Change in Positive Affect During Outpatient Cardiac Rehabilitation Predicts Vital Exhaustion in Patients with Coronary Heart Disease

Vital exhaustion is an acknowledged psychosocial risk factor of incident coronary heart disease (CHD) and recurrent CHD events. Little is known about trajectories in vital exhaustion in patients with CHD and the factors predicting this change. We hypothesized that vital exhaustion would decrease during outpatient cardiac rehabilitation and that an increase in positive affect over time would be associated with decreased vital exhaustion at discharge from cardiac rehabilitation. We also explored the role of the patient's sex in this context. Vital exhaustion was reduced during outpatient cardiac rehabilitation, especially in patients who experienced an increase in positive affect over time (p < .001). This relationship was significant in men (p < .001) but not in women (p = .11).     

Telomeres are shorter in myocardial infarction patients compared to healthy subjects: correlation with environmental risk factors

Shorter telomeres have been reported in premature myocardial infarction (MI) patients. Our work aimed at confirming the association of shorter telomere with MI in two case–control studies and in familial hypercholesterolemia (FH) patients with coronary heart disease (CHD). The HIFMECH study compared 598 white male patients (<60 years) who survived a first MI and 653 age-matched controls from North and South Europe. Additionally, from the UK, 413 coronary artery bypass graft (CABG) patients and two groups of 367 and 94 FH patients, of whom 145 and 17 respectively had premature CHD, were recruited. Leukocyte telomere length (LTL) was measured using a real-time polymerase chain reaction-based method. In HIFMECH, LTL was significantly shorter in subjects from the North (7.99 kb, SD 4.51) compared to the South (8.27 kb, SD 4.14; p?=?0.02) and in cases (7.85 kb, SD 4.01) compared to controls (8.04 kb, SD 4.46; p?=?0.04). In the CABG study, LTL was significantly shorter (6.89 kb, SD 4.14) compared to the HIFMECH UK controls (7.53, SD 5.29; p?=?0.007). In both samples of FH patients, LTL was shorter in those with CHD (overall 8.68 kb, SD 4.65) compared to the non-CHD subjects (9.23 kb, SD 4.83; p?=?0.012). Apart from a consistent negative correlation with age, LTL was not associated across studies with any measured CHD risk factors. The present data confirms that subjects with CHD have shorter telomeres than controls and extends this to those with monogenic and polygenic forms of CHD.     

Diurnal saliva cortisol levels and relations to psychosocial factors in a population sample of middle-aged swedish men and women

Whereas psychosocial risk factors increase the risk for disease, psychosocial resources reduce this risk. To examine a possible pathway for these effects, the relations between saliva cortisol levels and psychosocial factors were studied in a random sample of 257 men and women aged 30 to 64 years. Saliva samples were collected at home on waking, 30 min after waking, and in the evening. A flatter diurnal rhythm of cortisol, that is, lower deviations between awakening and evening cortisol levels, was related to high levels of psychosocial risk factors (cynicism, depression, and vital exhaustion), whereas a steeper diurnal rhythm was related to psychosocial resources (social support and coping), general health, and well-being (all p < .05). Our results support earlier suggestions that the capacity of the hypothalamic-pituitary-adrenal-axis to dynamically respond to stress is 1 pathway for observed effects of psychosocial factors regarding risk for disease development.     

