Jo-Ann Eastwood

Comorbid depression and anxiety symptoms as predictors of cardiovascular events: Results from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study

Objective: To study the independent and interactive effects of depression and anxiety symptoms as predictors of cardiovascular disease (CVD) events in a sample of women with suspected myocardial ischemia. Symptoms of depression and anxiety overlap strongly and are independent predictors of CVD events. Although these symptoms commonly co-occur in medical patients, little is known about combined effects of depression and anxiety on CVD risk. Method: A total of 489 women completed a baseline protocol including coronary angiogram, CVD risk factor assessment, and questionnaire-based measures of depression and anxiety symptoms, using the Beck Depression Inventory (BDI) and State Trait Anxiety Inventory (STAI), respectively. Participants were followed for a median 5.9 years to track the prevalence of CVD events (stroke, myocardial infarction, heart failure, and CVD-related mortality). We tested the BDI × STAI interaction effect in addition to the BDI and STAI main effects. Results: Seventy-five women (15.3% of sample) experienced a CVD event, of which 18 were deaths attributed to cardiovascular causes. Results using Cox regression indicated a significant BDI × STAI interaction effect in the prediction of CVD events (p = .02) after covariate adjustment. Simple effect analyses indicated that depression scores were significant predictors of CVD events among women with low anxiety scores (hazard ratio [HR] = 2.3 [in standard deviation units]; 95% Confidence Interval [CI] = 1.3–3.9; p = .005) but not among women with higher levels of anxiety (HR = 0.99; 95% CI = 0.70–1.4; p = .95). Conclusion: Among women with suspected myocardial ischemia, the value of depression symptoms for predicting CVD events varied by the severity of comorbid anxiety. These results suggest that the clinical utility of depression measures may be improved by using them in combination with measures of anxiety. WISE = Womens Ischemia Syndrome Evaluation; CVD = cardiovascular disease; CAD = coronary artery disease; GAD = generalized anxiety disorder; CHF = congestive heart failure; MI = myocardial infarction; BDI = Beck Depression Inventory; STAI = State Trait Anxiety Inventory.

Gender differences in coronary artery disease.

Coronary artery disease in women is associated with higher morbidity and mortality than in men. The purpose of this article is to summarize recent literature concerning gender-based differences. Specific differences in pathophysiology, traditional and psychosocial risk factors, symptom presentation, treatments, and outcomes between women and men will be reviewed.

Self-rated versus objective health indicators as predictors of major cardiovascular events: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation.

Objective: To determine the association between self-rated health and major cardiovascular events in a sample of women with suspected myocardial ischemia. Previous studies showed that self-rated health is a predictor of objective health outcomes, such as mortality. Method: At baseline, 900 women rated their health on a 5-point scale ranging from poor to excellent as part of a protocol that included quantitative coronary angiography, cardiovascular disease (CVD) risk factor assessment, cardiac symptoms, psychotropic medication use, and functional impairment. Participants were followed for a maximum of 9 years (median, 5.9 years) to determine the prevalence of major CVD events (myocardial infarction, heart failure, stroke, and CVD-related death). Results: A total of 354 (39.3% of sample) participants reported their health as either poor or fair. After adjusting for demographic factors, CVD risk factors, and coronary artery disease severity, women who rated their health as poor (hazard ratio, 2.1 [1.1-4.2]) or fair (hazard ratio, 2.0 [1.2-3.6]) experienced significantly shorter times to major CVD events compared with women who rated their health as excellent or very good. Further adjustment for functional impairment, however, attenuated the self-rated health relationships with major CVD events. Conclusions: Among women with suspected myocardial ischemia, self-rated health predicted major CVD events independent of demographic factors, CVD risk factors, and angiogram-defined disease severity. However, functional impairment seemed to explain much of the self-rated health association. These results support the clinical utility of self-rated health scores in women and encourage a multidimensional approach to conceptualizing these measures. CAD = coronary artery disease; CVD = cardiovascular disease; DASI = Duke Activity Status Index; HR = hazard ratio; SES = socioeconomic status; WISE = Women’s Ischemia Syndrome Evaluation.

