Robert P. Nolan

Depression and anxiety in adult congenital heart disease: Predictors and prevalence

BACKGROUND Adult congenital heart disease (ACHD) patients face unique medical and social challenges that may contribute to psychological difficulties. The goals of this study were to identify predictors of symptoms of depression and anxiety and evaluate the prevalence of mood and anxiety disorders among North American ACHD patients. METHODS In this cross-sectional study, consecutive patients were recruited from two ACHD outpatient clinics. All patients completed self-report psychosocial measures and a subset was randomly selected to participate in structured clinical interviews. Linear regression models were used to predict symptoms of depression and anxiety. RESULTS A total of 280 patients (mean age=32 years; 52% female) completed self-report measures. Sixty percent had defects of moderate complexity and 31% had defects of great complexity. Significant predictors of depressive symptoms were loneliness (p<0.001), perceived health status (p<0.001), and fear of negative evaluation (p=0.02). Predictors of anxiety symptoms were loneliness (p<0.001) and fear of negative evaluation (p<0.001). Disease severity and functional class did not predict mood or anxiety symptoms. Fifty percent of interviewed patients (29/58) met diagnostic criteria for at least one lifetime mood or anxiety disorder, of whom 39% had never received any mental health treatment. CONCLUSIONS The results confirm an increased risk and under-treatment of mood and anxiety disorders in ACHD patients. Social adjustment and patient-perceived health status were more predictive of depression and anxiety than medical variables. These factors are modifiable and therefore a potential focus of intervention.

Effects of drug, biobehavioral and exercise therapies on heart rate variability in coronary artery disease: a systematic review

Background Heart rate variability (HRV) is reported as a surrogate index for clinical outcome in trials of secondary prevention strategies for coronary artery disease (CAD), but a standardized guide for interpreting HRV change is not established. Design We evaluated HRV change in trials with CAD patients who received conventional medications (β-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors), biobehavioral treatment (psychotropics, biofeedback, relaxation) or exercise training. Methods Medline, Pubmed, Psycinfo, the Cochrane database, and Embase were searched until July 2007, without language restriction. We identified 33 randomized controlled trials. Two reviewers independently abstracted all trials using a standardized form. A hierarchy of frequency and time domain HRV indices defined outcome. Results A random-effects model yielded an overall pooled standardized mean difference (SMD) between treatment and control groups of moderate magnitude across treatment classes, based on a composite of time and frequency domain indices (SMD = 0.40, P < 0.0001), or only time or frequency indices (SMD = 0.37 and 0.43, respectively, both P < 0.0001). This change was equivalent to an increase in standard deviation of all normal-to-normal RR intervals of 9.0 ms (95% Confidence Interval, CI, 7.3, 10.7 ms) or a relative increase of 15.9% (95% CI, 13.2, 18.6%). To detect HRV change of this magnitude, a hypothetical trial would require a sample size of 660 patients for conventional medications or 1232 patients for all treatment classes. Conclusion Pharmacologic, biobehavioral and exercise strategies for secondary prevention of CAD significantly increase HRV. This review provides a framework to assist efforts to evaluate the contribution of HRV change to CAD prognosis. Eur J Cardiovasc Prev Rehabil 15:386-396

Prevalence of, and barriers to, preventive lifestyle behaviors in hypertension (from a national survey of Canadians with hypertension).

Patients with hypertension are advised to lower their blood pressure to <140/90 mm Hg through sustained lifestyle modification and/or pharmacotherapy. To describe the use of lifestyle changes for blood pressure control and to identify the barriers to these behaviors, the data from 6,142 Canadians with hypertension who responded to the 2009 Survey on Living With Chronic Diseases in Canada were analyzed. Most Canadians with diagnosed hypertension reported limiting salt consumption (89%), having changed the types of food they eat (89%), engaging in physical activity (80%), trying to control or lose weight if overweight (77%), quitting smoking if currently smoking (78%), and reducing alcohol intake if currently drinking more than the recommended levels (57%) at least some of the time to control their blood pressure. Men, those aged 20 to 44 years, and those with lower educational attainment and lower income were, in general, less likely to report engaging in lifestyle behaviors for blood pressure control. A low desire, interest, or awareness were commonly reported barriers to salt restriction, changes in diet, weight loss, smoking cessation, and alcohol reduction. In contrast, the most common barrier to engaging in physical activity to regulate blood pressure was the self-reported challenge of managing a coexisting physical condition or time constraints. In conclusion, programs and interventions to improve the adherence to lifestyle changes to treat hypertension may need to consider the identified barriers to lifestyle behaviors in their design.

