen. Insgesamt ist die Evidenzbasierung fur die therapeutische Umsetzung schwacher als fur Diagnostik und Fruherkennung. Das Positionspapier formuliert eine Reihe von konkreten Anwendungsfeldern mit hoher Prioritat fur die Einbeziehung psychosozialer Faktoren in die kardiologische Praxis, die eine leitlinienkonforme Evidenz aufweisen. Forschungsdefizite existieren weiterhin fur die Bewertung der Wirksamkeit von psychotherapeutischen Konzepten bei kardialen Patienten. Curricula fur die Vermittlung von (psycho)diagnostischer, kommunikativer und differenzialdiagnostischer Kompetenz mussen rasch entwickelt werden, um eine Transmission des aktuellen Wissensstandes in die Alltagspraxis zu ermoglichen.

Emotionally stressful events appear to trigger malignant ventricular arrhythmias and myocardial infarction in cardiac patients. However, the physiological pathways linking psychological stress to arrhythmias and adverse disease outcomes remain incompletely understood. In patients with implanted cardioverter-defibrillators (ICD) we investigated the impact of emotions and social support on cardiovascular recovery from mental stress. The hypothesis tested was that psychosocial resources help to maintain adaptive hemodynamic responses to mental stress.In 55 ICD patients we noninvasively measured hemodynamic and autonomic parameters during two sequentially performed mental stress tests (arithmetic and anger recall tests). The cardiovascular data obtained were associated with results from well-validated psychometric self-rating tests for anxiety and depression (HADS), anger (STAXI), and perceived social support (FSozU).In the rest period after mental stress application the majority of the study participants (82%) showed a rapid fall in cardiac index, arterial blood pressure, and heart rate, as well as an increase in high-frequency heart rate variability, while the remainder had no or unexpected changes in the hemodynamic parameters examined. Patients missing hemodynamic recovery in the post-stress phase reported significantly less social support than normally reacting patients (P.05). Multivariate logistic regression models confirm that social support is an independent and significant predictor of preserved hemodynamic recovery from mental stress, even after controlling for somatic confounders (multivariate odds ratio 4.1; 95% confidence interval 1.3-12.7; P=.015).Our data indicate that in ICD patients better perceived social support is associated with a more pronounced hemodynamic recovery after mental stress.

Objective The aim of this study was to evaluate whether depressive symptoms and the type-D personality are predictive of early recurrence of atrial fibrillation (or atrial flutter; AF) after successful electrical cardioversion (CV). Background Depressive symptoms are associated with an adverse prognosis in patients with coronary artery disease, congestive heart failure, and ventricular arrhythmias. Anger and hostility have been shown to be predictive of development of AF. However, little is known about the effects of depression on AF. Methods Fifty-four patients with persistent AF completed the Hospital Anxiety and Depression Scale (HADS) and the Type D Scale (DS-14) prior to elective electrical CV. Patients with a successful CV were followed for 2 months. Results During the follow-up period, 27 patients (50%) had recurrence of the arrhythmia. Depressive mood (HADS depression scale >7) was the only significant nonsomatic predictor of recurrence, which was observed in 85% of depressed versus 39% of nondepressed patients [odds ratio=8.6; 95% confidence interval (CI)=1.7–44.0, P =.004]. HADS anxiety scores and the presence of the type-D personality pattern were not associated with recurrence of AF. On multivariate Cox regression analysis, including variables with a prevalence >10% of the total study population and a univariate discriminative effect yielding a P value of 7 was found to be the only independently predictive variable of arrhythmia recurrence (hazard ratio=2.7; 95% CI=1.05–7.2; P =.046). Conclusions Our results indicate that depressive mood is a major risk factor for recurrence of AF after electrical CV. Heightened adrenergic tone and a proinflammatory state are possible mechanisms responsible for the observed association. Identification of depression may be of value prior to the decision to perform electrical CV.

