Depression in Patients With Heart Failure

Recognition of Depression in Medical Patients With Heart Failure

Harold G. Koenig, M.D.
From the Duke University Medical Center and GRECC VA Medical Center. Send correspondence and reprint requests to Dr. Koenig, Box 3400, Duke University Medical Center, Durham, NC 27710.

The author examined physician and patient factors related to recognition of depression in depressed medical patients. Medical inpatients over age 50 were systematically identified with depressive disorder (N=1,000). Medical physicians (N=422) treating these patients were asked whether they believed patients had depression warranting specific treatment. Frequency of seeing and treating older depressed patients and attitudes toward treatment effectiveness were key factors related to physicians’ recognition of depression. Patient factors were younger age, white race, female gender, and persistence of depression after discharge. Although physicians’ intuition about depression course was often correct, persistent depression was not recognized in nearly 40% of patients.

For patients with congestive heart failure (CHF), depression accounts for nearly $5 billion of the $20 billion total treatment costs, and severely depressed CHF patients show a fourfold increase in mortality. Approximately 14 to 20 million Americans have chronic pulmonary disease (CPD), which is the fourth leading cause of death in the United States, and death rates are likewise increased by over threefold among depressed patients. Studies using structured psychiatric interviews have reported that depressive disorder is present in 36%–59% of medical inpatients with CHF (16%–22% with minor and 20%–37% with major depression). Depression rates in patients with CPD are also high (7%–57%). This is particularly true for hospitalized CPD patients, where the rate of depressive disorder is close to 60% (unpublished data). Thus, a significant proportion of hospitalized patients with CHF/CPD (CHF and/or CPD) have depressive disorders that interfere with functioning, quality of life, and medical outcomes. Underrecognition of depression is widespread among older medical patients in general and CHF/CPD patients in particular (over 90% in one study).

When told that their patient met criteria for a depressive disorder, only two-thirds of physicians agreed with the diagnosis and need for treatment. Although physicians were often quite accurate in assessment (based on remission of depression after hospitalization), nearly 40% of the time they were wrong, and these patients continued to suffer from depression for months after discharge (most without treatment). For physicians managing patients in the hospital, there are patient characteristics (age, gender, race) and physicians’ attitudes toward treatment that influence whether or not they believe that patients have depressive disorder warranting treatment, and these factors are independent of the type of depressive disorder, severity of depression, or the course of depression after discharge. This may be partially the result of bias or stereotyping. Medical training programs should emphasize the recognition and treatment of depression in older patients with CHF/CPD and the necessity for referral if patients are not responding to treatment.

Full Text

Psychosomatics 48:338-347, August 2007

© 2007 Academy of Psychosomatic Medicine

Association Between Birth Weight and Hypertension

Genetic and Shared Environmental Factors Do Not Confound the Association Between Birth Weight and Hypertension
A Study Among Swedish Twins

Niklas Bergvall, MSc; Anastasia Iliadou, PhD; Stefan Johansson, MD; Ulf de Faire, MD, PhD; Michael S. Kramer, MD; Yudi Pawitan, PhD; Nancy L. Pedersen, PhD; Paul Lichtenstein, PhD; Sven Cnattingius, MD, PhD

From the Department of Medical Epidemiology and Biostatistics (N.B., A.I., S.J., Y.P., N.L.P., P.L., S.C.), Division of Cardiovascular Epidemiology, Institute of Environmental Medicine and Department of Cardiology, Karolinska University Hospital (U.d.F.), Karolinska Institutet, Stockholm, Sweden, and Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal, Canada (M.S.K.).

Background. Studies have found associations between low birth weight and increased risks of cardiovascular diseases in adulthood. However, these associations could be due to confounding by genetic or socioeconomic factors.

