John Wallert

Young adulthood cognitive ability predicts statin adherence in middle-aged men after first myocardial infarction: A Swedish National Registry study:

Background Cognitive ability (CA) is positively related to later health, health literacy, health behaviours and longevity. Accordingly, a lower CA is expected to be associated with poorer adherence to medication. We investigated the long-term role of CA in adherence to prescribed statins in male patients after a first myocardial infarction (MI). Methods CA was estimated at 18–20 years of age from Military Conscript Register data for first MI male patients (≤60 years) and was related to the one- and two-year post-MI statin adherence on average 30 years later. Background and clinical data were retrieved through register linkage with the unselected national quality register SWEDEHEART for acute coronary events (Register of Information and Knowledge about Swedish Heart Intensive Care Admissions) and secondary prevention (Secondary Prevention after Heart Intensive Care Admission). Previous and present statin prescription data were obtained from the Prescribed Drug Register and adherence was calculated as ≥80% of prescribed dispensations assuming standard dosage. Logistic regression was used to estimate crude and adjusted associations. The primary analyses used 2613 complete cases and imputing incomplete cases rendered a sample of 4061 cases for use in secondary (replicated) analyses. Results One standard deviation increase in CA was positively associated with both one-year (OR 1.15 (CI 1.01–1.31), P < 0.05) and two-year (OR 1.14 (CI 1.02–1.27), P < 0.05) adherence to prescribed statins. Only smoking attenuated the CA–adherence association after adjustment for a range of > 20 covariates. Imputed and complete case analyses yielded very similar results. Conclusions CA estimated on average 30 years earlier in young adulthood is a risk indicator for statin adherence in first MI male patients aged ≤60 years. Future research should include older and female patients and more socioeconomic variables.

Internet-Based Cognitive Behavioral Therapy for Symptoms of Depression and Anxiety Among Patients With a Recent Myocardial Infarction: The U-CARE Heart Randomized Controlled Trial

Background Symptoms of depression and anxiety are common after a myocardial infarction (MI). Internet-based cognitive behavioral therapy (iCBT) has shown good results in other patient groups. Objective The aim of this study was to evaluate the effectiveness of an iCBT treatment to reduce self-reported symptoms of depression and anxiety among patients with a recent MI. Methods In total, 3928 patients were screened for eligibility in 25 Swedish hospitals. Of these, 239 patients (33.5%, 80/239 women, mean age 60 years) with a recent MI and symptoms of depression or anxiety were randomly allocated to a therapist-guided, 14-week iCBT treatment (n=117), or treatment as usual (TAU; n=122). The iCBT treatment was designed for post-MI patients. The primary outcome was the total score of the Hospital Anxiety and Depression Scale (HADS) 14 weeks post baseline, assessed over the internet. Treatment effect was evaluated according to the intention-to-treat principle, with multiple imputations. For the main analysis, a pooled treatment effect was estimated, controlling for age, sex, and baseline HADS. Results There was a reduction in HADS scores over time in the total study sample (mean delta=−5.1, P<.001) but no difference between the study groups at follow-up (beta=−0.47, 95% CI −1.95 to 1.00, P=.53). Treatment adherence was low. A total of 46.2% (54/117) of the iCBT group did not complete the introductory module. Conclusions iCBT treatment for an MI population did not result in lower levels of symptoms of depression or anxiety compared with TAU. Low treatment adherence might have influenced the result. Trial Registration ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22)

Factors associated with emotional distress in patients with myocardial infarction: Results from the SWEDEHEART registry.