Other experts who contributed to parts of the guidelines: Edmond Walma, Schoonhoven (The Netherlands), Tony Fitzgerald, Dublin (Ireland), Marie Therese Cooney, Dublin (Ireland), Alexandra Dudina, Dublin (Ireland) European Society of Cardiology (ESC) Committee for Practice Guidelines (CPG):, Alec Vahanian (Chairperson) (France), John Camm (UK), Raffaele De Caterina (Italy), Veronica Dean (France), Kenneth Dickstein (Norway), Christian Funck-Brentano (France), Gerasimos Filippatos (Greece), Irene Hellemans (The Netherlands), Steen Dalby Kristensen (Denmark), Keith McGregor (France), Udo Sechtem (Germany), Sigmund Silber (Germany), Michal Tendera (Poland), Petr Widimsky (Czech Republic), José Luis Zamorano (Spain) Document reviewers: Irene Hellemans (CPG Review Coordinator) (The Netherlands), Attila Altiner (Germany), Enzo Bonora (Italy), Paul N. Durrington (UK), Robert Fagard (Belgium), Simona Giampaoli(Italy), Harry Hemingway (UK), Jan Hakansson (Sweden), Sverre Erik Kjeldsen (Norway), Mogens Lytken Larsen (Denmark), Giuseppe Mancia (Italy), Athanasios J. Manolis (Greece), Kristina Orth-Gomer (Sweden), Terje Pedersen (Norway), Mike Rayner (UK), Lars Ryden (Sweden), Mario Sammut (Malta), Neil Schneiderman (USA), Anton F. Stalenhoef (The Netherlands), Lale Tokgözoglu (Turkey), Olov Wiklund (Sweden), Antonis Zampelas (Greece)

Zusammenfassung Hintergrund Die krankheitsspezifische Lebensqualitat gilt als ein wichtiger Pradiktor fur Mortalitat und Wiedereinweisung bei Patienten mit Herzinsuffizienz. Unsere Studie sollte die krankheitsspezifische Lebensqualitat hausarztlicher Patienten in Beziehung zu psychischen Kosymptomen untersuchen. Methoden Hausarztliche Patienten mit Herzinsuffizienz wurden zu Lebensqualitat, psychosozialer Belastung, Krankheitsverarbeitung und sozialer Unterstutzung (MLHFQ, HADS, FKV, F-SozU, DS-14) untersucht. Der Schweregrad der Herzinsuffizienz nach NYHA und Goldman und soziodemographische Charakteristika wurden durch Selbstauskunft anhand standardisierter Fragebogen erhoben. Ergebnisse Insgesamt nahmen 363 Patienten aus 44 hausarztlichen Praxen an der Befragung teil, davon 191 (52,6%) Frauen. Sie empfanden mehr korperliche, aber nicht mehr emotionale Probleme als Manner. Patienten, die mit einem Partner zusammenlebten, hatten signifikant weniger Korperprobleme als Patienten ohne Partner. Korperprobleme, emotionale Probleme und auch der Gesamtwert der krankheitsbedingten Belastung (F=63,29; p p p =0,027], Schweregrad der Herzinsuffizienz [NYHA, Goldman; p Schlussfolgerungen Psychosoziale Belastung bei Herzinsuffizienz ist ein wesentlicher Risikofaktor fur eine beeintrachtige Lebensqualitat. Da psychische Symptome nicht nur fur die Langzeitprognose bei Herzinsuffizienz, sondern auch fur die krankheitsspezifische Lebensqualitat bedeutsam sind, sollte ihre Diagnostik und Therapie als fester Bestandteil in die Routineversorgung integriert werden.

Aims To analyse the effect of diabetes (DM) on diastolic function in hypertensive patients. Methods 439 hypertensive patients were selected for participation in this study. All participants had an echocardiographic evaluation of systolic and diastolic function. The overall degree of diastolic function and specific parameters (e.g. E/Ea ratio) were analysed. Results We divided the cohort (63±10 years) into those with diabetes mellitus (DM(+), n=124) and without diabetes mellitus (DM(–), n=315). The prevalence of normal diastolic function was lower in DM(+) than DM(–) (19.4% vs. 30.8%); mild (65.3% vs. 60.0%) and moderate/ severe diastolic dysfunction were more frequent in DM(+) (15.3% vs. 9.2%, p=0.022). The E/Ea ratio, an estimate of left ventricular end-diastolic pressure, was significantly higher in DM(+) (12.3±4.4) as compared to DM(–) (10.8±3.6, p

Funktionelle Herz-Kreislauf-Beschwerden sind in der arztlichen Praxis haufig und mit extensiver Diagnostik und ineffizienter Therapie verknupft. Haufig finden sich chronifizierte Verlaufe. Die Behandlung stellt besondere Anforderungen an den Arzt und an den Psychotherapeuten, denen jedoch mit spezifischen Techniken im Rahmen der psychosomatischen Grundversorgung bzw. Psychotherapie erfolgreich begegnet werden kann. Eine medikamentose Therapie ist v. a. bei psychischer Komorbiditat indiziert.