Methods and Results. We performed a study on Swedish like-sexed twins with known zygosity who were born from 1926 to 1958. First, to obtain an overall effect of birth weight on risk of hypertension, we performed cohort analyses on all twins (n=16 265). Second, to address genetic and shared environmental confounding, we performed a nested co-twin control analysis within 594 dizygotic and 250 monozygotic twin pairs discordant for hypertension. Birth characteristics, including birth weight, were obtained from original birth records. Information from adulthood was collected from a postal questionnaire in 1973 (body mass index, height, smoking, and alcohol use) and from a telephone interview conducted from 1998 to 2002 (hypertension and socioeconomic status). Hypertension was defined as reporting both high blood pressure and treatment with antihypertensive medication. In the cohort analysis, the adjusted odds ratio for hypertension in relation to a 500-g decrease in birth weight was 1.42 (95% confidence interval, 1.25 to 1.61). In the co-twin control analyses, the corresponding odds ratios were 1.34 (95% confidence interval, 1.07 to 1.69) for dizygotic and 1.74 (95% confidence interval, 1.13 to 2.70) for monozygotic twins.

Conclusions. In the largest twin study on the fetal origins of hypertension, we found that decreased birth weight is associated with increased risk of hypertension independently of genetic factors, shared familial environment, and risk factors for hypertension in adulthood, including body mass index.

Circulation. 2007;115:2931-2938.
© 2007 American Heart Association, Inc.
http://circ.ahajournals.org/cgi/content/abstract/115/23/2931

Hibiscus flower: Control cholesterol levels

Hibiscus Flowers to Prevent Heart Attacks

Hibiscus flower extract may have the same health benefits as red wine and tea according to new research by scientists in Taiwan. Hibiscus contains antioxidants that help control cholesterol levels and reduce heart disease, says the research in Journal of the Science of Food and Agriculture.

Chau-Jong Wang and his team at Chung Shan Medical University in the Republic of China found that the antioxidant properties of flavonoids, polyphenolic compounds and anthocyanins contained in the flower can prevent the oxidation of Low-Density Lipoproteins (LDL), which is associated with the disease.

Healthy properties
Hibiscus sabdariffa is used in folk medicine to treat hypertension and liver disorder, and is used to make popular soft drinks in various countries across the world. Some health benefits of taking Hibiscus have now been verified: "Experiments have shown that compounds extracted from red wine and tea reduces cholesterol and lipid build-up in the arteries of rats. This is the first study to show that Hibiscus extract has the same effect", says Wang.

Diet testing
In the study, rats were divided in to four groups and given different diets; one control, one high cholesterol control, and two high cholesterol diets supplemented with different amounts of Hibiscus extract. After 12 weeks, the rats were given blood tests to assess their health. Results showed that the extract significantly reduced cholesterol content in blood serum and successfully prevented oxidation of Low-density Lipoproteins.

These data strongly suggest that the extract has potential to prevent cholesterol deposition and may therefore be useful in the prevention and even treatment of a number of cardiovascular diseases in which cholesterol plays a major role.

Society of Chemical Industry
http://www.brightsurf.com/news/

Tobacco smoke: Influencing on the Healthy Children

Tobacco Smoke Exposure Is Associated With Attenuated Endothelial Function in 11-Year-Old Healthy Children

Katariina Kallio, MD; Eero Jokinen, MD, PhD; Olli T. Raitakari, MD, PhD; Mauri Hämäläinen, PhD; Marja Siltala; Iina Volanen, MD; Tuuli Kaitosaari, MD; Jorma Viikari, MD, PhD; Tapani Rönnemaa, MD, PhD; Olli Simell, MD, PhD
From the Research Centre of Applied and Preventive Cardiovascular Medicine (K.K., M.S., I.V., T.K.), and the Departments of Clinical Physiology (O.T.R.), Medicine (J.V., T.R.), and Pediatrics (O.S.), University of Turku, Turku, Finland; Department of Pediatrics (E.J.), University of Helsinki, Helsinki, Finland; and Joint Clinical Biochemistry Laboratory of University of Turku, Turku University Central Hospital and Wallac Oy (M.H.), Turku, Finland.

Background. Passive smoking is associated with early arterial damage in adults, but its effect on endothelial function in children is unknown.