Behavioral Neurocardiac Training in Hypertension A Randomized, Controlled Trial

It is not established whether behavioral interventions add benefit to pharmacological therapy for hypertension. We hypothesized that behavioral neurocardiac training (BNT) with heart rate variability biofeedback would reduce blood pressure further by modifying vagal heart rate modulation during reactivity and recovery from standardized cognitive tasks (“mental stress”). This randomized, controlled trial enrolled 65 patients with uncomplicated hypertension to BNT or active control (autogenic relaxation), with six 1-hour sessions over 2 months with home practice. Outcomes were analyzed with linear mixed models that adjusted for antihypertensive drugs. BNT reduced daytime and 24-hour systolic blood pressures (−2.4±0.9 mm Hg, P=0.009, and −2.1±0.9 mm Hg, P=0.03, respectively) and pulse pressures (−1.7±0.6 mm Hg, P=0.004, and −1.4±0.6 mm Hg, P=0.02, respectively). No effect was observed for controls (P>0.10 for all indices). BNT also increased RR-high-frequency power (0.15 to 0.40 Hz; P=0.01) and RR interval (P<0.001) during cognitive tasks. Among controls, high-frequency power was unchanged (P=0.29), and RR interval decreased (P=0.03). Neither intervention altered spontaneous baroreflex sensitivity (P>0.10). In contrast to relaxation therapy, BNT with heart rate variability biofeedback modestly lowers ambulatory blood pressure during wakefulness, and it augments tonic vagal heart rate modulation. It is unknown whether efficacy of this treatment can be improved with biofeedback of baroreflex gain. BNT, alone or as an adjunct to drug therapy, may represent a promising new intervention for hypertension.

Physical Activity Behavior, Motivational Readiness and Self-Efficacy among Ontarians with Cardiovascular Disease and Diabetes

This cross-sectional study examined physical activity and its correlates among 355 diabetes, 144 cardiovascular disease, 75 diabetes and cardiovascular disease, and 390 residents with cardiovascular risk factors. Community residents (N=2566) were screened by telephone, and 964 participants completed a self-report survey. Non-diabetes participants participated in a greater range of physical activities (p<.001), more frequently (p=.013). Diabetes participants had lower physical activity readiness and efficacy (ps<.009). In a regression model (p<.001), region and disease, work, marital and smoking status were significant correlates of physical activity frequency. Interventions which increase motivational readiness and efficacy among diabetics are required to prevent and delay complications, particularly in regions with environmental barriers such as cold weather and homogeneous, low-density land use.

Biobehavioral factors in the context of ischemic cardiovascular diseases

OBJECTIVE We set out to examine the development of current thinking on the relationship between behavioral factors and ischemic heart disease, with the latter being viewed as an epidemic. METHODS The present work is a nonsystematic review of the subject. RESULTS Atherogenic components of the coronary-prone or type A behavior pattern (TABP), including hostility, cynicism, and suppression of anger, as well as stress reactivity, depression, and social isolation, are emerging as particularly significant behavioral characteristics, although their pathophysiology is not yet fully understood. Effective patient management, particularly for lifestyle modification, requires an appreciation of an individuals stage in their readiness to change. CONCLUSION The control and prevention of cardiovascular diseases depend on a multidisciplinary approach that recognizes the importance and intricacies of lifestyle behaviors.

Therapeutic benefit of preventive telehealth counseling in the Community Outreach Heart Health and Risk Reduction Trial.