Alterations in blood pressure in attention-deficit/hyperactivity disorder (ADHD), specifically during dopaminergic stimulant intake, are not fully understood. It has been reported that vitamin D deficiency might modify dopaminergic pathways and thus influence ADHD symptoms. Using data from the nationwide German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study, we compared blood pressure and vitamin D levels in healthy controls to both diagnosed ADHD patients and suspected ADHD subjects, as defined by a value of ≥7 on the hyperactivity-inattention subscale of the Strengths and Difficulties Questionnaire. In a total cohort of n = 6922 study participants aged 11-17 years, mean arterial blood pressure was significantly higher in controls (86.7 ± 8.2 mmHg) than in the two groups of confirmed (85.5 ± 7.8 mmHg, p = 0.004, n = 430) and suspected ADHD patients (84.6 ± 8.2, p

The "National Competency-Based Catalogue of Learning Objectives for Medicine" ("Nationaler Kompetenzbasierter Lernzielkatalog Medizin,"NKLM) is a core curriculum developed for medical training. Here, the classic division by discipline and organ system has been abandoned, which requires each discipline to define its own core curriculum in specific catalogues of learning objectives. This article presents such a catalogue for Psychosomatic Medicine and Psychotherapy.A two-step DELPHI-method was used to survey faculty representatives for Psychosomatic Medicine and Psychotherapy. It reflected the discipline-specific university catalogues of learning objectives as well as the NKLM. A catalogue of learning objectives was then developed and approved.The catalogue consists of two parts: (1) a 12-module core curriculum for Psychosomatic Medicine and Psychotherapy and (2) selected interdisciplinary learning objectives from the NKLM with relevant participation of the discipline in ten modules.For the first time in Germany, this article presents a catalogue of learning objectives for Psychosomatic Medicine and Psychotherapy that is agreed upon by the relevant representatives. This enables the integration of psychosomatic and psychotherapeutic teaching contents from a department into the overall curriculum as required by the NKLM. In the future, methods should be established to allow regular updating and further development of this catalogue.

Background and objective: Evaluation is an integral part of education in German medical schools. According to the quality standards set by the German Society for Evaluation, evaluation tools must provide an accurate and fair appraisal of teaching quality. Thus, data collection tools must be highly reliable and valid. This review summarises the current literature on evaluation of medical education with regard to the possible dimensions of teaching quality, the psychometric properties of survey instruments and potential confounding factors. Methods: We searched Pubmed, PsycINFO and PSYNDEX for literature on evaluation in medical education and included studies published up until June 30, 2011 as well as articles identified in the “grey literature”. Results are presented as a narrative review. Results: We identified four dimensions of teaching quality: structure, process, teacher characteristics, and outcome. Student ratings are predominantly used to address the first three dimensions, and a number of reliable tools are available for this purpose. However, potential confounders of student ratings pose a threat to the validity of these instruments. Outcome is usually operationalised in terms of student performance on examinations, but methodological problems may limit the usability of these data for evaluation purposes. In addition, not all examinations at German medical schools meet current quality standards. Conclusion: The choice of tools for evaluating medical education should be guided by the dimension that is targeted by the evaluation. Likewise, evaluation results can only be interpreted within the context of the construct addressed by the data collection tool that was used as well as its specific confounding factors., Hintergrund und Fragestellung: Die Evaluation ist fester Bestandteil der Lehre an Medizinischen Fakultäten. Gemäß den Standards der Deutschen Gesellschaft für Evaluation müssen Evaluationsinstrumente eine faire und genaue Beurteilung der Lehrqualität erlauben. Entsprechend müssen die genutzten Erhebungsinstrumente eine hohe Reliabilität und Validität aufweisen. In dieser Übersichtsarbeit wird die verfügbare Literatur zur Evaluation des Medizinstudiums mit Hinblick auf die möglichen Dimensionen der Lehrqualität, die psychometrischen Eigenschaften der Instrumente und potentielle Störfaktoren dargestellt. Methoden: Ausgehend von einer Schlagwortsuche in Pubmed, PsycINFO und PSYNDEX wurde eine Literatur-Recherche zur Evaluation im Medizinstudium durchgeführt. Berücksichtigung fanden Arbeiten, die bis zum 30.6.2011 in die Datenbanken aufgenommen wurden sowie „graue Literatur“. Die Ergebnisse werden in narrativer Form präsentiert. Ergebnisse: Es wurden vier Dimensionen der Lehrqualität im Medizinstudium identifiziert: Strukturen, Prozesse, Dozenten-Charakteristika und das Lehr-Ergebnis. Zur Betrachtung der ersten drei Dimensionen werden in erster Linie studentische Bewertungen herangezogen. Hierfür liegen einige reliable, in deutscher Sprache verfügbare Instrumente vor. Die Validität studentischer Bewertungen wird jedoch durch zahlreiche potentielle Störfaktoren eingeschränkt. Zur Beurteilung des Lehr-Ergebnisses werden vor allem Prüfungsleistungen herangezogen, deren Nutzbarkeit allerdings aufgrund methodischer Probleme eingeschränkt sein kann. Zudem genügen nicht alle Prüfungen an deutschen medizinischen Fakultäten den gängigen Qualitätsstandards. Folgerung: Die Auswahl von Instrumenten zur Evaluation des Medizinstudiums sollte sich daran orientieren, welche Dimension der Lehre beurteilt werden soll. Entsprechend können Evaluationsergebnisse auch nur vor dem Hintergrund des vom genutzten Erhebungsinstrument abgebildeten Konstrukts und dessen spezifischen Störfaktoren interpretiert werden., GMS German Medical Science; 13:Doc15

