Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence,relevance, clinical implications and management principles

Objective

To review evidence regarding the prevalence, causation, clinical implications, aspects of healthcare utilisation and management of depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease.

Design

A critical review of the literature (1994–2009).

Findings

The prevalence of depression and anxiety is high in both chronic obstructive pulmonary disease (8–80% depression; 6–74% anxiety) and chronic heart failure (10–60% depression; 11–45% anxiety). However, methodological weaknesses and the use of a wide range of diagnostic tools make it difficult to reach a consensus on rates of prevalence. Co‐morbid depression and anxiety are associated with increased mortality and healthcare utilisation and impact upon functional disability and quality of life. Despite these negative consequences, the identification and management of co‐morbid depression and anxiety in these two diseases is inadequate. There is some evidence for the positive role of pulmonary/cardiac rehabilitation and psychotherapy in the management of co‐morbid depression and anxiety, however, this is insufficient to guide recommendations.

Conclusions

The high prevalence and associated increase in morbidity and mortality justifies future research regarding the management of anxiety and depression in both chronic heart failure and chronic obstructive pulmonary disease. Current evidence suggests that multi‐faceted interventions such as pulmonary and cardiac rehabilitation may offer the best hope for improving outcomes for depression and anxiety. Copyright © 2009 John Wiley & Sons, Ltd.

     

倍他乐克联合洛丁新治疗老年CHF的分析

目的探讨倍他乐克联合洛丁新治疗老年慢性充血性心力衰竭（CHF）的临床效果及安伞性。方法将我院70例老年CHF患者随机分为观察组和对照组,均予以常规抗心力衰竭治疗,观察组在此基础上加用倍他乐克和洛丁新,在治疗前后测定两组左心室收缩末期容积（LVESV）和左心室舒张末期容积（LVEDV）,并进行临床疗效评价。结果两组治疗后LVESV较治疗前均有明显改善（P〈0．01）;治疗后观察组LVESV改善明显优于对照组（P〈0．01）观察组临床总有效率为88．57％,明显高于对照组的74．29％（P〈0．05）。结论倍他乐克联合洛丁新能明显改善CHF患者的临床症状和心功能。     

ACEI类药物降低高血压患者充血性心力衰竭风险的Meta分析

目的评价血管紧张素转换酶抑制剂（ACEIs）是否能降低充血性心力衰竭（CHF）的发生风险。方法通过计算机检索CENTRAL（the Cochrane central register of controlledtrials）、EMBASE、Medline、万方数据库、中国期刊全文数据库（CNKI）、中国生物医学文献数据库系统（CBM）等,收集公开发表的涉及ACEI类药物预防CHF作用的随机对照研究（RCT）。研究人群为高血压高危人群;干预措施为口服ACEI类药物;对照组为安慰剂;结局指标为充血性心力衰竭发生率,并以相对危险度（relative risk,RR）及相应的95%可信区间（95%confidence interval,95%CI）为效应指标对结局进行比较。I2检验来检测各研究间的统计学异质性。双侧P〈0.05认为各研究间存在明显的异质性。采用Egger法对发表偏倚进行量化检测。应用统计软件ReviewMan 5.0和Stata 11.0进行数据分析。结果纳入分析的文章有5篇,共31750例受试者,其中ACEIs组15894例,对照组15856例。ACEIs组共发生CHF 336例,发生率为2.1%;对照组共发生CHF 442例,发生率为2.7%。Meta分析结果显示,ACEI组受试者随访期间发生CHF的风险是安慰剂组的67%（RR=0.67,95%CI：0.66～0.87,P〈0.001）。结论 ACEIs可以显著降低高血压高危人群CHF的发生风险。     

参草通脉颗粒对心衰大鼠双向调节药效学研究

参草通脉颗粒是临床治疗慢性心衰的经验方,用于防治慢性心衰已取得较好的疗效。通过观察参草通脉颗粒对慢性心衰大鼠心肌基质金属蛋白酶-1(MMP-1)和基质金属蛋白酶特异性抑制物-1(TIMP-1)的双向调节作用。研究中药对慢性心衰的药效学作用和作用靶点,为中医药防治慢性心衰提供客观依据。     

