Belinda Chen

Early cognitive behavioral therapy for depression after cardiac surgery.

BACKGROUND Despite high rates of postcardiac surgery depression, studies of depression treatment in this population have been limited. OBJECTIVE The aim of this study was to evaluate early cognitive behavioral therapy (CBT) in a home environment in patients recovering from cardiac surgery. METHODS : From July 2006 through October 2009, we conducted a randomized controlled trial and enrolled 808 patients who were screened for depressive symptoms using the Beck Depression Inventory (BDI) in the hospital and 1 month later. Patients were interviewed using the Structured Clinical Interview for DSM-IV; those who met criteria for clinical depression (n = 81) were randomized to CBT (n = 45) or usual care (UC; n = 36). After completion of the UC period, 25 individuals were offered later CBT (UC + CBT). RESULTS Main outcomes (depressive symptoms [BDI] and clinical depression [Structured Clinical Interview for DSM-IV]) were evaluated after 8 weeks using intention-to-treat principles and linear mixed models. Compared with the UC group, in the CBT group, there was greater decline in BDI scores (β = 1.41; 95% confidence interval [CI], 0.81-2.02; P = < .001) and greater remission of clinical depression (29 [64%] vs 9 [25%]; number need to treat, 2.5; 95% CI, 1.7-4.9; P < .001). Compared with the early CBT group (median time from surgery to CBT, 45.5 days) the later UC + CBT group (median time from surgery to CBT, 122 days) also experienced a reduction in BDI scores, but the group × time effect was smaller (β = 0.79; 95% CI, 0.10-1.47; P = .03) and remission rates between the 2 groups did not differ. CONCLUSIONS Early home CBT is effective in depressed postcardiac surgery patients. Early treatment is associated with greater symptom reduction than similar therapy given later after surgery.

Electrocardiographic abnormalities in the first year after heart transplantation.

STUDY AIM Describe ECG abnormalities in the first year following transplant surgery. METHODS Analysis of 12-lead ECGs from heart transplant subjects enrolled in an ongoing multicenter clinical trial. RESULTS 585 ECGs from 98 subjects showed few with abnormal cardiac rhythm (99% of ECGs were sinus rhythm/tachycardia). A majority of subjects (69%) had either right intraventricular conduction delay (56%) or right bundle branch block (13%). A second prevalent ECG abnormality was atrial enlargement (64% of subjects) that was more commonly left atrial (55%) than right (30%). CONCLUSIONS Right intraventricular conduction delay or right bundle branch block is prevalent in heart transplant recipients in the first year following transplant surgery. Whether this abnormality is related to acute allograph rejection or endomyocardial biopsy procedures is the subject of the ongoing clinical trial. Atrial enlargement ECG criteria (especially, left atrial) are also common and are likely due to transplant surgery with subsequent atrial remodeling.

Cognitive behavioral therapy for depression improves pain and perceived control in cardiac surgery patients

Background: Depression after cardiac surgery (CS) is associated with increased pain and decreased sleep quality. While cognitive behavioral therapy (CBT) aimed at depression is effective in relieving depressive symptoms after cardiac surgery, little is known about its ability to ameliorate other common postoperative problems that affect recovery and quality of life. Aims: The purpose of this study was to evaluate the effects of CBT for depression on pain severity, pain interference, sleep, and perceived control in patients recovering from CS. Methods: Depressed patients recovering from CS were randomized to receive either eight weeks of CBT or usual care. At baseline and post-intervention, patients completed questionnaires for depressive symptoms, pain, sleep, and perceived control. Group comparisons were conducted using t-tests or chi square analysis. Repeated measures analysis was used to assess the effect of the intervention in changes over time. Results: The sample (n=53) included 16.9% women and had a mean age of 67.8±9.2 years. CBT for depression increased perceived control (p<0.001) and decreased pain interference (p=0.02) and pain severity (p=0.03). Group effects remained significant (p<0.05) for perceived control and pain interference and a trend was observed for pain severity (p<0.10) after controlling for variables that differed at baseline. There were no group differences in sleep disturbance over time. Conclusions: A depression-focused CBT intervention yields benefits in other common postoperative problems, specifically improved perceived control and decreased pain in depressed cardiac surgery patients.

Persistent depressive symptoms and pain after cardiac surgery.