The role of biomarkers in asymptomatic diastolic dysfunction (DD) has not been investigated so far. The aim of the study was to evaluate the clinical associations and the diagnostic property of different biomarkers in patients with asymptomatic DD.Within a population based observational study, healthy participants (50-85 years) with an LVEF ≥ 50 % and no cardiovascular risk factor were prospectively identified. Patients were classified as having either DD (grade ≥ 1, n = 103) or no DD (CON: n = 85). All patients underwent physical examination including medical history, six-minute-walk-testing, QoL (SF-36), comprehensive echocardiography and blood sampling to measure routine values and specified biomarkers (NTproBNP, MRproANP, GDF-15, MRproADM, CTproET1, CTproAVP).In the DD-group plasma concentration of GDF-15 (p = 0,002), MRproADM (p 0,001), and CTproAVP (p = 0,003) were significantly higher than in the CON-group. In contrast, NTproBNP (p = 0,390), MRproANP (p = 287), and CTproET1 (p = 0,393) did not differ. GDF-15, MRproADM and CTproAVP were significantly associated with the presence of DD. However, the significance of the seen associations was lost after multiple adjustments. NTproBNP, MRproANP, and MRproADM were significantly related to E / e' as a continuous measure of diastolic function. The significance of the seen associations was lost after multiple adjustments. In ROC analyses, none of the investigated biomarkers was able to relevantly improve the diagnosis of DD.In patients with asymptomatic DD plasma concentrations of GDF-15, MRproADM and CT-proAVP were significantly higher when compared with controls. In contrast, NTproBNP, MRproANP and CTproET1 did not differ. After adjustment for age, sex, BMI and renal function, no significant association between DD or E / e' and different biomarkers could be observed. Furthermore, none of the investigated biomarkers was able to substantially improve the diagnosis of DD.

Aims: In heart failure, a holistic approach incorporating the patient’s perspective is vital for prognosis and treatment. Self-rated health has strong associations with adverse events and short-term mortality risk, but long-term data are limited. We investigated the predictive value of two consecutive self-rated health assessments with regard to long-term mortality in a large, well characterised sample of elderly patients with stable chronic heart failure. Methods and results: We measured self-rated health by asking ‘In general, would you say your health is: 1, excellent; 2, very good; 3, good; 4, fair; 5, poor?’ twice: at baseline and the end of a 12-week beta-blocker up-titration period in the CIBIS-ELD trial. Mortality was assessed in an observational follow-up after 2–4 years. A total of 720 patients (mean left ventricular ejection fraction 45±12%, mean age 73±5 years, 36% women) rated their health at both time points. During long-term follow-up, 144 patients died (all-cause mortality 20%). Fair/poor self-rated health in at least one of the two reports was associated with increased mortality (hazard ratio 1.42 per level; 95% confidence interval 1.16–1.75; P