Background Emotional distress, symptoms of depression and anxiety, is common among patients after a myocardial infarction (MI), and is associated with an increased risk of cardiovascular morbidity. Real world population data on factors associated with emotional distress in MI patients are scarce. The aim was to determine factors associated with incident emotional distress two and 12 months post MI respectively, and with persistent emotional distress, versus remittent, in patients <75 years old. Design This was a registry-based observational study. Methods Data from the national SWEDEHEART registry on 27,267 consecutive patients with a first-time MI, followed up at two and 12 months post MI (n = 22,911), were included in the analyses. Emotional distress was assessed with the EuroQol-5D questionnaire. Several candidate sociodemographic and clinical factors were analysed for their association with emotional distress in multivariate models. Results Symptoms of emotional distress were prevalent in 38% and 33% at two and 12 months post MI respectively. At both time-points, previous depression and/or anxiety, readmission for new cardiovascular event, female gender, younger age, born outside the neighbouring Nordic countries, smoking and being neither employed nor retired showed the strongest associations with emotional distress. Other factors related to medical history, the MI and its care or were only modestly associated with emotional distress. Persistent emotional distress was associated with younger age, female gender, smoking and being born outside of the Nordic countries. Conclusion Previous depression/anxiety, female gender, younger age, smoking, born outside of the Nordic countries, neither employed nor retired and readmission due to cardiovascular events were strongly associated with emotional distress post MI. These factors may be of relevance in tailoring rehabilitation programmes.

Emotional distress as a predictor of statin non-adherence among Swedish first-time myocardial infarction patients, 2006–2013

BACKGROUND Emotional distress (depression and anxiety) has been known to affect mortality after a myocardial infarction (MI). One possible mechanism is through medication non-adherence. Few studies have investigated the link between statin adherence and emotional distress, and results are not consistent. We aimed to explore whether emotional distress affects adherence among first-time MI patients younger than 75years old receiving a prescription for the first time. METHODS We identified first-MI individuals younger than 75years from the SWEDEHEART national quality registers discharged with a statin prescription. The main exposure was the anxiety/depression portion of the EQ-5D from Interview 1 (6-10weeks post-MI) and Interview 2 (12-14months post-MI). We calculated adherence from the Swedish Prescribed Drugs Register during three observation periods (OP): [1] Interview 1 to Interview 2, [2] one year post Interview 2, and [3] two years post Interview 1. RESULTS Emotional distress at Interview 1 was not associated with statin adherence for OP1 (RR: 0.99, 95% CI: 0.98, 1.01). Emotional distress at Interview 2 was associated with lower adherence one year later (RR: 0.95, 95% CI: 0.93, 0.98). Emotional distress at Interview 1 was associated with a small decrease in adherence in the complete OP for adherence (RR: 0.98, 95% CI: 0.96, 0.99). CONCLUSION Emotional distress was marginally, but independently, associated with lower adherence to statin two years after the MI. Our study suggests that emotional distress may be an important factor for long-term statin adherence, and, thus, may play a clinically important role in long-term outcome.

Cognitive ability, lifestyle risk factors, and two-year survival in first myocardial infarction men : A Swedish National Registry study

BACKGROUND General cognitive ability (CA) is positively associated with later physical and mental health, health literacy, and longevity. We investigated whether CA estimated approximately 30years earlier in young adulthood predicted lifestyle-related risk factors and two-year survival in first myocardial infarction (MI) male patients. METHODS Young adulthood CA estimated through psychometric testing at age 18-20years was obtained from the mandatory military conscript registry (INSARK) and linked to national quality registry SWEDEHEART/RIKS-HIA data on smoking, diabetes, hypertension, obesity (BMI>30kg/m2) in 60years or younger Swedish males with first MI. Patients were followed up in the Cause of Death registry. The 5659 complete cases (deceased=106, still alive=5553) were descriptively compared. Crude and adjusted associations were modelled with logistic regression. RESULTS After multivariable adjustment, one SD increase in CA was associated with a decreased odds ratio of being a current smoker (0.63 [0.59, 0.67], P<0.001), previous smoker (0.79 [0.73, 0.84], P<0.001), having diabetes (0.82 [0.74, 0.90], P<0.001), being obese (0.90 [0.84, 0.95], P<0.001) at hospital admission, and an increased odds ratio of two-year survival (1.26 [1.02, 1.54], P<0.001). CA was not associated with hypertension at hospital admission (1.03 [0.97, 1.10], P=0.283). CONCLUSIONS This study found substantial inverse associations between young adulthood CA, and middle-age lifestyle risk factors smoking, diabetes, and obesity, and two-year survival in first MI male patients. CA assessment might benefit risk stratification and possibly aid further tailoring of secondary preventive strategy.