Objective Our objectives were to describe trajectories of depressive symptoms and pain at hospital discharge and 6 weeks later and to examine the relationship of persistent depressive symptoms to pain. Methods Before and 6 weeks after hospital discharge, 251 patients undergoing cardiac surgery (mean [SD] age = 67.3 [9.5] years; 73% male) completed the Beck Depression Inventory and the Brief Pain Inventory (BPI). Patients were categorized into two groups based on the presence or absence of persistent depressive symptoms (Beck Depression Inventory score >10 at both times). Between-group differences in pain interference (BPI-INT) and pain severity (BPI-SEV) were evaluated using repeated-measures analysis of variance. Linear regressions were performed to determine if changes in depressive symptoms were related to BPI-INT and BPI-SEV, controlling for demographic and clinical data. Results Persistent (16.3%) or worsening depressive symptoms (15.3%) from hospital discharge to 6 weeks were observed; many experienced at least some persistent pain (BPI-INT 67.8%, BPI-SEV 47.8%). From discharge to 6 weeks, patients with persistent depressive symptoms sustained higher levels of BPI-INT (p < .001) and BPI-SEV (p < .003). In multivariate analysis, only changes in depressive symptoms, not clinical and demographic variables, were related to BPI-INT (p < .001) and BPI-SEV (p = .001). Conclusions Persistent depressive symptoms are independently associated with continued pain up to 6 weeks after hospital discharge. Successful treatment of ongoing pain should include screening for depressive symptoms and initiation of appropriate treatment. Trial Registraton Clinicaltrials.gov Identifier: NCT00522717.

Evaluation of the SIPAT instrument to assess psychosocial risk in heart transplant candidates: A retrospective single center study

Objectives We evaluated the reliability of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) in heart transplant (HT) recipients and explored its usefulness in predicting post‐transplant outcomes. Background Pre‐transplant psychosocial and behavioral risk is associated with post‐transplant clinical outcomes. SIPAT is a risk assessment tool created for pre‐transplant psychosocial evaluation. Methods Via retrospective chart review, three examiners applied the SIPAT to 51 adult HT recipients. Examiners blinded to SIPAT scores extracted data and interviewed clinicians for one‐year post‐transplant outcomes. Analysis included Intra‐class correlation coefficient (ICC), Pearsons correlation coefficient and Chi‐square. Results SIPAT demonstrated strong inter‐rater reliability (ICC = 0.89, 95% CI = 0.76–0.96). Compared to those with SIPAT ratings of “Excellent/Good”, the “Minimally Acceptable Candidate/High Risk” group was more likely to miss clinic visits (p = 0.004). Conclusions The SIPAT tool had strong IRR. Less favorable SIPAT ratings were associated with nonadherence to clinic visits. Further study is warranted to determine association of SIPAT ratings to clinical outcomes.

Cognitive behavioral therapy in depressed cardiac surgery patients: role of ejection fraction.

Aims:The aim of this study was to evaluate the relationship of ejection fraction (EF) and depressive symptoms in cardiac surgery patients assigned to nurse-guided cognitive behavioral therapy (CBT) or usual care (UC). Methods:Depressive symptoms were assessed using the Beck Depression Inventory (BDI). Seventy-seven patients (31% women; mean [SD] age, 63.6 [9.8] years) received 8 weeks of either CBT or UC. Using repeated-measures analysis of variance, changes in depressive symptoms over time were evaluated. Results:There was a significant interaction among time, treatment group, and EF status (p = 0.019). In the patients with preserved EF (≥40%), mean BDI scores in the UC group worsened by 1.9%, whereas those in the CBT group improved by 31.0%. In the patients with low EF (<40%), mean BDI scores worsened by 26.8% and improved by 75.3% in the UC and CBT groups, respectively. Conclusions:Nurse-guided CBT is effective in reducing depressive symptoms after cardiac surgery, particularly in patients with low EF.