Quality of life, health status, and depression: comparison between adolescents and adults after the Fontan procedure with healthy counterparts.

Background:Quality of life (QOL) in adolescents and adults who have undergone the Fontan procedure and are living with only 1 ventricle is presumed to be diminished. Objectives:This study aimed to compare QOL, health status, and prevalence of depression in adolescents/adults after the Fontan procedure with healthy counterparts and to identify predictors of QOL in the Fontan group. Methods:Using a comparative, cross-sectional design, 54 adolescents and adults with single ventricle congenital heart disease who have undergone the Fontan procedure were compared with 66 age-matched healthy counterparts. Quality of life, health status, depression, and social support were measured using the Satisfaction With Life Scale, Short Form Survey Version 2, Patient Health Questionnaire Depression Module, and Multidimensional Scale of Perceived Social Support. Clinical variables were abstracted from medical records. Predictors of QOL were determined using multiple linear regression. Results:Adolescents and adults in the Fontan group reported lower physical health status (mean [SD] = 46.5 [9.3] vs mean [SD] = 55.9 [5.1], P < .001) and were more depressed (mean [SD] = 7.3 [5.9] vs mean [SD] = 4.5 [4.3], P < .004) than their healthy counterparts. There were no differences in QOL, mental health status, or social support between the 2 groups. Functional status (New York Heart Association class), depression, and social support accounted for 55% of the variance in QOL in the Fontan group. Conclusions:Despite lower levels of physical health, the QOL of Fontan patients was comparable with that of their healthy counterparts; this finding contradicts previous proxy reports, self-reports, and assumptions that QOL is lower in patients with complex single ventricle congenital heart disease. However, because Fontan patients were more depressed than their healthy counterparts, the need for early screening and detection is warranted.

Anginal symptoms, coronary artery disease, and adverse outcomes in Black and White women: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study.

BACKGROUND Black women are less likely to be evaluated and treated for anginal symptoms, despite a higher premature cardiac mortality rate compared to white women. Our objective was to compare angina symptoms in black versus white women regarding (1) angina symptoms characterization; (2) relationship with obstructive coronary artery disease (CAD); and (3) relationship with subsequent mortality. METHODS A cohort of 466 women (69 black and 397 white) undergoing coronary angiography for suspected ischemia and without prior history of CAD completed symptom checklists. Four symptom clusters (CHEST, UPPER, STOMACH, and TYPICAL TRIGGERS) were derived by factor analysis. All angiograms were analyzed by core lab. Mortality data over 10 years were obtained from National Death Index. RESULTS (1) Black women had lower mean CHEST cluster scores (0.60±0.30 vs. 0.73±30, p=0.002), but higher STOMACH scores (0.41±0.25 vs. 0.30±0.25, p=0.011) than white women. (2) Prevalence and severity of CAD did not differ in black and white women and was not predicted by symptom cluster scores. (3) All-cause mortality rates were 24.9% in blacks versus 14.5% in whites, p=0.007; and cardiovascular mortality 22.5% vs.8.8%, p=0.001. Symptom clusters were not predictive of adverse events in white women. However, black women with a low TYPICAL score had significantly higher mortality compared to those with a high TYPICAL score (43% vs. 10%, p=0.006). CONCLUSIONS Among women undergoing coronary angiography, black women report fewer chest-related and more stomach-related symptoms, regardless of presence or severity of CAD, and these racial symptom presentation differences are linked with the more adverse prognosis observed in the black women. Atypical symptom presentation may be a barrier to appropriate and timely diagnosis and treatment and contribute to poorer outcomes for black women.

Relationships between cardiovascular disease risk factors and depressive symptoms as predictors of cardiovascular disease events in women.