We evaluated whether telehealth counseling augments lifestyle change and risk factor decrease in subjects at high risk for primary or secondary cardiovascular events compared to a recommended guideline for brief preventive counseling. Subjects at high risk or with coronary heart disease (35 to 74 years of age, n = 680) were randomized to active control (risk factor feedback, brief advice, handouts) or telehealth lifestyle counseling (active control plus 6 weekly 1-hour teleconferenced sessions to groups of 4 to 8 subjects). Primary outcome was questionnaire assessment of adherence to daily exercise/physical activity and diet (daily vegetable and fruit intake and restriction of fat and salt) after treatment and at 6-month follow-up. Secondary outcomes were systolic and diastolic blood pressures, ratio of total to high-density lipoprotein cholesterol, and 10-year absolute risk for coronary disease. After treatment and at 6-month follow-up, adherence increased for telehealth versus control in exercise (29.3% and 18.4% vs 2.5% and 9.3%, respectively, odds ratio 1.60, 95% confidence interval 1.2 to 2.1) and diet (37.1% and 38.1% vs 16.7% and 33.3%, respectively, odds ratio 1.41, 95% confidence interval 1.1 to 1.9). Telehealth versus control had greater 6-month decreases in blood pressure (mean ± SE, systolic -4.8 ± 0.8 vs -2.8 ± 0.9 mm Hg, p = 0.04; diastolic -2.7 ± 0.5 vs -1.5 ± 0.6 mm Hg, p = 0.04). Decreases in cholesterol ratio and 10-year absolute risk were significant for the 2 groups. In conclusion, telehealth counseling augments therapeutic lifestyle change in subjects at high risk for cardiovascular events compared to a recommended guideline for brief preventive counseling.

Sex-based differences in the association between duration of type 2 diabetes and heart rate variability

We examined the association between heart rate variability (HRV) and duration of type 2 diabetes among 155 female and 106 male subjects: mean±SD for duration=49.6±65.6 and 57.3±77.1 months, respectively, p=0.38. Among males, duration of diabetes was independently and inversely associated with vagal-heart rate modulation (high frequency (HF) power, 0.15—0.40 Hz, standardised ß = -0.32, p=0.001; root mean square of successive differences between R-R intervals, ß = -0.26, p=0.006) and total R-R variability (standard deviation of normal R-R intervals, ß = -0.36, p=0.001); but not among females (p≥0.80 for each HRV index). In contrast, HF was inversely associated with age of diabetes diagnosis (ß = -0.16, p=0.04) and 10-year absolute risk for coronary heart disease (ß = -0.16, p=0.04) among female subjects. Longitudinal research is needed to establish whether risk factors for early cardiac autonomic impairment differ among men and women with type 2 diabetes.

Assessing adaptive and maladaptive coping in the early phase of acute myocardial infarction

We assessed retrospectively symptom management behaviors among 45 patients with acute myocardial infarction (AMI). Cluster analysis was conducted on data from the Structured Interview (SI), in order to group patients according to the global TABP, Anger-In, Potential for Hostility, and a newly derived measure of Behavioral Compensation for Stress (BEH-COMP). Two groups were identified. MALADAPT SI-copers (N=24) had higher scores on Anger-In and Hostility and lower scores on BEH-COMP in comparison to the ADAPT SI-copers (N=21), while no difference was observed on TABP. The SI groups were next compared on AMI symptom management behaviors. A hierarchical discriminant analysis found that the MALADAPT group reported greater distraction from AMI symptoms, more relief-seeking behavior, and greater perceived vulnerability to reinfarction. AMI coping behaviors correlated meaningfully with delay in seeking medical assistance. Further research is warranted, given the potential for using the ADAPT/MALADAPT SI-profiles to predict adjustment to AMI.

Autonomic response to standardized stress predicts subsequent disease activity in ulcerative colitis.

Objectives Prospective studies of the role of psychological stress in ulcerative colitis are inconsistent or show a modest relationship. We tested the hypothesis that individual differences in autonomic function are associated with differences in the disease course of ulcerative colitis. Methods The spectral power of heart rate variability, an indirect marker of autonomic function, was measured during a standardized stress protocol in 93 ulcerative colitis patients. Patients were categorized as typical or atypical by an increase or decrease, respectively, in the high frequency band of heart rate variability from a period of acute stress to recovery 5 min later. Disease activity was measured at baseline (time 1) and a second time point (time 2) 7–37 months later. Results An atypical pattern of heart rate variability at time 1, present in 29% of patients, was associated with lower mean disease activity at time 2 (atypical, 0.56±0.93; typical, 2.27±2.56, P=0.001). The contribution of heart rate variability pattern to explaining time 2 disease activity was independent of the contributions of other factors that differed between groups, including time 1 disease activity and lifetime corticosteroid use. Discussion An atypical pattern of autonomic reactivity may be a marker of individual differences in stress regulation that has prognostic significance in ulcerative colitis.