氨氯地平对CHF大鼠血浆ET-1和BNP表达的影响

目的探讨氨氯地平对充血性心力衰竭（CHF）大鼠血浆中内皮素-1（ET-1）和B型钠尿肽（BNP）表达的影响。方法SD大鼠随机分为3组：对照组、心衰组、氨氯地平组。CHF组大鼠腹腔注射阿霉素累积剂量达20mg/kgBW制作CHF模型,氨氯地平组大鼠腹腔注射阿霉素同时每天给予氨氯地平10mg/kg。4周后各组大鼠经颈内动脉插管至左心室行血流动力学测定,同时测定大鼠血浆中ET-1和BNP的含量。结果CHF组大鼠左室压力最大上升速率（＋dp/dtmax）和最大下降速率（-dp/dtmax）均显著低于对照组,其血浆内ET-1和BNP均显著高于对照组（P〈0.01）。氨氯地平组±dp/dtmax均显著低于对照组但高于CHF组,其血浆内ET-1和BNP均显著高于对照组低于CHF组（P〈0.01）。结论氨氯地平治疗CHF大鼠的作用机制之一可能是通过保护CHF大鼠左室功能、结构及心肌细胞,间接降低ET-1、BNP表达水平。     

Central sleep apnea: Pathophysiology and treatment

Central sleep apnea (CSA) is characterized by a lack of drive to breathe during sleep, resulting in repetitive periods of insufficient ventilation and compromised gas exchange. These nighttime breathing disturbances can lead to important comorbidity and increased risk of adverse cardiovascular outcomes. There are several manifestations of CSA, including high altitude-induced periodic breathing, idiopathic CSA, narcotic-induced central apnea, obesity hypoventilation syndrome, and Cheyne-Stokes breathing. While unstable ventilatory control during sleep is the hallmark of CSA, the pathophysiology and the prevalence of the various forms of CSA vary greatly. This brief review summarizes the underlying physiology and modulating components influencing ventilatory control in CSA, describes the etiology of each of the various forms of CSA, and examines the key factors that may exacerbate apnea severity. The clinical implications of improved CSA pathophysiology knowledge and the potential for novel therapeutic treatment approaches are also discussed.     

Acute pulmonary embolism is an independent predictor of adverse events in severe decompensated heart failure patients

BACKGROUND: Congestive heart failure (CHF) is a well-recognized risk factor for venous thromboembolism (VTE) and is associated with higher mortality in patients with an acute pulmonary embolism (PE). There are very few data on how acute PE affects the clinical course of patients with heart failure. The purpose of this study was to determine the impact of an acute PE on the short-term prognosis of patients hospitalized for decompensated CHF. METHODS: This was a prospective cohort study of 198 patients admitted to a coronary care unit between July 2001 and March 2003 with severe decompensated CHF. The primary outcome measure was death or rehospitalization at 3 months. RESULTS: PE was confirmed in 18 of 198 patients enrolled (9.1%). The groups with and without PE were comparable with regards to demographics, the prevalence of comorbid conditions, and severity of CHF (p > 0.05). The prevalence of cancer (p = 0.0001), previous VTE (p = 0.003), and right ventricular overload (p = 0.006) was higher in the PE group. The presence of PE was also associated with a longer hospital stay (37.5 +/- 71.6 days vs 15.4 +/- 15.0 days, p = 0.001) [mean +/- SD] and a higher incidence of death or rehospitalization at 3 months (72.2% vs 43.9%, p = 0.02). In a multiple logistic regression analysis, PE remained an independent predictor of death or rehospitalization at 3 months (odds ratio, 4.0; 95% confidence interval, 1.1 to 15.1; p = 0.038). CONCLUSIONS: Acute PE commonly complicates the hospital course of patients with severe CHF, increasing the length of hospital stay and the chance of death or rehospitalization at 3 months.     

Natriuretic peptides

Natriuretic peptides (NPs) are released from the heart in response to pressure and volume overload. B-type natriuretic peptide (BNP) and N-terminal-proBNP have become important diagnostic tools for assessing patients who present acutely with dyspnea. The NP level reflects a compilation of systolic and diastolic function as well as right ventricular and valvular function. Studies suggest that using NPs in the emergency department can reduce the consumption of hospital resources and can lower costs by either eliminating the need for other, more expensive tests or by establishing an alternative diagnosis that does not require hospital stay. Caveats such as body mass index and renal function must be taken into account when analyzing NP levels. Natriuretic peptide levels have important prognostic value in multiple clinical settings, including in patients with stable coronary artery disease and with acute coronary syndromes. In patients with decompensated heart failure due to volume overload, a treatment-induced drop in wedge pressure is often accompanied by a rapid drop in NP levels. Knowing a patient's NP levels might thus assist with hemodynamic assessment and subsequent treatment titration. Monitoring NP levels in the outpatient setting might also improve patient care and outcomes.