Methods and Results. Serum cotinine concentration was measured annually in children between 8 and 11 years of age who had participated since infancy in a randomized, prospective atherosclerosis prevention trial (Special Turku Coronary Risk Factor Intervention Project for children [STRIP]). At age 11, endothelium-dependent flow-mediated vasodilatory responses of the brachial artery were examined with high-resolution ultrasound in 402 children. These children were divided into 3 groups according to serum cotinine concentrations: the noncotinine group (nondetectable cotinine, n=229), the low cotinine group (cotinine between 0.2 and 1.6 ng/mL, n=134), and the top decile cotinine group (cotinine 1.7 ng/mL, n=39). Longitudinal cotinine data in children aged 8 to 11 years and ultrasound studies were available in 327 children. At age 11, the increase in cotinine concentration was associated with attenuated peak flow-mediated dilation response (mean±SD: the noncotinine group 9.10±3.88%, the low-cotinine group 8.57±3.78%, and the top-decile cotinine group 7.73±3.85%; P=0.03 for trend). Similarly, total dilation response (the area under the dilation response versus time curve between 40 and 180 seconds after hyperemia) was affected by the cotinine level (P=0.02 for trend). These trends were not explained by traditional atherosclerosis risk factors. Arterial measures and passive smoking showed even stronger associations when longitudinal cotinine data were used (peak flow-mediated dilation, P=0.01 for trend; total dilation response, P=0.008 for trend).

Conclusions. Exposure to environmental tobacco smoke confirmed by serum cotinine concentrations impairs endothelial function in a dose-dependent manner in 11-year-old children.

Circulation. 2007;115:3205-3212.
© 2007 American Heart Association, Inc.
http://circ.ahajournals.org/cgi/content/abstract/115/25/3205

Cold periods and Coronary events

Cold periods and coronary events: an analysis of populations worldwide

Adrian G Barnett (1), Annette J Dobson (1), Patrick McElduff (2), Veikko Salomaa (3), Kari Kuulasmaa (3), Susana Sans (4) for the WHO MONICA project

1) School of Population Health, University of Queensland, Herston, Australia; 2) The Medical School, University of Manchester, Manchester, UK; 3) KTL-NPHI, Department of Epidemiology, Helsinki, Finland; 4) Institute of Health Studies, Department of Health, Barcelona, Spain

Study objective: To investigate the association between cold periods and coronary events, and the extent to which climate, sex, age, and previous cardiac history increase risk during cold weather.

Design: A hierarchical analyses of populations from the World Health Organisation’s MONICA project.

Setting: Twenty four populations from the WHO’s MONICA project, a 21 country register made between 1980 and 1995.

Patients: People aged 35–64 years who had a coronary event.

Main results: Daily rates of coronary events were correlated with the average temperature over the current and previous three days. In cold periods, coronary event rates increased more in populations living in warm climates than in populations living in cold climates, where the increases were slight. The increase was greater in women than in men, especially in warm climates. On average, the odds for women having an event in the cold periods were 1.07 higher than the odds for men (95% posterior interval: 1.03 to 1.11). The effects of cold periods were similar in those with and without a history of a previous myocardial infarction.

Conclusions: Rates of coronary events increased during comparatively cold periods, especially in warm climates. The smaller increases in colder climates suggest that some events in warmer climates are preventable. It is suggested that people living in warm climates, particularly women, should keep warm on cold days.

Keywords: coronary disease; myocardial infarction; risk factors; MONICA project

Journal of Epidemiology and Community Health 2005;59:551-557
© 2005 BMJ Publishing Group Ltd
http://jech.bmj.com/cgi/content/abstract/59/7/551

Cardiopulmonary arrest: Seasonal variations

Seasonal variations in out of hospital cardiopulmonary arrest

J P Pell (a), J Sirel (b), A K Marsden (c), S M Cobbe (b)

a) Department of Public Health Medicine, Greater Glasgow Health Board, Dalian House, 350 St Vincents Street, Glasgow G3 8YU, UK; b) Department of Medical Cardiology, Glasgow Royal Infirmary, Glasgow, UK; c) Scottish Ambulance Service, Edinburgh, UK

OBJECTIVE. To determine whether there are seasonal variations in survival following out of hospital cardiopulmonary arrest.

DESIGN. Prospective cohort study using the Heartstart (Scotland) database.

SETTING. All of Scotland.

PATIENTS. 10 890 people who suffered out of hospital cardiopulmonary arrest in the summer or winter between December 1988 and August 1997 inclusive.

INTERVENTION. Univariate comparisons of 5406 arrests occurring in summer with 5484 in winter, in terms of patient characteristics, management, and survival using 2 and Mann-Whitney U tests. Multivariate analysis of the association between season and survival following adjustment for case mix.

