Stefano Urbinati

Psychological Assessment in Cardiac Rehabilitation

Background: While there has been an upsurge of interest in the psychiatric correlates of myocardial infarction, little is known about the presence of psychological distress in the setting of cardiac rehabilitation. Methods: A consecutive series of 61 patients with recent myocardial infarction who participated in a cardiac rehabilitation program was evaluated by means of both observer-rated (DSM and DCPR) and self-rated (Psychosocial Index) methods. A follow-up of this patient population was undertaken (median = 2 years). Survival analysis was used to characterize the clinical course of patients. Results: Twenty percent of patients had a DSM-IV diagnosis (in half of the cases minor depression). An additional 30% of patients presented with a DCPR cluster, such as type A behavior and irritable mood. Only high levels of self-perceived stressful life circumstances and psychological distress approached statistical significance as a psychological risk factor for cardiovascular events after myocardial infarction. Conclusions: Psychological evaluation of patients undergoing cardiac rehabilitation needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Type A behavior was present in about a quarter of patients and can be studied in specific subgroups of cardiovascular patients defined by DCPR.

Frequency and prognostic significance of silent coronary artery disease in patients with cerebral ischemia undergoing carotid endarterectomy

To evaluate the prevalence and prognostic role of silent coronary artery disease (CAD) in patients with symptomatic high-grade carotid stenosis (70 to 99%) undergoing carotid endarterectomy, and with neither history nor symptoms of CAD, 106 patients (76 men, 30 women, mean age 58.7 years [range 42 to 71]) with recent cerebral ischemia were prospectively studied. Patients were stratified as to the presence (n = 27, 25%) or absence (n = 79, 75%) of silent CAD defined by concordant abnormal exercise electrocardiographic testing and thallium-201 myocardial scintigraphy. The male sex, the severity of the symptomatic carotid lesion (greater than 90%), and the coexistence of contralateral carotid disease identified patients with higher probability of coexisting CAD. The 106 patients underwent 121 operations (bilateral in 15). In the perioperative period, no deaths or cardiac events occurred, 1 patient suffered a recurrent stroke and 3 had a transient ischemic attack. During a mean follow-up period of 5.4 years, 9 patients died (1.7%/year): fatal myocardial infarction occurred in 5 (all in the silent CAD group), cancer in 3 and vertebrobasilar stroke in 1. Nonfatal events occurred in 9 patients: myocardial infarction in 1 (without silent CAD), unstable angina in 3 (with silent CAD), and cerebral ischemic attacks in 5. After 7 years, the Kaplan-Meier estimated survival free from coronary events was 51% in patients with silent CAD, and 98% in patients without CAD (p less than 0.01). In conclusion, among patients with symptomatic high-grade carotid stenosis undergoing carotid endarterectomy, even in absence of history or symptoms of CAD, a silent CAD is detectable in one fourth of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive Screening for Silent Ischemic Heart Disease in Patients with Cerebral Ischemia: Use of Dipyridamole-Thallium Myocardial Imaging

To evaluate the incidence of silent ischemic heart disease in cerebrovascular patients unable to exercise, we performed intravenous dipyridamole-thallium myocardial imaging in 38 consecutive patients

New Echocardiographic Markers of Embolic Risk in Atrial Fibrillation

Atrial fibrillation (AF) carries a high risk of systemic embolism, in particular stroke. This is true not only when AF is associated with rheumatic valvular heart disease, but also in the so-called no

Role and Indication of Two-Dimensional Echocardiography in Young Adults with Cerebral Ischemia: A Prospective Study in 125 Patients

We prospectively evaluated 125 patients with cerebral ischemia aged less than 45 years with cerebral angiography, CT and cardiac tests including two-dimensional echocardiography. Cardiac abnormalities were disclosed in 36 patients (33.6%). Potential sources of embolism were detected in 17 patients (15.8%); in 13 of them the cardiac lesion had previously been unrecognized. Mitral valve prolapse was the commonest cardiac lesion (6.5%). In 5 of these patients carotid atherosclerotic lesions were absent, and associated prothrom-botic factors were always present. In the remaining 2 cases dysplasia and/or dissection of carotid arteries were disclosed. Six patients showed an idiopathic aortic dilation; in 4 of them dysplasia or dissection of carotid arteries was observed. The idiopathic pattern of aortic root dilation (dilation limited to the first tract of the aortic root, normal echogenicity and aortic profile) was different from the atherosclerotic pattern (extensive dilation, increased echogenicity, irregular profile of aortic wall). Only few patients had cardiac lesions with high embolic risk, most patients having asymptomatic, previously unrecognized cardiac diseases. Therefore two-dimensional echocardiography is warranted for the etiological screening of cerebral ischemia in young adults. The detection of a cardiac lesion with low or unknown embolic risk should not preclude a search for other coexisting or prothrombotic factors. Finally, mitral valve prolapse and idiopathic aortic root dilation may be an expression of a minor connective tissue disorder accountable for dysplasia or dissection of carotid arteries.

Interactions Between Cardiovascular and Cerebrovascular Disease

Opininion statementAll patients with ischemic stroke should undergo a comprehensive assessment of cardiovascular risk. Patients with carotid artery disease, symptoms of cerebral ischemia and high cardiovascular risk profiles should be considered for noninvasive testing for coronary artery disease (CAD). Routine testing for CAD before carotid endarterctomy is not recommended. Patients with coexisting coronary and carotid artery disease should be more aggressively treated for reducing their “very high” risk of cardiovascular events. In patients candidates to carotid revascularization, a preoperative coronary angiography and coronary revascularization are not recommended. Warfarin is recommended in all patients with moderate to high risk of stroke. Novel oral anticoagulants represent an attractive alternative to warfarin. However, their place in therapy in clinical practice is not yet established. Percutaneous closure of the left atrial appendage for stroke prophylaxis may be considered in selected patients with atrial fibrillation and contraindications for oral anticoagulant therapy. Warfarin is not indicated in patients with heart failure who are in sinus rhythm. Percutaneous closure of patent foramen does not seem to be superior to medical therapy for the prevention of recurrences in patients with cryptogenic stroke.