Self-involvement and coronary heart disease incidence in the multiple risk factor intervention trial

At intake into a multiple coronary heart disease (CHD) risk factor intervention trial, 3110 individuals were interviewed to assess Type A behavior. After an average of 7 years followup, the 193 individuals who manifested their first CHD event were matched with 384 CHD-free individuals. To assess self-involvement, auditors counted all verbal self-references (I, me, my) and clauses spoken in the audiotaped baseline interviews. Self-references were entered into multiple logistic regression analyses that controlled for age, diastolic blood pressure, cholesterol, cigarette smoking, and Type A behavior. Relative to matched controls, those who incurred CHD spoke more self-references at baseline [p = 0.017; relative risk (RR) = 1.20], but did not self-reference more densely. Relative to matched controls, those who died from CHD spoke more self-references (p = 0.008; RR = 1.62) and self-referenced more densely (p = 0.027; RR = 1.54). Neither total self-references nor self-reference density was predictive of angina pectoris or nonfatal myocardial infarction (MI). However, among those who incurred MI, self-reference frequency was the strongest predictor of mortality among all the measured risk factors (p = 0.01, RR = 2.0). The results suggest that self-involvement is related to CHD incidence.     

Ethnic differences in low-density lipoprotein particle size in hypertensive adults

BackgroundHypertensive African Americans have higher rates of coronary heart disease (CHD) than their non-Hispanic white counterparts, despite having higher high-density lipoprotein cholesterol (HDL-C) levels and lower triglyceride levels.ObjectiveThe goal of the present study was to assess whether low-density lipoprotein (LDL) particle size, a correlate of the above lipid traits and a risk factor for CHD, differs between hypertensive African Americans and whites.MethodsParticipants included 1,177 hypertensive African Americans from Jackson, MS (60 ± 7 years, 72.4% women) and 860 hypertensive whites from Rochester, MN (58 ± 7 years, 56.7% women). LDL particle size was measured by polyacrylamide gradient gel electrophoresis. Within each gender, we assessed whether ethnicity was significantly associated with differences in LDL particle size after adjustment for CHD risk factors (age, total cholesterol, HDL-C, triglycerides, systolic blood pressure, diabetes, history of smoking, body mass index), statin use, and estrogen use (in women), and lifestyle variables (physical activity and alcohol intake).ResultsAlthough HDL-C levels were higher and triglyceride levels lower in African Americans, LDL particle size (adjusted for CHD risk factors) was lower (P < 0.0001) in African-American men and women than in their white counterparts (mean ± SD; men, 267.6 ± 5.2 Å vs 270.2 ± 4.8 Å; women 268.7 ± 5.1 Å vs 271.3 ± 5.1 Å). In both genders, African-American ethnicity was associated with lower LDL particle size after adjustment for CHD risk factors, statin use and estrogen use (in women), as well as physical activity and alcohol intake.ConclusionHypertensive African-American men and women have lower LDL particle size than their white counterparts, despite having higher HDL-C and lower triglycerides.     

Assessment of vital exhaustion and identification of subjects at increased risk of myocardial infarction in general practice

Vital exhaustion, a state characterized by unusual fatigue, loss of energy, increased irritability, and feelings of demoralization, is one of the cardiovascular risk factors. The authors investigated whether vital exhaustion contributes to the identification of subjects at increased risk of myocardial infarction in general practice. In this prospective cohort study, vital exhaustion was assessed with the Maastricht Interview on Vital Exhaustion. Other cardiovascular risk factors established were age, gender, systolic and diastolic blood pressure, total cholesterol, body mass index, smoking habits, cardiovascular disease, and diabetes mellitus. A Cox regression analysis was used. The subjects were adults (41-66 years) in an average Dutch village population. Outcome measures were fatal and nonfatal myocardial infarction. At the univariate level, vital exhaustion doubled the risk of myocardial infarction. The effect of exhaustion was confounded by gender; women had higher exhaustion scores and a lower incidence of myocardial infarction. With control for gender, age, systolic blood pressure, total cholesterol, smoking habits, self-reported cardiovascular disease, and diabetes mellitus, vital exhaustion almost tripled the risk of myocardial infarction. Assessment of vital exhaustion contributes to the identification of subjects at increased risk of myocardial infarction in general practice.     

