Andrew B. Littman

Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly

OBJECTIVES The aim of this study was to determine the effects of cardiac rehabilitation and exercise training on plasma lipids, indexes of obesity and exercise capacity in the elderly and to compare the benefits in elderly patients with coronary heart disease with benefits in a younger cohort. BACKGROUND Despite the well proved benefits of cardiac rehabilitation and exercise training, elderly patients with coronary heart disease are frequently not referred or vigorously encouraged to pursue this therapy. In addition, only limited data are available for these elderly patients on the benefits of cardiac rehabilitation on plasma lipids, indexes of obesity and exercise capacity. METHODS At two large multispecialty teaching institutions, baseline and post-rehabilitation data including plasma lipids, indexes of obesity and exercise capacity were compared in 92 elderly patients (> or = 65 years, mean age 70.1 +/- 4.1 years) and 182 younger patients (< 65 years, mean 53.9 +/- 7.4 years) enrolled in phase II cardiac rehabilitation and exercise programs after a major cardiac event. RESULTS At baseline, body mass index (26.0 +/- 3.9 vs. 27.8 +/- 4.2 kg/m2, p < 0.001), triglycerides (141 +/- 55 vs. 178 +/- 105 mg/dl, p < 0.01) and estimated metabolic equivalents (METs) (5.6 +/- 1.6 vs. 7.7 +/- 3.0, p < 0.0001) were lower and high density lipoprotein cholesterol was greater (40.4 +/- 12.1 vs. 37.5 +/- 10.4 mg/dl, p < 0.05) in the elderly than in younger patients. After rehabilitation, the elderly demonstrated significant improvements in METs (5.6 +/- 1.6 vs. 7.5 +/- 2.3, p < 0.0001), body mass index (26.0 +/- 3.9 vs. 25.6 +/- 3.8 kg/m2, p < 0.01), percent body fat (24.4 +/- 7.0 vs. 22.9 +/- 7.2%, p < 0.0001), high density lipoprotein cholesterol (40.4 +/- 12.1 vs. 43.0 +/- 11.4 mg/dl, p < 0.001) and the ratio of low density to high density lipoprotein cholesterol (3.6 +/- 1.3 vs. 3.3 +/- 1.0, p < 0.01) and a decrease in triglycerides that approached statistical significance (141 +/- 55 vs. 130 +/- 76 mg/dl, p = 0.14) but not in total cholesterol or low density lipoprotein cholesterol. Improvements in functional capacity, percent body fat and body mass index, as well as lipids, were statistically similar in the older and younger patients. CONCLUSIONS Despite baseline differences, improvements in exercise capacity, obesity indexes and lipids were very similar in older and younger patients enrolled in cardiac rehabilitation and exercise training. These data emphasize that elderly patients should not be categorically denied the psychosocial, physical and risk factor benefits of secondary coronary prevention including formal cardiac rehabilitation and supervised exercise training.

The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease.

Objecetive: There is accumulating evidence of high prevalence of comorbid psychiatric disorders in patients with coronary heart disease (CHD). However, most of these studies focused on one psychiatric disorder or one set of psychological symptoms and detected psychiatric disorders in acutely ill CHD patients. To date, no systematic comprehensive psychiatric diagnostic evaluation has been performed in a consecutive sample of stable CHD outpatients. Methods: One hundred stable CHD outpatients of the Cardiology Division outpatient clinic at the Massachusetts General Hospital were included in the study. Psychiatric diagnoses were established by using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (axes I-V). Results: Frequent comorbid psychiatric diagnoses were detected, including single past major depressive episode (29%), current dysthymic disorder (15%), recurrent major depressive disorder with current major depressive episode (31%), current alcohol abuse (19%), posttraumatic stress disorder (29%), current generalized anxiety disorder (24%), current binge-eating disorder (10%), and current primary insomnia (13%). The mean number of comorbid clinical psychiatric disorders per subject was 1.7. Conclusion: The findings suggest high prevalence rates of comorbid psychiatric disorders as well as a broad spectrum of psychiatric disorders in stable CHD outpatients. However, larger epidemiological studies are needed in order to determine the true prevalence of these disorders in CHD patients. CHD = coronary heart disease; MGH = Massachusetts General Hospital; IRB = Institutional Review Board; MI = myocardial infarction; PCI = percutaneous coronary intervention; CABG = coronary artery bypass graft surgery; CHF = congestive heart failure; SCID = structured clinical interview for DSM; DSM = Diagnostic and Statistical Manual of Mental Disorders; PD = personality disorder; MDE = major depressive episode; MDD = major depressive disorder; PTSD = posttraumatic stress disorder; GAD = generalized anxiety disorder; BMI = body mass index; GAF = Global Assessment of Functioning Scale.