Prophylaxis of thromboembolic events in congestive heart failure.

In patients with heart failure the incidence of thromboembolism is 0.9-5.5%/year (mean 1.9%/year), but no randomized studies are available to support the indication for anticoagulant therapy in those patients. Atrial fibrillation and previous thromboembolic events seem to be the major risk factors, whereas the effect of ventricular dysfunction has not been independently evaluated; nonetheless several studies suggest that thromboembolism is more likely among those patients with lower ejection fraction and lower peak exercise oxygen consumption. Anticoagulant therapy seems to be indicated also in patients with left ventricular aneurysm with mobile and protruding thrombi. Several studies of patients with dilated cardiomyopathy show that the incidence of thromboembolism ranges from 1.6 to 4.5%/year in patients not treated with anticoagulants, while it is virtually absent in anticoagulated patients. The clinical opportunity of long-term anticoagulant treatment in heart failure patients should be weighted not only on the clinical markers of thromboembolic risk, but also on the relative risk/benefit ratio of the single patient.

Clinical and Subclinical Distress, Quality of Life, and Psychological Well-Being after Cardiac Rehabilitation

BACKGROUNDnThe literature has outlined positive effects of cardiac rehabilitation (CR) on clinical psychological distress (DSM depression and anxiety) and quality of life (QoL). In cardiac settings, subclinical distress (subthreshold depressive and anxious symptomatology) and psychological well-being also showed relevant clinical implications. This research explored these psychological variables, their changes over time and cardiac course of CR patients.nnnMETHODSnClinical and subclinical distress, QoL, and psychological well-being were assessed in 108 consecutive patients undergoing CR, at baseline and up to 12xa0months after the programs completion.nnnRESULTSnOf all patients, 25.9 per cent showed high distress with a DSM diagnosis, 31.5 per cent high distress without a DSM diagnosis, and 42.6 per cent low distress. Comparing these subgroups, worse QoL and psychological well-being were significantly linked not only to clinical but also to subclinical distress. After CR completion, a significant reduction in DSM diagnoses was observed, whereas there were no positive effects on subclinical distress, QoL, and well-being, or when they initially occurred, they were not long lasting. Moreover, only the subgroup with high distress without a DSM diagnosis was at greater risk for adverse cardiac outcomes, showing worse scores on items of contentment.nnnCONCLUSIONSnThese findings confirm data on clinical distress reduction after CR completion. However, a large amount of relevant subclinical distress remains and predicts adverse cardiac events.

Well-being, ill-being and symptoms of atrial fibrillation.

Letter to the editor Atrial fibrillation is a common arrhythmia affecting about 10% of people aged over 75. Atrial fibrillation could become a chronic illness, complicating mental health and quality of life (QoL). Patients with atrial fibrillation usually experience greater psychological distress than the general population in terms of depression and anxiety, which are seen as strong predictors of medical outcomes and worsened QoL.

Unhealthy behaviour modification, psychological distress, and 1‐year survival in cardiac rehabilitation

OBJECTIVEnCardiac rehabilitation (CR) is considered the recommended secondary prevention treatment for cardiovascular diseases (CVD), in terms of health behaviours and, secondarily, better cardiac outcomes promotion. However, the role of psychiatric and psychosomatic distress on the efficacy of CR is unclear. This research aimed to evaluate the impact of CR on unhealthy behaviour modification and cardiac course, considering the moderating role of depression, anxiety, and psychosomatic syndromes.nnnDESIGNnA longitudinal design between and within groups was employed. The assessment was repeated four times: at admission to CR (T1), at discharge (T2), 6 (T3) and 12xa0months following CR completion (T4).nnnMETHODnOne hundred and eight patients undergoing CR versus 85 patients with CVD not referred to CR, underwent psychiatric, psychosomatic, and health behaviour assessment. The assessment included the Structured Clinical Interview for DSM-IV (depression and anxiety), the interview based on Diagnostic Criteria for Psychosomatic Research, GOSPEL Study questionnaire (health behaviours), Pittsburgh Sleep Quality Index, and 8-item Morisky Medication Adherence Scale.nnnRESULTSnCardiac rehabilitation was associated with maintenance of physical activity, improvement of behavioural aspects related to food consumption, stress management, and sleep quality. On the contrary, CR was not associated with weight loss, healthy diet, and medication adherence. Depression and psychosomatic syndromes seem to moderate the modification of specific health-related behaviours (physical activity, behavioural aspects of food consumption, stress management, and pharmacological adherence).nnnCONCLUSIONnIn CR settings, an integrated assessment including both psychiatric and psychosomatic syndromes is needed to address psychological factors associated with unhealthy behaviour modification. Statement of contribution What is already known on this subject? Cardiac rehabilitation (CR) is considered a class 1A treatment recommendation and the most cost-effective model of secondary prevention to reduce cardiovascular events. There is evidence about the association between psychological distress and both unhealthy behaviour and cardiac course. Depression and psychosomatic distress, such as type A behaviour and demoralization, are frequently associated with CVD course. However, the role of psychiatric and psychosomatic distress in CR is not well known. What does this study add? CR exerted a protective effect on physical activity and a positive effect on eating behaviour, stress management, and quality of sleep. CR did not show any particular effect on smoking, overweight/obesity, dietary habits, medication adherence, and patients 1-year survival. Findings from this study suggest the importance to consider specific psychological and psychosomatic aspects in affecting lifestyle.