MAIN OUTCOMES MEASURES. Survival to discharge from hospital, survival pre-admission, in-hospital survival.

RESULTS. Only 6% of people who arrested in winter survived to discharge, compared to 8% of those who arrested in summer (odds ratio 0.77, p < 0.001). People who arrested in winter had a poorer risk profile in that they were older, more likely to arrest at home, less likely to have a witness, and less likely to receive defibrillation. However, after adjustment for case mix, people who arrested in winter were still 19% less likely to survive compared to those who arrested in summer. Deaths pre-admission were significantly higher in winter (odds ratio 1.18, p < 0.05) but in-hospital deaths were not.

CONCLUSIONS. People who suffer cardiopulmonary arrest in winter have a significantly lower likelihood of surviving. This is, in part, caused by the higher frequency of a number of recognised risk factors. However, their prognosis remains poorer even after adjustment for these factors.

Keywords: cardiopulmonary arrest; cardiopulmonary resuscitation; seasonal variations; ischaemic heart disease

Heart 1999;82:680-683 ( December )
http://heart.bmj.com/cgi/content/abstract/82/6/680

Grapefruit - Help at heart disease

Red grapefruit appears to lower cholesterol, fight heart disease

A grapefruit a day - particularly the red variety - can help keep heart disease at bay, according to a new study by Israeli researchers. In a controlled study group of patients with heart disease, the scientists found that feeding some patients the equivalent of one grapefruit daily significantly reduced levels of cholesterol in comparison to patients that did not eat grapefruit. Chronic high blood cholesterol is a major risk factor for heart disease.

The study, which strengthens a growing body of evidence supporting the heart-healthy benefits of eating citrus fruit, was published Feb. 3 on the website of the American Chemical Society's Journal of Agricultural and Food Chemistry . The findings come at an appropriate time: The month of February has been designated as American Heart Month and heart disease is the number one killer of women in the United States. The study will appear in the journal's March 22 print issue.

The study included 57 patients, both men and women, with hyperlipidemia (high blood cholesterol) who recently had coronary bypass surgery and whose high lipid levels failed to respond significantly to statin drugs. Statins are commonly prescribed to lower cholesterol, according to study leader Shela Gorinstein, Ph.D., a chief scientist at the Hebrew University of Jerusalem.

The patients, equally divided into three treatment groups, were given either a single serving of fresh red grapefruit, white (blond) grapefruit or no grapefruit, along with regular, balanced meals for 30 consecutive days. Israeli Jaffa red and white grapefruit varieties, which are available in the U.S., were used in this study.

The patients who received either red or white grapefruit showed significant decreases in blood lipid levels, whereas the patients that did not eat grapefruit showed no changes in lipid levels, according to the researchers. Red grapefruit was more effective than white in lowering lipids, particularly blood triglycerides, a type of cholesterol whose elevated levels are often associated with heart problems, the researchers say.

It is likely that antioxidants in the grapefruits are responsible for their health benefits, says Gorinstein, adding that the red variety generally has higher antioxidants than the white. But it's also possible that red grapefruit may contain unknown chemicals that are responsible for the observed triglyceride-lowering effect, she says. Additional studies are planned.

Both the fresh fruit and the juice are believed to be equally beneficial, Gorinstein and her associates say. One cup of fresh grapefruit is roughly equivalent to half a cup of juice.

Grapefruit is known to interact with certain medications -sometimes adversely - so the researchers caution people on prescription medication to consult with their doctor or pharmacist to determine whether their medicine will interact before consuming grapefruit products. Appropriate exercise, well-balanced nutrition and avoidance of tobacco also are important factors in reducing the risk of heart disease, health experts say.

American Chemical Society

http://www.brightsurf.com/news/

Heart Failure Therapy: men and women

Clinical Investigations Does Heart Failure Therapy Differ According to Patient Sex?

Josep Lupón M.D., Agustín Urrutia, M.D., Beatriz González C.N., Crisanto Díez, M.D., Salvador Altimir, M.D., Carlos Albaladejo, M.D., Teresa Pascual, M.D., Celestino Rey-Joly, M.D., Vicente Valle, M.D.
Unitat d'Insuficiència Cardíaca, Hospital Universitari Germans Trias i Pujol, Badalona, Spain

Objectives. To assess differences in clinical characteristics, treatment and outcome between men and women with heart failure (HF) treated at a multidisciplinary HF unit. All patients had their first unit visit between August 2001 and April 2004.

