Wafia Eteiba

Depressive Symptom Dimensions and Cardiovascular Prognosis Among Women With Suspected Myocardial Ischemia: A Report From the National Heart, Lung, and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation

CONTEXT Symptoms of depression and cardiovascular disease (CVD) overlap substantially. Differentiating between dimensions of depressive symptoms may improve our understanding of the relationship between depression and physical health. OBJECTIVE To compare symptom dimensions of depression as predictors of cardiovascular-related death and events among women with suspected myocardial ischemia. DESIGN Cohort study of women with suspected myocardial ischemia who underwent evaluation at baseline for a history of cardiovascular-related problems, depressive symptoms using the Beck Depression Inventory, and coronary artery disease severity via coronary angiography. Principal components analyses (PCAs) of the Beck Depression Inventory items were conducted to examine differential cardiovascular prognosis according to symptom dimensions of depression. SETTING The Womens Ischemia Syndrome Evaluation (WISE), a multicenter study sponsored by the National Heart, Lung, and Blood Institute to assess cardiovascular function using state-of-the-art techniques in women referred for coronary angiography to evaluate chest pain or suspected myocardial ischemia. PARTICIPANTS Five hundred fifty women (mean [SD] age, 58.4 [11.2] years) enrolled in the WISE study and followed up for a median of 5.8 years. MAIN OUTCOME MEASURES Cardiovascular-related mortality and events (stroke, myocardial infarction, and congestive heart failure). RESULTS When a 3-factor structure from PCA was used, somatic/affective (hazards ratio, 1.35; 95% confidence interval, 1.04-1.74) and appetitive (1.42; 1.21-1.68) but not cognitive/affective (0.89; 0.70-1.14) symptoms predicted cardiovascular prognosis in adjusted multivariate Cox regression analysis. When a 2-factor structure from PCA was used, adjusted results indicated that somatic (hazards ratio, 1.63; 95% confidence interval, 1.28-2.08) but not cognitive/affective (0.87; 0.68-1.11) symptoms predicted worse prognosis. CONCLUSIONS In a sample of women with suspected myocardial ischemia, somatic but not cognitive/affective depressive symptoms were associated with an increased risk of cardiovascular-related mortality and events. These results support the need to research dimensions of depression in CVD populations and have implications for understanding the connection between depression and CVD.

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.

Depression and Cardiovascular Health Care Costs Among Women With Suspected Myocardial Ischemia: Prospective Results From the WISE (Women's Ischemia Syndrome Evaluation) Study

OBJECTIVES This study evaluated 3 novel questions in a prospective clinical cohort of women undergoing evaluation for suspected myocardial ischemia: 1) What is the relationship between depression and cardiovascular costs? 2) Does the relationship vary by definition of depression? 3) Do depression-cost relationship patterns differ among women with versus without coronary artery disease (CAD)? BACKGROUND Comorbid depression has been linked to higher medical costs in previous studies of cardiovascular patients. METHODS A total of 868 women presenting with suspected myocardial ischemia completed an extensive baseline examination including cardiovascular risk factor assessment and coronary angiogram. Depression was defined by: 1) current use of antidepressants; 2) a reported history of depression treatment; and 3) Beck Depression Inventory scores. Direct (hospitalizations, office visits, procedures, and medications) and indirect (out-of-pocket, lost productivity, and travel) costs were collected through 5 years of follow-up to estimate cardiovascular costs. RESULTS Using the study criteria, 17% to 45% of the women studied met study depression criteria. Depressed women showed adjusted annual cardiovascular costs

Psychotropic medication use and risk of adverse cardiovascular events in women with suspected coronary artery disease: outcomes from the Women’s Ischemia Syndrome Evaluation (WISE) study

1,550 to

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

3,300 higher than nondepressed groups (r = 0.08 to 0.12, p < 0.05). Depression-cost relationships also varied by CAD status, with stronger associations present among women without evidence of significant CAD. CONCLUSIONS Depression was associated with 15% to 53% increases in 5-year cardiovascular costs, and cost differences were present using 3 definitions of depression. The results reinforce the importance of assessing depression in clinical populations and support the hypothesis that improved management of depression in women with suspected myocardial ischemia could reduce medical costs.

Cardiac syndrome X and microvascular coronary dysfunction.

Objective: This study investigated the relation between psychotropic medication use and adverse cardiovascular (CV) events in women with symptoms of myocardial ischaemia undergoing coronary angiography. Method: Women enrolled in the Women’s Ischemia Syndrome Evaluation (WISE) were classified into one of four groups according to their reported antidepressant and anxiolytic medication usage at study intake: (1) no medication (n = 352); (2) anxiolytics only (n = 67); (3) antidepressants only (n = 58); and (4) combined antidepressant and anxiolytics (n = 39). Participants were followed prospectively for the development of adverse CV events (for example, hospitalisations for non-fatal myocardial infarction, stroke, congestive heart failure and unstable angina) or all-cause mortality over a median of 5.9 years. Results: Use of antidepressant medication was associated with subsequent CV events (HR 2.16, 95% CI 1.21 to 3.93) and death (HR 2.15, 95% CI 1.16 to 3.98) but baseline anxiolytic use alone did not predict subsequent CV events and death. In a final regression model that included demographics, depression and anxiety symptoms, and risk factors for cardiovascular disease, women in the combined medication group (that is, antidepressants and anxiolytics) had higher risk for CV events (HR 3.98, CI 1.74 to 9.10, p = 0.001 and all-cause mortality (HR 4.70, CI 1.7 to 2.97, p = 0.003) compared to those using neither medication. Kaplan-Meier survival curves indicated that there was a significant difference in mortality among the four medication groups (p = 0.001). Conclusions: These data suggest that factors related to psychotropic medication such as depression refractory to treatment, or medication use itself, are associated with adverse CV events in women with suspected myocardial ischaemia.

Review articleCardiac Syndrome X and Microvascular Coronary Dysfunction

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.

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

Women with cardiac chest pain indicated by signs and symptoms of myocardial ischemia in the absence of obstructive CAD are often labelled as cardiac syndrome X (CSX). A subset of patients with CSX may have symptoms of ischemia due to microvascular dysfunction. Angina due to microvascular coronary dysfunction (MCD) is an etiologic mechanism in women with vascular dysfunction. New data provide improve understanding of coronary vascular dysfunction and resultant myocardial ischemia that characterize MCD among patients with cardiac syndrome X. MCD has an adverse prognosis and health care cost expenditure comparable to obstructive CAD. The high prevalence of this condition, particularly in women, adverse prognosis and substantial health care costs, coupled with a lack of evidence regarding treatment strategies, places MCD as a research priority area.

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

Women with cardiac chest pain indicated by signs and symptoms of myocardial ischemia in the absence of obstructive CAD are often labelled as cardiac syndrome X (CSX). A subset of patients with CSX may have symptoms of ischemia due to microvascular dysfunction. Angina due to microvascular coronary dysfunction (MCD) is an etiologic mechanism in women with vascular dysfunction. New data provide improve understanding of coronary vascular dysfunction and resultant myocardial ischemia that characterize MCD among patients with cardiac syndrome X. MCD has an adverse prognosis and health care cost expenditure comparable to obstructive CAD. The high prevalence of this condition, particularly in women, adverse prognosis and substantial health care costs, coupled with a lack of evidence regarding treatment strategies, places MCD as a research priority area.

Lipid-lowering medication use and aggression scores in women: a report from the NHLBI-sponsored 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.