Depression and risk of sudden cardiac death after acute myocardial infarction: testing for the confounding effects of fatigue

OBJECTIVES: This study examined the impact of depressive symptoms and social support on 2-year sudden cardiac death (SCD) risk, controlling for fatigue symptoms. METHODS: Myocardial infarction (MI) patients (N = 671) participating in the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial completed measures of depression, hostility, and social support. RESULTS: After controlling for significant biological predictors, psychosocial predictors of increased SCD risk in the survival analysis were greater social network contacts (RR = 1.04; 95% CI = 1.01-1.06; p < .007), lower social participation (RR = 0.98; 95% CI = 0.96-1.00; p < .05), and, in placebo-treated patients, elevated depressive symptoms (RR = 2.45; 95% CI = 1.14-5.35; p < .02). Fatigue was associated with SCD (RR = 1.31; 95% CI = 1.11-1.53; p < .001), and, when included in the model, diminished the influence of depression (RR = 1.73; 95% CI = 0.75-3.98; p = .20). When the cognitive-affective depressive symptoms were examined separately from somatic symptoms, there was a trend for an association between cognitive-affective symptoms and SCD in placebo-treated patients after controlling for fatigue (RR = 1.09; 95% CI = 0.99-1.19, p < .06). CONCLUSIONS: Symptoms of depression and fatigue overlap in patients with MI. The trend for the cognitive-affective symptoms of depression to be associated with SCD risk, even after controlling for dyspnea/fatigue, suggests that the association between depression and mortality after AMI cannot be entirely explained as a confound of cardiac-related fatigue. The independent contribution of social participation suggests a role of both depressive symptomatology and social factors in influencing mortality risk after MI.     

Antagonistic behavior, dominance, hostility, and coronary heart disease

PURPOSE: This study investigated the relationship between antagonistic behavior, dominance, attitudinal hostility, and coronary heart disease (CHD). METHODS: One hundred one men and 95 women referred for thallium stress testing were administered the Structured Interview and the Cook-Medley Hostility Scale. The Hostile Behavior Index, derived from the Structured Interview and developed by Haney et al., served as an index of antagonism, and the frequency with which interviewees interrupted their interviewer served as a measure of dominance. On the basis of their medical history and thallium stress test results, patients were classified as having (N = 44) or not having (N = 99) CHD. RESULTS AND CONCLUSIONS: Multivariate logistic regressions (with age, gender, disease, and lifestyle risk factors in the model) revealed that both the Hostile Behavior Index and dominance were significant independent risk factors for CHD (relative risk [RR] = 1.22 and 1.47, p < .03). Of the two Hostile Behavior Index component scores, indirect challenge and irritability, only the latter correlated significantly with CHD (RR = 1.27, p < .03). Separate logistic regressions for men and women suggest that subtle, indirect manifestations of antagonism confer CHD risk in women and that more overt expressions of anger confer risk in men. A significant univariate correlation between hostility scale scores and CHD became not significant when we adjusted for socioeconomic status.     

25 years of HIV-1 research – progress and perspectives

Background

Recent genome wide association (GWA) studies identified two Single Nucleotide Polymorphisms (SNP) (rs10757278 and rs10757274) in the region of the CDK2NA and CDK2NB genes to be consistently associated with the risks of coronary heart disease (CHD) and myocardial infarction (MI). We examined the SNPs in relation to the risk of CHD and MI in a large population based study of elderly population.

Methods

The Rotterdam Study is a population-based, prospective cohort study among 7983 participants aged 55 years and older. Associations of the polymorphisms with CHD and MI were assessed by use of Cox proportional hazards analyses.

Results

In an additive model, the age and sex adjusted hazard ratios (HRs) (95% confidence interval) for CHD and MI were 1.03 (0.90, 1.18) and 0.94 (0.82, 1.08) per copy of the G allele of rs10757274. The corresponding HRs were 1.03 (0.90, 1.18) and 0.93 (0.81, 1.06) for the G allele of rs10757278. The association of the SNPs with CHD and MI was not significant in any of the subgroups of CHD risk factors.