The magnitude of the contribution of psychosocial stressors to the development of hypertension remains controversial. Using data from the population-based, nationwide German Health Interview and Examination Survey for Adults, we investigated the relationship between objectively measured and subjectively perceived stressors and blood pressure (BP).The study sample comprised 3352 participants not taking antihypertensive medication, for whom data on stress exposure and resting BP measurements were available. The Trier Inventory for the Assessment of Chronic Stress screening scale (TICS-SSCS) was used as a measurement of self-perceived chronic stress, and work-related stress was assessed using the recently developed occupational Overall Job Index.On the basis of bivariate tests, TICS-SSCS was negatively associated with both systolic (β-coefficient [B] = -0.16, standard error = 0.03, p.001) and diastolic BP (B = -0.10, standard error = 0.02, p.001). After adjustment for age, sex, and body mass index, the TICS-SSCS but not the Overall Job Index was significantly related to systolic and diastolic BP. When alcohol consumption, smoking, physical activity, residential traffic intensity, caregiving, socioeconomic status, social support, and living without a partner were added to the model, the TICS-SSCS again remained independently associated with both BP measures (p ≤ .007).In a large and representative German study, we found that less perceived stress is associated with higher BP levels, whereas the exposure to objective stressors was unrelated to BP. These findings suggest that stress perception and objective stressors influence BP regulation via different biobehavioral pathways.

Exaggerated procoagulant responses to acute mental stress may contribute to coronary thrombosis, and continuing low-grade systemic coagulation activation may link negative affect with the development of coronary artery disease. We investigated whether negative and positive affect and perceived social support would moderate stress procoagulant reactivity. Psychological functioning, exhaustion, negative affectivity, depression, anxiety, worrying, vigor, and social support were assessed in 27 apparently healthy men (mean age 47 ± 8 years) who underwent the 13-min Trier Social Stress Test combining preparation, speech, and mental arithmetic. Plasma levels of von Willebrand factor antigen (VWF:Ag), fibrinogen, factor VII clotting activity (FVII:C), FVIII:C, FXII:C, and D-dimer were measured immediately before and after stress. Acute stress elicited significant increases in hemodynamic, cortisol, and coagulant activity (p values

Psychosomatisch-somatopsychische Interaktionen sind bei Koronarpatienten haufig und verlaufsrelevant. Seit den 1960er-Jahren kommen daher psychosoziale Interventionen zur Verbesserung von Befinden und Krankheitsverlauf zum Einsatz. Neben psychoedukativen und unspezifisch-supportiven Angeboten oder Entspannungsverfahren finden sich auch explizit psychotherapeutische Interventionen. Diese beabsichtigen einerseits, durch Reduktion von Stressbelastungen und Forderung gesundheitsbewusster Verhaltensweisen den Krankheitsverlauf zu verlangsamen. Zuletzt wurde zudem auch die Psychotherapie psychischer Komorbiditaten untersucht. Hier spielt die prognostisch relevante Depression eine besondere Rolle. In der grosten Psychotherapiestudie bei Koronarpatienten, der ENRICHD-Studie, wurde bei 2481 Infarktpatienten mit Depression oder mangelnder sozialer Unterstutzung eine maximal halbjahrige kognitive Verhaltenstherapie eingesetzt. Diese fuhrte zur deutlichen Besserung der Depressivitat; bei hoher Spontanremissionsrate in der Kontrollgruppe blieb der Nettoeffekt jedoch bescheiden. Eine Lebensverlangerung wurde in der Interventionsgruppe nicht erreicht. Die Befundlage verlangt differenzielle Indikationsstellungen und behandlungstechnische Weiterentwicklungen der therapeutischen Konzepte bzw. die Erprobung anderer Therapieverfahren, erlaubt jedoch noch keine evidenzbasierte allgemeine Behandlungsempfehlung. Therapieentscheidungen stutzen sich heute auf die Wurdigung des Einzelfalls, auf gut belegte subjektiven Therapieeffekte, theoretische Annahmen uber Stressbewaltigungs- und Entspannungsverfahren sowie die an anderen Patientenkollektiven gewonnenen Wirksamkeitsnachweise psychotherapeutischer Verfahren. Dabei sind generell eine Beachtung der kardialen Situation und der typischen Problembereiche der koronaren Herzkrankheit (KHK) sowie eine gute Abstimmung mit den somatischen Behandlern wichtig.