Temporal changes in myocardial infarction incidence rates are associated with periods of perceived psychosocial stress : A SWEDEHEART national registry study

Background Psychosocial stress might trigger myocardial infarction (MI). Increased MI incidence coincides with recurrent time periods during the year perceived as particularly stressful in the population. Methods A stress‐triggering hypothesis on the risk of MI onset was investigated with Swedish population data on MI hospital admission date and symptom onset date (N = 156,690; 148,176) as registered from 2006 through 2013 in the national quality registry database Swedish Web‐system for Enhancement and Development of Evidence‐based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART). Poisson regression was applied to analyze daily MI rates during days belonging to the Christmas and New Year holidays, turns of the month, Mondays, weekends, and summer vacation in July compared with remaining control days. Results Adjusted incidence rate ratios (IRRs) for MI rates were higher during Christmas and New Year holidays (IRR = 1.07 [1.04–1.09], P < .001) and on Mondays (IRR = 1.11 [1.09–1.13], P < .001) and lower in July (IRR = 0.92 [0.90–0.94], P < .001) and over weekends (IRR = 0.88 [0.87–0.89], P < .001), yet not during the turns of the month (IRR = 1.01 [1.00–1.02], P = .891). These findings were also predominantly robust with symptom onset as alternative outcome, when adjusting for both established and some suggested‐but‐untested confounders, and in 8 subgroups. Conclusions Fluctuations in daily MI incidence rates are systematically related to time periods of presumed psychosocial stress. Further research might clarify mechanisms that are amenable to clinical alteration.

Feminist activist women are masculinized in terms of digit-ratio and social dominance: a possible explanation for the feminist paradox

The feminist movement purports to improve conditions for women, and yet only a minority of women in modern societies self-identify as feminists. This is known as the feminist paradox. It has been suggested that feminists exhibit both physiological and psychological characteristics associated with heightened masculinization, which may predispose women for heightened competitiveness, sex-atypical behaviors, and belief in the interchangeability of sex roles. If feminist activists, i.e., those that manufacture the public image of feminism, are indeed masculinized relative to women in general, this might explain why the views and preferences of these two groups are at variance with each other. We measured the 2D:4D digit ratios (collected from both hands) and a personality trait known as dominance (measured with the Directiveness scale) in a sample of women attending a feminist conference. The sample exhibited significantly more masculine 2D:4D and higher dominance ratings than comparison samples representative of women in general, and these variables were furthermore positively correlated for both hands. The feminist paradox might thus to some extent be explained by biological differences between women in general and the activist women who formulate the feminist agenda.

Recovery after aerobic exercise is manipulated by tempo change in a rhythmic sound pattern, as indicated by autonomic reaction on heart functioning.

Physical prowess is associated with rapid recovery from exhaustion. Here we examined whether recovery from aerobic exercise could be manipulated with a rhythmic sound pattern that either decreased or increased in tempo. Six men and six women exercised repeatedly for six minutes on a cycle ergometer at 60 percent of their individual maximal oxygen consumption, and then relaxed for six minutes while listening to one of two sound pattern conditions, which seemed to infinitely either decrease or increase in tempo, during which heart and breathing activity was measured. Participants exhibited more high-frequent heart rate variability when listening to decreasing tempo than when listening to increasing tempo, accompanied by a non-significant trend towards lower heart rate. The results show that neuropsychological entrainment to a sound pattern may directly affect the autonomic nervous system, which in turn may facilitate physiological recovery after exercise. Applications using rhythmic entrainment to aid physical recovery are discussed.

Predicting Adherence to Internet-Delivered Psychotherapy for Symptoms of Depression and Anxiety After Myocardial Infarction: Machine Learning Insights From the U-CARE Heart Randomized Controlled Trial