Conclusion

we were not able to show an association of the studied SNPs with risks of CHD and MI. This may be due to differences in genes involved in the occurrence of CHD in young and older people.     

Vital exhaustion in relation to lifestyle and lipid profile in healthy women

“Vital exhaustion,” characterized by fatigue, irritability, and demoralization, precedes new and recurrent coronary events. Biological mechanisms explaining this association are not fully understood. The objective was to investigate the relationship between vital exhaustion, lifestyle, and lipid profile. Vital exhaustion, smoking, body mass index (BMI), alcohol consumption, exercise capacity, and serum lipids were determined in 300 healthy women, aged 56.4 ± 7.1 years. No statistically significant associations were found between vital exhaustion and lifestyle variables. Divided into quartiles, vital exhaustion was inversely related to high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1 in a linear fashion after adjustment for age, BMI, exercise capacity, and alcohol consumption. A multivariate-adjusted vital exhaustion-score in the top quartile, as compared to one in the lowest, was associated with 12% lower HDL-C and8% lower apolipoprotein A1(p < .05). Inconclusion, alterations in lipid metabolism may be a possible mediating mechanism between vital exhaustion and coronary heart disease. The impact of lifestyle variables was weak. This study was made possible by the following support sources: US National Institutes of Health (HL45785); Swedish Medical Research Council (B93-19X-10407); Swedish Labor Market Insurance Company; and the Swedish Heart and Lung Foundation.     

Burnout as a risk factor for coronary heart disease

During the preparation of a prospective study of exhaustion as a precursor of myocardial infarction (MI), the authors found that many coronary patients said that they had been burned out at some time in their lives. Therefore, the question, "Have you ever been burned out?" was included in the study. The cohort was formed by 3,877 men, aged 39 to 65, and was followed up on for 4.2 years. Among the men who were free of coronary heart disease (CHD) at screening, 59 subjects experienced a fatal or nonfatal myocardial infarction during follow-up. Those who endorsed the above question when they entered the study were found to be at increased risk for myocardial infarction when the authors controlled for age, blood pressure, smoking, and cholesterol; RR (relative risk) = 2.13; p less than .01. About one third of those who were exhausted before myocardial infarction had been burned out at some time in their lives, chi 2 = 7.09, p less than .01. The data indicate that a state of exhaustion before myocardial infarction is often a reactivation of earlier periods of breakdown in adaptation to stress.     

Lipoprotein (a) as an independent risk factor for myocardial infarction in patients with common hypercholesterolaemia.

AIMS: To examine whether lipoprotein (a) (Lp(a)) increases the risk of myocardial infarction (MI) in patients with common hypercholesterolaemia. METHODS: 15 middle aged men with common hypercholesterolaemia (mean serum low density lipoprotein (LDL) cholesterol 4.94 mmol/l, SD 1.0) and a history of MI were selected consecutively from referrals to a lipid clinic. A control group that had not sustained an MI and with similar age, sex, cigarette smoking and blood pressure characteristics was also selected from the same clinic. Serum cholesterol, triglyceride, LDL cholesterol, high density lipoprotein cholesterol, apolipoproteins AI and B and Lp(a) were measured in both groups. Lp(a) was assayed by immunoturbidity. RESULTS: The serum concentration of Lp(a) was significantly higher in patients with MI (geometric mean 0.64 (95% confidence interval 0.36 to 1.14) v 0.30 (0.21 to 0.42) g/l, p = 0.02), but there were no significant differences in other variables. Stepwise logistic regression analysis showed that Lp(a) was the only significant predictor of MI (p < 0.02). The odds ratio of MI (adjusted for age, smoking, blood pressure and apolipoprotein B) for an Lp(a) of > 0.57 g/l was 16.5, 95% confidence interval 2.3 to 125.4 (p = 0.001). CONCLUSION: In middle aged men with common hypercholesterolaemia the serum concentration of Lp(a) is a powerful and independent risk factor for MI. Lp(a) should probably be routinely measured in all patients referred to a lipid clinic.     