BACKGROUND Modifiable risk factors for cardiovascular disease (CVD) account for much of the variability in CVD outcomes and are also related to psychosocial variables. There is evidence that depression can undermine the treatment and advance the progression of CVD risk factors, suggesting that CVD risk factor relationships with CVD events may differ among those with depression. METHODS This study tracked CVD events and mortality over a median of 5.9 years among a prospective cohort of 620 women (mean age 59.6 years [11.6]) completing a diagnostic protocol including coronary angiography and CVD risk factor assessment. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). The study outcome was combined cardiovascular mortality and events. RESULTS Over the follow-up interval, 16.1% of the sample experienced one or more of the cardiovascular outcomes. In separate Cox regression models adjusting for age, education history, ethnicity, and coronary angiogram scores, we observed statistically significant CVD risk factor × BDI score interactions for diabetes, smoking, and waist-hip ratio factors. Simple effect analyses indicated that diabetes and smoking status were more strongly associated with cardiovascular outcomes among participants with lower BDI scores, whereas waist-hip ratio values predicted outcomes only among those with higher BDI scores. CONCLUSIONS These results suggest that the relationship between modifiable CVD risk factors and CVD outcomes may vary with depression status in clinical samples of women. This evidence augments prior research by demonstrating that depression may influence CVD risk jointly with or independent of CVD risk factors. It also provides further support for the inclusion of depression assessment in cardiovascular clinic settings.

Commonalities and differences in correlates of depressive symptoms in men and women with heart failure

Objective: (i) To compare the prevalence and severity of depressive symptoms between men and women enrolled in a large heart failure (HF) registry. (ii) To determine gender differences in predictors of depressive symptoms from demographic, behavioral, clinical, and psychosocial factors in HF patients. Methods: In 622 HF patients (70% male, 61 ± 13 years, 59% NYHA class III/IV), depressive symptoms were assessed by the Patient Health Questionnaire (PHQ-9). Potential correlates were age, ethnicity, education, marital and financial status, smoking, exercise, body mass index (BMI), HF etiology, NYHA class, comorbidities, functional capacity, anxiety, and perceived control. To identify gender-specific correlates of depressive symptoms, separate logistic regression models were built by gender. Results: Correlates of depressive symptoms in men were financial status (p = 0.027), NYHA (p = 0.001); functional capacity (p < 0.001); health perception (p = 0.043); perceived control (p = 0.002) and anxiety (p < 0.001). Correlates of depressive symptoms in women were BMI (p = 0.003); perceived control (p = 0.013) and anxiety (p < 0.001). Conclusions: In HF patients, lowering depressive symptoms may require gender-specific interventions focusing on weight management in women and improving perceived functional capacity in men. Both men and women with HF may benefit from anxiety reduction and increased control.

Combining psychosocial data to improve prediction of cardiovascular disease risk factors and events: The National Heart, Lung, and Blood Institute--sponsored Women's Ischemia Syndrome Evaluation study.