Psychosocial risk factors like low socio-economic status, lack of social support and social isolation, chronic work or family stress, as well as negative emotions, e. g. depression and hostility, contribute significantly to the development and adverse outcome of coronary heart disease (CHD). Negative effects of psychosocial risk factors are conveyed via behavioural pathways including unhealthy lifestyle, e. g. food choice, smoking, sedentary life, inadequate utilisation of medical resources, and psychobiological mechanisms like disturbed autonomic and hormonal regulation: all these factors contribute to metabolic dysfunction and inflammatory and haemostatic processes, which are directly involved in the pathogenesis of CHD. Interventions to improve pychosocial factors are available and have demonstrated positive effects on risk factors and - at least in part - on CHD morbidity and mortality. The prevention of CHD should therefore include screening for psychosocial risk factors and adequate interventions. Recommedations for the screening of risk factors, behavioural change and further management of psychosocial risk factors in clinical practice are pointed out.

Background Prospective studies on physically healthy subjects have shown an association between depression and the subsequent development of coronary heart disease (CHD). The relative risk in meta-analytic aggregation is 1.64 (confidence interval [CI], 1.29-2.08) for any CHD event. However, the adverse impact of depression on CHD patients has not yet been the subject of a meta-analysis. Objective To quantify the impact of depressive symptoms (eg, BDI, HADS) or depressive disorders (major depression) on cardiac or all-cause mortality. We analyzed the strength of the relationship, the time dependency, and the differences in studies using depressive symptoms or a clinical diagnosis as predictors of mortality. Method English and German language databases (Medline, PsycInfo, PSYNDEX) from 1980 to 2003 were searched for prospective cohort studies. Sixty-two publications were identified. The inclusion criteria were met by 29 publications reporting on 20 studies. A random model was used to estimate the combined overall effect as crude odds ratios (OR) or adjusted hazard ratios (HR [adj]). Results Depressive symptoms increase the risk of mortality in CHD patients. The risk of depressed patients dying in the 2 years after the initial assessment is two times higher than that of nondepressed patients (OR, 2.24; 1.37-3.60). This negative prognostic effect also remains in the long-term (OR, 1.78; 1.12-2.83) and after adjustment for other risk factors (HR [adj], 1.76; 1.27-2.43). The unfavorable impact of depressive disorders was reported for the most part in the form of crude odds ratios. Within the first 6 months, depressive disorders were found to have no significant effect on mortality (OR, 2.07; CI, 0.82-5.26). However, after 2 years, the risk is more than two times higher for CHD patients with clinical depression (OR, 2.61; 1.53-4.47). Only three studies reported adjusted hazard ratios for clinical depression and supported the results of the bivariate models. Conclusions Depressive symptoms and clinical depression have an unfavorable impact on mortality in CHD patients. The results are limited by heterogeneity of the results in the primary studies. There is no clear evidence whether self-report or clinical interview is the more precise predictor. Nevertheless, depression has to be considered a relevant risk factor in patients with CHD.

The Type D personality pattern, consisting of negative affectivity and social inhibition, has been shown by Denollet et al. to predict adverse prognosis in patients with coronary heart disease. For measuring the Type D characteristics, Denollet has devised the 14 item Type D scale (DS14). In the present study, this instrument was translated into German. The validity, reliability and adequacy of the German DS14 were then tested in 2421 persons, including cardiological and psychosomatic patients as well as healthy factory workers. The results document sound psychometric properties of the scale. Cronbach's alpha was 0.87 for the negative affectivity subscale and 0.86 for social inhibition. The two-factor structure of the original instrument could be clearly replicated. The prevalence rates of the Type D pattern were lowest in cardiological patients (25 %) and highest in psychosomatic patients (62 %). The prevalence in this German sample of cardiology patients was also lower than the one observed in healthy factory workers (32.5 %) and in CHD samples reported in the literature. These group differences could not be accounted for by differences in age and sex distribution. In conclusion, the DS14 is a valid and reliable instrument that can be used for an economic evaluation of the Type D characteristics in patients and healthy persons. The possible meaningfulness of the low Type D prevalence in cardiac patients and the prognostic relevance of this pattern require further study.