Relationship between leisure-time physical activity and risk factors for coronary heart disease in middle-aged Finnish women

Risk factors for coronary heart disease (CHD) and levels of leisure-time physical activity (LTPA) were measured in a random sample of 4,059 women aged 25-64 years, residing in four areas of Finland. LTPA indexed as the product of weekly exercise sessions X their usual intensity showed an inverse association with smoking (p = 0.02) and with CHD risk estimate which combines the three main risk factors, smoking, serum cholesterol and blood pressure (p = 0.06), and a positive association with HDL cholesterol (p = 0.002). It was not associated with mean arterial pressure and serum total cholesterol. In a multiple regression analysis LTPA contributed independently, though modestly, to the model for CHD risk estimate. Age and body mass index were the most important independent predictors of both mean arterial pressure and CHD risk estimate. It is concluded that in middle-aged Finnish women, unlike men of the same population, high LTPA is only weakly related to lower CHD risk factor levels.     

Relationship between plasminogen activator inhibitor activity and menopausal status

A higher incidence of coronary heart disease (CHD) in postmenopausal or oophorectomised women than in premenopausal women of similar age has been reported. The difference cannot be entirely attributable to changes in established CHD risk factors. Raised plasminogen activator inhibitor (PAI) activity may be involved in the pathogenesis of CHD. We have therefore investigated the menopause-related changes in PAI in 214 healthy women aged 45 to 54 years. Mean levels of PAI (m±SD) were higher in postmenopausal women (n=85) than in premenopausal women (n=129) of the same age (9.39±5.64 and 7.47±4.39 U/ml respectively, p<0.001), whether menopause was natural or surgically induced. PAI activity was positively correlated with body mass index (BMI) and triglyceride concentrations in both postmenopausal women (r=0.22, p<0.05 and r=0.27, p<0.01 respectively) and premenopausal women (r=0.30, p<0.001. and r=0.28, p<0.001 respectively). Multiple regression analysis showed that body mass index, triglycerides and menopause made an independent contribution to the prediction to PAI levels (total r²=0.17, p<0.0001). These results suggest that raised PAI activity may contribute to an increased risk of CHD in postmenopausal women.     

Psychological Resources Are Independently Associated with Markers of Inflammation in a Middle-Aged Community Sample

Purpose

To elucidate possible independent associations of psychological resources with inflammatory markers, all linked with coronary heart disease (CHD).

Method

In a middle-aged general population (n?=?944), psychological resources (coping, self-esteem, and sense of coherence (SOC)), a global measure of quality of life (Cantril’s self-anchoring ladder, also called “ladder of life”), and psychological risk factors (hopelessness, vital exhaustion, and depressive symptoms) were used in linear regression models to evaluate associations with the inflammatory markers interleukin (IL)-6, C-reactive protein (CRP), and matrix metalloproteinase (MMP)-9. Adjustments were done for age, sex, medical conditions, and cardiovascular risk factors.

Results

After full adjustments, self-esteem was independently associated with all three biomarkers. Ladder of life was associated with IL-6 and log-CRP; coping, vital exhaustion, and depressive symptoms with IL-6; and SOC with MMP-9 (p?<?0.05 for all associations).

Conclusion

Numerous significant associations of psychological resources and risk factors with IL-6, CRP, and MMP-9 were found in a community-based sample. The associations of psychological resources were mostly independent, while the psychological risk factors seemed preferentially dependent on lifestyle factors as smoking, physical activity, and body mass index (BMI). This suggests that the psychological resources’ (in particular self-esteem) protective effects on CHD are linked to inflammatory markers.