Background There is overlap among psychosocial predictors of cardiovascular disease (CVD). The usefulness of combining psychosocial variables as risk markers for CVD needs investigation. Methods Participants were 493 women in the NHLBI WISE study. Multivariate combination of Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Social Network Index (SNI), and Cook-Medley hostility subscales was evaluated, and principal components analysis also conducted. Relationships of composite psychosocial risk markers to CVD events and risk factors were assessed. Results The multivariate block of SNI, Cook-Medley Hostile Affect subscale, STAI, and BDI predicted CVD events (&khgr;2 = 27.8, df = 6, p < .001). Scalewise factor analysis revealed 2 factors: negative affectivity (NA) and hostility (explained variance, 45.6% and 17.1%, respectively). NA was associated with BMI (&bgr; [SE] = 0.18 [0.09], p = .04), hostility with metabolic syndrome (exp(&bgr;) = 0.60 [0.28], p = .04). Both factors were associated with blood pressure (BP): NA with SBP (&bgr; = 2.53 [1.04], p = .02) and DBP (&bgr; = 1.66 [0.60], p = .02); hostility with SBP (&bgr; = 2.72 [1.13], p = .02) and DBP (&bgr; = 1.83 [0.65], p = .005). Neither factor predicted CVD events. Original scales predicted CVD events: lower SNI (HR = 0.74, CI = 0.57–0.96), lower Hostile Affect (HR = 0.80, CI = 0.56–1.03), and higher BDI (HR = 1.33, CI = 1.08–1.74). Conclusions In women with suspected ischemia, multivariate combination of psychosocial risk markers predicts CVD events; derived psychosocial factors were associated with CVD risk factors but not events. Measuring common variance among psychosocial variables may be a useful research strategy. Abbreviations CVD = cardiovascular disease; BMI = body mass index; MI = myocardial infarction; CAD = coronary artery disease; CV = cardiovascular; WISE = The Women’s Ischemia Syndrome Evaluation; PCA = principal components analysis; STAI = State-Trait Anxiety Inventory; BDI = Beck Depression Inventory; NA = negative affectivity; CM = Cook-Medley; NHLBI = The National Heart, Lung, and Blood Institute; IHD = ischemic heart disease; BP = blood pressure; SBP = systolic blood pressure; DBP = diastolic blood pressure; SE = standard error; CI = confidence interval

Battery optimization in smartphones for remote health monitoring systems to enhance user adherence

Remote health monitoring (RHM) can help save the cost burden of unhealthy lifestyles. Of increased popularity is the use of smartphones to collect data, measure physical activity, and provide coaching and feedback to users. One challenge with this method is to improve adherence to prescribed medical regimens. In this paper we present a new battery optimization method that increases the battery lifetime of smartphones which monitor physical activity. We designed a system, WANDA-CVD, to test our battery optimization method. The focus of this report describes our in-lab pilot study and a study aimed at reducing cardiovascular disease (CVD) in young women, the Womens Heart Health study. Conclusively, our battery optimization technique improved battery lifetime by 300%. This method also increased participant adherence to the remote health monitoring system in the Womens Heart Health study by 53%.

Anxiety associations with cardiac symptoms, angiographic disease severity, and healthcare utilization: The NHLBI-sponsored Women's Ischemia Syndrome Evaluation

BACKGROUND Anxiety is common among patients presenting with suspected coronary artery disease (CAD). In a sample of women with signs and symptoms of ischemia, we examined three anxiety markers as predictors of CAD endpoints including: 1) cardiac symptom indicators; 2) angiographic CAD severity; and 3) healthcare utilization (cardiac hospitalizations and 5-year cardiovascular [CVD] healthcare costs). METHODS Participants completed a baseline protocol including coronary angiogram, cardiac symptoms, psychosocial measures and a median 5.9-year follow-up to track hospitalizations. We calculated CVD costs based on cardiac hospitalizations, treatment visits, and CVD medications. Anxiety measures included anxiolytic medication use, Spielberger Trait Anxiety Inventory (STAI) scores, and anxiety disorder treatment history. RESULTS The sample numbered 514 women with anxiety measure data and covariates (mean age=57.5 [11.1]). One in five (20.4%) women reported using anxiolytic agents. Anxiety correlated with cardiac symptom indicators (anxiolytic use with nighttime angina and nitroglycerine use; STAI scores and anxiety disorder treatment history with nighttime angina, shortness of breath, and angina frequency). Anxiety disorder treatment history (but not STAI scores or anxiolytics) predicted less severe CAD. Anxiolytic use (but not STAI scores or anxiety disorder treatment history) predicted hospitalizations for chest pain and coronary catheterization (HRs=2.0, 95% CIs=1.1-4.7). Anxiety measures predicted higher 5-year CVD costs (+9.0-42.7%) irrespective of CAD severity. CONCLUSIONS Among women with signs and symptoms of myocardial ischemia, anxiety measures predict cardiac endpoints ranging from cardiac symptom severity to healthcare utilization. Based on these findings, anxiety may warrant greater consideration among women with suspected CAD.