Psychosocial risk factors like low socio-economic status, chronic family or work stress, social isolation, negative emotions (e.g., chronic depression or acute anxiety), and negative personality patterns such as Type-D-pattern or hostility, may contribute significantly to the development and adverse outcome of coronary heart disease. Therefore, systematic screening for psychosocial risk factors in cardiological practice is recommended in order to initiate adequate intervention strategies, e.g., to involve additional psychosocial counselling or treatment. Reliable methods to assess psychosocial risk factors are: (1) standardized, structured interviews; (2) standardized questionnaires, and (3) 'single-item' questions to be included into the cardiologists' clinical interviews. While structured interviews should be restricted to trained professionals, questionnaires are easily to administer, and have frequently been used in the field of cardiology. 'Single item' questions are sufficiently reliable and the most timesaving way to screen for psychosocial factors. For clinical practice, a two-step evaluation is recommended: firstly, cardiologists should include 'single-item' questions into their routine interview and/or use questionnaires in order to screen for a potential problem. Secondly, if problems are indicated, patients should be passed to qualified professionals for structured clinical interview. Instruments of all three methods are briefly presented, and implications for further treatment are discussed.

Objective To compare the validity of detecting panic disorder using the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ), a screening question, and physicians' diagnosis, and to test whether modified evaluation algorithms improve the operating characteristics of these questionnaires. Additionally, patient and physician acceptability of the screening questionnaires was investigated. Methods The total sample of 499 patients comprised 348 medical outpatients and 151 psychosomatic outpatients. The Structured Clinical Interview for DSM-IV (SCID) was the criterion standard for the presence of a panic disorder. Sensitivity, specificity, predictive values, and overall accuracy were compared for the different measures. The conditional test characteristics were calculated based on the observed prevalence of panic disorder in the medical and psychosomatic subsample, respectively. Results Panic disorder was diagnosed in 4.3% of the medical outpatients and in 19.2% of the psychosomatic outpatients. The HADS, PHQ, and screening question achieved good operating characteristics. In contrast, physicians detected only 15% of cases with panic disorder. Modified evaluation algorithms of the questionnaires lead to an improvement of test characteristics. Of all measures, the PHQ had the best operating characteristics. The use of screening questionnaires was accepted by 96% of the patients and 97% of the physicians. Conclusion The questionnaires as well as the screening question performed well in detecting panic disorder. Thus, the integration of these highly accepted measures into clinical evaluation is suggested. Recommendations for the selection of specific evaluation algorithms are given.

Zusammenfassung Depressive Storungen einschlieslich der hier oft bedeutsamen leichteren Storungsformen sind in der somatischen Medizin haufig, werden aber oft nicht erkannt. Dabei haben wissenschaftliche Erkenntnisse der letzten Jahrzehnte umfangreiche Belege fur ihre Relevanz ergeben. Depressive Storungen, aber auch schon erhohte Fragebogen werte fur Depressivitat, weisen klare Beziehungen zu Krankheitsverhalten und Lebensqualitat, bei vielen Krankheitsgruppen auch zum somatischen Krankheitsverlauf einschlieslich der Mortalitat auf. Am Beispiel der HIV-Infektion, der Krebserkrankungen sowie der koronaren Herzkrankheit werden exemplarisch Befunde zur Relevanz und zur Behandlung komorbider Depressivitat dargestellt. Diese zeigen, dass die subjektiven Depressionseffekte in ahnlicher Weise bei ganz unterschiedlichen somatischen Krankheitsbildern deutlich werden. Auch Interaktionen mit dem somatischen Krankheitsverlauf wurden aus Kollektiven mit verschiedenen somatischen Grunderkrankungen beschrieben. Die phy...