Patients. We studied 350 patients, 256 men, with a mean age of 65 ± 10.6 years. In order to assess the pharmacological intervention more homogeneously, the analysis was made at one year of follow-up.

Results. Women were significantly older than men (69 ± 8.8 years vs. 63.6 ± 10.9 years, p < 0.001). Significant differences were found in the HF etiology and in co-morbidities. A higher proportion of men were treated with ACEI (83% vs. 68%, p < 0.001) while more women received ARB (18% vs. 8%, p = 0.006), resulting in a similar percentage of patients receiving either of these two drugs (men 91% vs. women 87%). No significant differences were observed in the percentage of patients receiving beta-blockers, loop diuretics, spironolactone, anticoagulants, amiodarone, nitrates or statins. More women received digoxin (39% vs. 22%, p = 0.001) and more men aspirin (41% vs. 31%, p = 0.004). Carvedilol doses were higher in men (29.4 ± 18.6 vs. 23.8 ± 16.4, p = 0.03), ACEI doses were similar between sexes, and furosemide doses were higher in women (66 mg ± 26.2 vs. 56 mg ± 26.2, p < 0.05). Mortality at 1 year after treatment analysis was similar between sexes (10.4% men vs. 10.5% women).

Conclusions. Despite significant differences in age, etiology and co-morbidities, differences in treatment between men and women treated at a multidisciplinary HF unit were small. Mortality at 1 year after treatment analysis was similar for both sexes.

Keywords: heart failure • treatment • sex

Clinical Cardiology Volume 30, Issue 6 , Pages 301 – 305 (June 2007)
Copyright © 2007 Wiley Periodicals, Inc.

http://www3.interscience.wiley.com/cgi-bin/abstract/114276980/ABSTRACT

Cocaine and Myocardial infarction

Clinical Investigations Traditional Risk Factors and Acute Myocardial Infarction in Patients Hospitalized with Cocaine-Associated Chest Pain

Darpan Bansal, M.D. (1), Marsha Eigenbrodt, M.D., MPH. (2), Ekta Gupta, M.D. 1, J. L. Mehta, M.D., Ph.D. (3)
1) Division of Cardiovascular Medicine, Department of Internal Medicine, Little Rock, Arkansas, USA; 2) Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; 3) Central Arkansas Veterans Healthcare System, Little Rock, Arkansas, USA

Background. Cocaine causes coronary artery constriction and may cause acute myocardial infarction (AMI). The role of traditional coronary risk factors in cocaine-associated myocardial infarction is unclear.

Hypothesis. We hypothesized that traditional risk factors play a major role in predicting AMI in patients admitted with cocaine-associated chest pain

Methods. After reviewing 165 admissions for chest pain in patients with a history of recent cocaine use and/or a positive drug screen from January 2001 to December 2004, we identified 151 patients with information available on at least 6 of the following 7 risk factors: gender, hypertension, hyperlipidemia, diabetes, smoking, family history of coronary artery disease (CAD) and known CAD. AMI was diagnosed using WHO criteria. A risk score was calculated on the basis of the number of risk factors, gender and age. Association of AMI was evaluated with the individual risk factors and with the risk score.

Results. AMI was identified in 21 patients (14%). All patients diagnosed with AMI were smokers. Continuous risk score (p < 0.0001), highest vs. lowest quartile of risk score (p = 0.007), known CAD, age, hyperlipidemia and family history of CAD were individually associated with the diagnosis of AMI (p0.05). Each quartile of risk score was associated with increased odds of the diagnosis of AMI and score of 8 or higher was statistically significant.

Conclusion. Several traditional risk factors are associated with the diagnosis of AMI among patients hospitalized with cocaine-associated chest pain and increasing risk factor score was associated with increasing odds of AMI diagnosis. Copyright © 2007 Wiley Periodicals, Inc.

Keywords: cocaine • chest pain • myocardial infarction

Clinical Cardiology - Volume 30, Issue 6 , Pages 290 – 294 (June 2007)
Copyright © 2007 Wiley Periodicals, Inc.