Omega-3 Fatty Acids, Homocysteine, and the Increased Risk of Cardiovascular Mortality in Major Depressive Disorder

Depression is associated with elevated rates of cardiovascular morbidity and mortality. This elevation seems to be due to a significantly increased risk of coronary artery disease and myocardial infarction and, once the ischemic heart disease is established, sudden cardiac death. Recent data suggest that the increased rates of cardiovascular disease in patients with depression may be the result of one or more still-unrecognized underlying physiological factors that predispose a patient to both depression and cardiovascular disease. Two possibly related factors that may have a causal relation with both depressive disorders and cardiovascular disease are an omega-3 fatty acid deficiency and elevated homocysteine levels. We present the available data connecting cardiovascular disease, depression, omega-3 fatty acids, and homocysteine. In addition, we suggest research strategies and some preliminary treatment recommendations that may reduce the increased risk of cardiovascular mortality in patients with major depressive disorder.

Psychiatric Disorders and Coronary Heart Disease in Women – A Still Neglected Topic: Review of the Literature from 1971 to 2000

Background: Coronary heart disease (CHD) is the leading cause of death in women aged over 40 years in the United States, for whom it conveys a worse prognosis than for men. Recently, psychosocial factors have been understood to represent significant risk factors for developing CHD, as well as having a worse outcome with established CHD. However, these factors are often overlooked, in particular comorbid psychiatric disorders and psychiatric symptoms. To summarize the current knowledge in this interdisciplinary field, the authors conducted a review of CHD in women, taking into account psychosocial aspects, in particular psychiatric disorders. Methods: Medline searches using the keywords ‘psychiatric disorder’ and ‘coronary heart disease’ and ‘women’, and ‘psychiatric disorder’ and ‘cardiac disease’ and ‘women’, were performed, covering the time span from the beginning of the Medline database until January 1, 2001. Results: Quoted items included depression, panic disorder, generalized anxiety disorder, mitral valve prolapse, chest pain, anorexia nervosa, menopause, alcohol abuse, cocaine use, sleep disorder, sexual dysfunction, hostility and type A behavior, as well as other psychosocial aspects. There is accumulating evidence of significant associations between psychosocial factors, in particular psychiatric disorders and psychiatric symptoms, and the development and recurrence of CHD in women. Conclusions: However, in summary, the topic still seems to be neglected. Future research into psychiatric disorders and psychiatric symptoms and CHD in women is strongly required, and the focus on women exclusively is underlined.

Review of Psychosomatic Aspects of Cardiovascular Disease

This review deals with the clinically most relevant psychosomatic aspects of cardiovascular disease. Smoking cessation, the role of physical activity in the prevention and rehabilitation of cardiac disease, the relationship of cholesterol to behavior, depression and heart disease, the pharmacotherapy of depression in this specific patient population, the psychiatric risk factors for coronary artery disease, and the treatment of hostility, stress and type A behavior are discussed.

Neuroendocrine correlates of the type A behavior pattern: a review and new hypotheses.

Various studies have tried to identify the possible neuroendocrine correlates of the action/emotion complex defined as Type A behavior pattern. Type A subjects have been observed quite consistently to respond to laboratory stressors with a greater sympathetic nervous system response than Type B subjects. There also seems to be a trend towards a hyperactivity of the hypothalamic-pituitary-adrenocortical axis in Type A individuals. The clinical relevance of these findings lies in the fact that there is an increasing clinical and laboratory evidence of a pathogenic role of catecholamines in coronary artery disease (CAD) and that some of these neuroendocrine correlates might actually be the mediators of the risk of CAD conferred by the Type A behavior pattern. We hypothesize that dehydroepiandrosterone-sulfate (DHEA-S), an adrenal weak androgen, is inversely correlated with the degree of Type A behavior pattern and this hypothesis seems to be confirmed by the results of a preliminary investigation that we have conducted.

