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 This is particularly true for hospitalized CPD patients, where the rate of depressive disorder is close to 60% (unpublished data).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