Background Low adherence to recommended treatments is a multifactorial problem for patients in rehabilitation after myocardial infarction (MI). In a nationwide trial of internet-delivered cognitive behavior therapy (iCBT) for the high-risk subgroup of patients with MI also reporting symptoms of anxiety, depression, or both (MI-ANXDEP), adherence was low. Since low adherence to psychotherapy leads to a waste of therapeutic resources and risky treatment abortion in MI-ANXDEP patients, identifying early predictors for adherence is potentially valuable for effective targeted care. Objectives The goal of the research was to use supervised machine learning to investigate both established and novel predictors for iCBT adherence in MI-ANXDEP patients. Methods Data were from 90 MI-ANXDEP patients recruited from 25 hospitals in Sweden and randomized to treatment in the iCBT trial Uppsala University Psychosocial Care Programme (U-CARE) Heart study. Time point of prediction was at completion of the first homework assignment. Adherence was defined as having completed more than 2 homework assignments within the 14-week treatment period. A supervised machine learning procedure was applied to identify the most potent predictors for adherence available at the first treatment session from a range of demographic, clinical, psychometric, and linguistic predictors. The internal binary classifier was a random forest model within a 3×10–fold cross-validated recursive feature elimination (RFE) resampling which selected the final predictor subset that best differentiated adherers versus nonadherers. Results Patient mean age was 58.4 years (SD 9.4), 62% (56/90) were men, and 48% (43/90) were adherent. Out of the 34 potential predictors for adherence, RFE selected an optimal subset of 56% (19/34; Accuracy 0.64, 95% CI 0.61-0.68, P<.001). The strongest predictors for adherence were, in order of importance, (1) self-assessed cardiac-related fear, (2) sex, and (3) the number of words the patient used to answer the first homework assignment. Conclusions For developing and testing effective iCBT interventions, investigating factors that predict adherence is important. Adherence to iCBT for MI-ANXDEP patients in the U-CARE Heart trial was best predicted by cardiac-related fear and sex, consistent with previous research, but also by novel linguistic predictors from written patient behavior which conceivably indicate verbal ability or therapeutic alliance. Future research should investigate potential causal mechanisms and seek to determine what underlying constructs the linguistic predictors tap into. Whether these findings replicate for other interventions outside of Sweden, in larger samples, and for patients with other conditions who are offered iCBT should also be investigated. Trial registration ClinicalTrials.gov NCT01504191; https://clinicaltrials.gov/ct2/show/NCT01504191 (Archived at Webcite at http://www.webcitation.org/6xWWSEQ22)

Differentiating Patients at the Memory Clinic With Simple Reaction Time Variables: A Predictive Modeling Approach Using Support Vector Machines and Bayesian Optimization

Background: Mild Cognitive Impairment (MCI) and dementia differ in important ways yet share a future of increased prevalence. Separating these conditions from each other, and from Subjective Cognitive Impairment (SCI), is important for clinical prognoses and treatment, socio-legal interventions, and family adjustments. With costly clinical investigations and an aging population comes a need for more cost-efficient differential diagnostics. Methods: Using supervised machine learning, we investigated nine variables extracted from simple reaction time (SRT) data with respect to their single and conjoined ability to discriminate both MCI/dementia, and SCI/MCI/dementia, compared to—and together with—established psychometric tests. One-hundred-twenty elderly patients (age range = 65–95 years) were recruited when referred to full neuropsychological assessment at a specialized memory clinic in urban Sweden. A freely available SRT task served as index test and was administered and scored objectively by a computer before diagnosis of SCI (n = 17), MCI (n = 53), or dementia (n = 50). As reference standard, diagnosis was decided through the multidisciplinary memory clinic investigation. Bonferroni-Holm corrected P-values for constructed models against the null model are provided. Results: Algorithmic feature selection for the two final multivariable models was performed through recursive feature elimination with 3 × 10-fold cross-validation resampling. For both models, this procedure selected seven predictors of which five were SRT variables. When used as input for a soft-margin, radial-basis support vector machine model tuned via Bayesian optimization, the leave-one-out cross-validated accuracy of the final model for MCI/dementia classification was good (Accuracy = 0.806 [0.716, INS [0].877], P < 0.001) and the final model for SCI/MCI/dementia classification held some merit (Accuracy = 0.650 [0.558, 0.735], P < 0.001). These two models are implemented in a freely available application for research and educatory use. Conclusions: Simple reaction time variables hold some potential in conjunction with established psychometric tests for differentiating MCI/dementia, and SCI/MCI/dementia in these difficult-to-differentiate memory clinic patients. While external validation is needed, their implementation within diagnostic support systems is promising.