Psychological Adaptation to Cardiovascular Disease

In elderly Americans, the most rapidly growing population group in the United States, cardiovascular disease represents the major cause of death and disability. In 1988, greater than 55% of all myocardial infarctions (MI) were in persons older than 65 years of age [2], and infarcts in this group are typically more severe and associated with increased complications, thus prolonging hospitalization with its attendant deconditioning. With the advent of improved technology and increasing survival following MI, the incidence of congestive heart failure has rapidly increased, with an eightfold increase among men in the seventh decade of life as compared to those in the fifth decade. Congestive heart failure is now the leading hospital discharge diagnosis in the United States in persons older than age 65 [3]. Depending on the severity of these cardiovascular disorders and the presence of comorbid conditions, elderly persons often have to make significant life-style modifications that impact a variety of daily functions, including social and recreational activities, occupational demands, relations with spouse and family, sexual function, activities of daily living, and mood [4, 5, 6]. These modifications can be accompanied by constructive behavioral change, such as cessation of smoking or compliance with medication, or by maladaptive behavior such as denial of symptoms or the illness itself, which can lead to further deterioration of the primary condition.

Depressive Symptoms Predict Functional Improvement Following Cardiac Rehabilitation and Exercise Program

The clinical significance of various psychological factors on cardiovascular diseases remains controversial, but data suggest that these factors have impact on recovery following major cardiac events. We utilized a questionnaire voluntarily completed by 77 patients to determine if depressive symptoms predicted improvement in functional capacity or in other modifiable risk factors in patients enrolled in an outpatient cardiac rehabilitation program. Sixteen patients (21%) indicated depressive symptoms (Group 1), and 61 (79%) denied depressive symptoms (Group 2). Baseline characteristics including age, sex, body mass index, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), functional class, and exercise capacity (METS) were not significantly different in the two groups. After completing the rehabilitation program, improvement in LDL-C and HDL-C were quite similar in both groups. After rehabilitation, METS improved by 26% in Group 2(7.7 ± 0.4 to 9.6 ± 0.5, P

Psychological behavioral and biochemical risk factors for coronary artery disease among American and Italian male corporate managers

Differences in psychological, behavioral and biochemical risk factors for coronary artery disease (CAD) among male corporate managers of 2 countries (United States and Italy), with very different age-specific rates of mortality for CAD were evaluated. In all, 129 American (mean age 43 +/- 7 years) and 80 Italian (mean age 45 +/- 7 years) managers volunteered to participate in this study. Each subject was administered several questionnaires assessing various psychological and behavioral risk factors for CAD, and all 129 Americans and 55 of 80 Italians had their blood drawn between 8:00 and 9:30 AM after overnight fasting for the measurement of plasma levels of dehydroepiandrosterone-sulfate (DHEA-S), total cholesterol, triglycerides, and apolipoproteins A-I and B. Italian managers reported significantly more cynicism and hostility, and less enjoyment in leisure activities than did American ones. Furthermore, 40 Italian (51%) and only 18 American (14%) managers were smokers (this difference being statistically significant). Although no significant differences were found in factors positively related with CAD (cholesterol, triglycerides and apolipoprotein B), there were clear differences in parameters inversely correlated with the incidence of CAD. Italian managers had significantly lower levels of plasma DHEA-S and apolipoprotein A-I than did American ones. In conclusion, this study found that Italian managers had a significantly more unhealthy psychological and behavioral profile than did American ones, and had lower levels of those biochemical parameters (apolipoprotein A-I and DHEA-S) thought to have a protective role against development of CAD.

Physiologic benefits of a stress reduction program for healthy middle-aged army officers ☆

Stress reduction programs (SRPs) can reduce morbidity and mortality in patients with coronary artery disease (CAD). This study evaluated the effect of an SRP on metabolic and hormonal risk factors for CAD. Twenty army officers participating in an SRP, Group I, and a comparison group of seventeen SRP nonparticipants, Group C, volunteered to undergo measurement of dehydroepiandrosterone-sulfate (DHEA-S), cortisol, DHEA-S/cortisol ratio, testosterone, apolipoprotein-A1, apolipoprotein-B, triglycerides, cholesterol, fibrinogen, and leukocyte count both before and after the SRP period. No differences in the changes in biochemical risk factors for CAD were found between participant and nonparticipant except for DHEA-S. While Group C had a marked reduction in DHEA-S levels, Group I had a small increase. Previous studies indicate DHEA-S is inversely associated with extent of CAD and age-adjusted DHEA-S levels below 3.78 mumol/l confer an increased risk for CAD mortality. SRP participation appears to effect DHEA-S levels, possibly partially accounting for the benefits observed in SRPs among CAD patients.