     

Psychological distress, physical illness and risk of myocardial infarction in the Caerphilly study

BACKGROUND: Studies have found associations between psychological distress (PD) and increased risk of myocardial infarction (MI). However, it is not clear whether the relationship reflects the subtle influence of pre-existing illness on both PD and MI. This study examines the association between PD and MI in a prospective epidemiological study of 1864 middle-aged men to examine if the association is explained by existing illness. METHOD: This study was a prospective cohort study modelling the association between PD, measured using the 30-item General Health Questionnaire (GHQ) and non-fatal myocardial infarction (NFMI) and fatal/non-fatal myocardial infarction (FNFMI).The relationship was modelled in a series of logistic regression models adjusted for age, then cigarette smoking, then social position, and finally for all sociodemographic characteristics, coronary heart disease (CHD) risk factors, and baseline CHD. RESULTS: PD was associated with a 70% and 68% increased risk of NFMI and FNFMI in fully adjusted analysis. However, PD was not associated with an increased risk of NFMI and FNFMI in analyses excluding those with baseline CHD. Further, being psychologically distressed and physically ill was associated with a greater than twofold risk of NFMI and FNFMI, 2.37 (95% CI 1.33-4.20) and 2.33 (95% CI 1.32-4.12) respectively. CONCLUSIONS: This study suggests that PD is a moderator of the increased risk of MI associated with existing physical illness. PD in men who are physically ill is a marker of an underlying chronic physical illness. The prospective association of PD with MI is not independent of baseline physical illness.     

Predictors of readmission and health related quality of life in patients with chronic heart failure: a comparison of different psychosocial aspects

Psychological distress is common in patients with chronic heart failure. The impact of different psychological variables on prognosis has been shown but the comparative effects of these variables remain unclear. This study examines the impact of depression, anxiety, vital exhaustion, Type D personality, and social support on prognosis in chronic heart failure patients. One hundred eleven patients (mean age 57 ± 14 years) having participated in an exercise based ambulatory cardiac rehabilitation program were enrolled in a prospective cohort study. Psychological baseline data were assessed at program entry. Mortality, readmission, and health-related quality of life were assessed at follow up (mean 2.8 ± 1.1 years). After controlling for disease severity none of the psychological variables were associated with mortality, though severe anxiety predicted readmission [HR = 3.21 (95% CI, 1.04–9.93; P = .042)]. Health-related quality of life was independently explained by vital exhaustion, anxiety and either body mass index (physical dimension) or sex (emotional dimension). As psychological variables have a strong impact on health-related quality of life they should be routinely assessed in chronic heart failure patients` treatment.     

Hormone therapy and coronary heart disease risk by vasomotor menopausal symptoms

Objectives

We examined whether the association between hormone therapy (HT) use and coronary heart disease (CHD) risk differed between women with and without vasomotor symptoms (VMS).

Study design

We used data from a Dutch (EPOS) and Swedish (WHILA) population-based sample of 8865 women, aged 46–64 years, and free of CHD, stroke, venous thrombosis/pulmonary embolism or cancer at baseline. Data on HT use, VMS and potential confounders were collected by questionnaires.

Main outcome measures

CHD endpoints, obtained via registries.

Results

252 CHD cases occurred during 10.3 years of follow-up. Neither for women with nor for women without flushing or (night) sweats ever HT use was associated with CHD risk, compared with never HT use. Among women with intense VMS, ever HT use borderline significantly decreased CHD risk compared with never HT use (HR 0.48 [95% CI 0.20–1.03]). Among women without intense VMS, ever HT use was associated with a borderline significant increased CHD risk (HR 1.28 [95% CI 0.96–1.70]; P for interaction = 0.02). However, after multivariate adjustment, as compared to never HT use, ever HT use was not associated with risk of CHD among women with or without intense VMS.

Conclusions

In both groups of women with and without VMS, HT use does not seem to be associated with the risk of CHD. Hence, our findings do not support the view that HT use increases the CHD risk among women with an indication, i.e. VMS, but this needs to be confirmed in specifically designed studies.