Perceived control and health-related quality of life in heart transplant recipients:

Background: Perceived control has been associated with improved mental health and health-related quality of life (HRQOL) in cardiac populations. However, this concept has not been well-studied in heart transplant groups. Aims: We examine the relationship of perceived control to symptoms of anxiety and depression and HRQOL after transplant. We also examine the extent to which anxiety and depressive symptoms mediate the relationship between perceived control and HRQOL. Methods: Our cross-sectional analysis included 113 adult heart transplant patients from the NEW HEART study. High versus low perceived control groups were determined by median split for chi-square and t-test analyses. Hierarchical multiple linear regression models were used to examine the influence of perceived control on symptoms of depression and anxiety and HRQOL. Mediation analyses included Baron and Kenny’s four-step regression approach and Preacher and Hayes’ bootstrapping technique to test the indirect effect of perceived control on HRQOL. Results: Heart transplant patients who reported lower perceived control were more likely to be female (p=0.003), and had significantly more depressive symptoms (p<0.001) and anxiety (p<0.001), and lower HRQOL (p<0.001) than those with higher perceived control. Perceived control was a significant predictor in regression models of depressive and anxiety symptoms and HRQOL. In mediation analyses, depressive and anxiety symptoms mediated the effect of perceived control on HRQOL. Conclusion: Perceived control is associated with improved depressive and anxiety symptoms and HRQOL after transplant. The relationship between perceived control and HRQOL is mediated by depressive and anxiety symptoms. Future interventions should target perceived control to improve overall HRQOL.

Clinical and gender differences in heart transplant recipients in the NEW HEART study

Background: Little attention has focused on gender differences in cardiac comorbidities and outcomes in patients undergoing orthotropic heart transplant. Objective: The objective of this study was to investigate gender differences at baseline and during follow-up among heart transplant patients. Methods: An observational cohort within the NEW HEART study was evaluated to determine gender differences in relation to age, coexisting cardiac comorbidities, and outcomes. Differences were assessed by t-test, Fisher’s exact test, and logistic regression analysis. Results: Male transplant recipients (n = 238) were significantly older than female recipients (n = 92), with a greater percentage over 60 years of age (45% vs. 24%, p = 0.0006). Males were more likely to have hypertension (63% vs. 49%, p = 0.034), dyslipidemia (62% vs. 45%, p = 0.006), a history of smoking (52% vs. 35%, p = 0.009), and diabetes (42% vs. 21%, p = 0.0002). Analysis of endomyocardial biopsies obtained during the 1-year follow-up period demonstrated that women averaged more episodes of acute rejection than men (3.9 vs. 3.0, p = 0.009). While most episodes of rejection were mild, women were more likely than men to have episodes of moderate or severe rejection (14% vs. 5%, p = 0.012) and to be hospitalized for acute rejection (15% vs. 6%, p = 0.013). There were no significant differences in mortality. Conclusions: Men were more likely than women to be older and to have diabetes, dyslipidemia, hypertension, and a history of smoking. Women were more likely to experience moderate or severe allograft rejection and to be hospitalized for acute rejection. Future investigation of the reasons for these gender differences is warranted and may improve clinical care of women undergoing cardiac transplantation.

Electrocardiographic Correlates of Acute Allograft Rejection Among Heart Transplant Recipients

&NA; Background Acute allograft rejection appears to be associated with increases in QT/QTc intervals. Objectives To determine the relationship between acute allograft rejection and electrocardiogram changes in patients undergoing an orthotopic heart transplant. Methods The study population comprised 220 adult patients undergoing heart transplant and enrolled in the NEW HEART study. Electrocardiograms obtained within 72 hours of endomyocardial biopsy were analyzed; electrocardiograms obtained fewer than 10 days after transplant surgery were excluded. Repeated‐measures analysis was performed with statistical models including effects for rejection severity (mild and moderate/severe) and time trends independent of rejection status. Results The 151 male and 69 female transplant recipients (mean age [SD], 54 [13] years) had 969 biopsy/electrocardiogram pairs: 677 with no rejection, 280 with mild rejection, and 12 with moderate/severe rejection. Moderate to severe organ rejection was associated with significant increases in QRS duration (P < .001), QT (P = .009), QTc (P = .003), and PR interval (P = .03), as well as increased odds of right bundle block branch (P = .002) and fascicular block (P = .009) occurring. Conclusions Moderate to severe acute allograft rejection was associated with electrocardiographic changes after transplant surgery. Studies are needed to assess the value of computerized electrocardiogram measurement algorithms for detecting acute allograft rejection.

Corrigendum to “QTc prolongation may be a late biomarker of orthotopic heart transplantation (OHT) rejection” [J Electrocardiol 49 (2016) 928–929]

Author(s): Carter, Erik V; Castillo, Carmen; Chen, Belinda; Doering, Lynn V; Drew, Barbara J; Hickey, Kathleen T; Pickham, David; Sciacca, Robert R