Zusammenfassung In einer prospektiven Langsschnittstudie wurde die deutsche Version der Hospital Anxiety and Depression Scale (HADS) zur Untersuchung der Pravalenz von Angst-Symptomatik und Depressivitat bei internistisch erkrankten stationar behandelten Patienten eingesetzt. Von insgesamt 376 Studienteilnehmern lagen bei Kranhauseinweisung und nach Ablauf einer Nachbeobachtungsphase von einem Jahr vollstandig ausgefullte Fragebogen vor. Die Auswertung ergab, das der mittlere Angst-Score von 6,7 ±3,5 bei Studieneinschlus signifikant auf 5,8±3,8 in der Verlaufsbefragung abgefallen war (p0,0005), wahrend die Werte auf der Depressions-Subskala demgegenuber relativ konstant blieben (5,3±3,6 gegenuber 5,4±4,3, p = n.s.). Die Odds-Ratios fur die Vorhersage auffalliger HADS-Werte in der Ein-Jahres-Folgebefragung lagen durch ihre Ausgangswerte fur Angstsymptome bei 4,1 (95%-KI 2,0-8,4) und fur depressive Symptome bei 8,2 (95%-KI 4,6-14,6). Patienten mit auffalligen HADS-Angst-Scores waren signifikant haufiger reh...

Background and purpose Silent atrial fibrillation (AF) and tachycardia (AT) are considered precursors of ischaemic stroke. Therefore, detection of paroxysmal atrial rhythm disorders is highly relevant, but is clinically challenging. We aimed to evaluate the diagnostic value of natriuretic peptide levels in the detection of paroxysmal AT/AF in a pilot study. Methods Natriuretic peptide levels were analysed in two independent patient cohorts (162 patients with arterial hypertension or other cardiovascular risk factors and 82 patients with retinal vessel disease). N-terminal-pro-brain natriuretic peptide (NT-proBNP) and BNP were measured before the start of a 7-day Holter monitoring period carefully screened for AT/AF. Results 244 patients were included; 16 had paroxysmal AT/AF. After excluding patients with a history of AT/AF (n=5), 14 patients had newly diagnosed AT/AF (5.8%) NT-proBNP and BNP levels were higher in patients with paroxysmal AT/AF in both cohorts: (1) 154.4 (IQR 41.7; 303.6) versus 52.8 (30.4; 178.0) pg/mL and 70.0 (31.9; 142.4) versus 43.9 (16.3; 95.2) and (2) 216.9 (201.4; 277.1) versus 90.8 (42.3–141.7) and 96.0 (54.7; 108.2) versus 29.1 (12.0; 58.1). For the detection of AT/AF episodes, NT-proBNP and BNP had an area under the curve in receiver operating characteristic analysis of 0.76 (95% CI, 0.64 to 0.88; p=0.002) and 0.75 (0.61 to 0.89; p=0.004), respectively. Conclusions NT-proBNP and BNP levels are elevated in patients with silent AT/AF as compared with sinus rhythm. Thus, screening for undiagnosed paroxysmal AF using natriuretic peptide level initiated Holter monitoring may be a useful strategy in prevention of stroke or systemic embolism.

Autonomic imbalance and exaggerated stress responses are associated with an increased risk of morbidity and mortality and have been associated with several psychosomatic disorders. Has in-patient psychotherapy any effect on autonomic regulation and mental stress reactivity? In 77 patients undergoing in-patient psychometric treatment psychometric examination and psychophysiological assessment of hemodynamic and autonomic parameters during rest and 2 mental stress tests was performed at the beginning and at the end of in-patient psychotherapy. Despite marked improvements in symptoms our short-term treatment for psychosomatic disorders did not affect autonomic and hemodynamic activation at rest or during stress testing. It remains to be investigated if increased physical activity and relaxation expected after improvement have beneficial physiological effects over longer time spans.

The long-term effects of exercise training (ET) in diastolic dysfunction (DD) and heart failure with preserved ejection fraction (HFpEF) are unknown. The present study compared the long-term effects of ET on exercise capacity, diastolic function, and quality of life (QoL) in patients with DD vs. HFpEF.A total of n = 43 patients with asymptomatic DD (n = 19) or HFpEF [DD and New York Heart Association (NYHA) ≥II, n = 24] and left ventricular ejection fraction ≥50% performed a combined endurance/resistance training over 6 months (2-3/week) on top of usual care. Cardiopulmonary exercise testing, echocardiography, and QoL were obtained at baseline and follow-up.Patients were 62 ± 8 years old (37% female). In the HFpEF group, 67% of patients were in NYHA class II (33% in NYHA III). Exercise capacity (peak oxygen consumption, peak VOA structured 6 months ET programme effectively improves exercise capacity and diastolic function in patients with DD and overt HFpEF. Therefore, controlled lifestyle modification with physical activity is effective both in DD and HFpEF.