[Chronic heart failure and depression]. / Chronische Herzinsuffizienz und Depression.

BACKGROUND: Depression is a frequent comorbidity in chronic heart failure. It can be triggered by the experience of suffering from heart disease, but it can also play a causal role in accelerated development and poor prognosis of heart failure. OBJECTIVES: The aim of this study was to investigate the interrelationships between heart failure and depression and the psychophysiological and behavioral mechanisms involved in this association. The effects of comorbid depression on quality of life in patients with heart failure were also examined and therapeutic options reviewed. METHODS: A narrative review of the literature was undertaken. RESULTS: Several psychophysiological and behavioral mechanisms have been identified as mediators of the association between depression and heart failure and the adverse prognostic effects of this comorbidity. Comorbid depression leads to substantial reductions in health-related quality of life. These effects are only incompletely antagonized by exercise training and cognitive behavioral therapy. No specific effect of antidepressant medication has been demonstrated as yet in patients with heart failure. DISCUSSION: While current guidelines recommend the identification and treatment of depressive comorbidity in patients with heart failure, the available evidence provides no convincing rationale for specific treatment recommendations beyond the guideline-based treatment of heart failure itself, lifestyle interventions and patient-centered medical care. If available, psychotherapy should be offered, ideally cognitive behavioral therapy. For patients that do not improve sufficiently under outpatient treatment, the German health care system offers dedicated psychocardiological inpatient treatment programs.

Natriuretic Peptides in Anxiety and Panic Disorder.

Natriuretic peptides exert pleiotropic effects on the cardiovascular system, including natriuresis, diuresis, vasodilation, and lusitropy, by signaling through membrane-bound guanylyl cyclases. In addition to their use as diagnostic and prognostic markers for heart failure, accumulating behavioral evidence suggests that these hormones also modulate anxiety symptoms and panic attacks. This review summarizes our current knowledge of the role of natriuretic peptides in animal and human anxiety and highlights some novel aspects from recent clinical studies on this topic.

[Assessment of subjective physical well-being in heart failure : Validation of the FEW16 questionnaire]. / Erfassung des subjektiven körperlichen Wohlbefindens bei Herzinsuffizienz : Validierung des FEW16-Fragebogens.

INTRODUCTION: Improvement in the quality of life (QoL) is a major goal of therapy for heart failure (HF) patients. Physical well-being as an important component of QoL has not yet been sufficiently covered by disease-specific assessment instruments. The aim of the study was to validate the questionnaire for assessing subjective physical well-being (FEW16) in HF patients with preserved ejection fraction (HFpEF) from the exercise training in diastolic heart failure (Ex-DHF­P) trial. METHOD: A total of 64 HFpEF patients (65 years, 56 % female) were randomized to usual routine treatment with (n = 44) or without training (n = 20). At baseline and 3 months, patients were clinically evaluated and assessed using appropriate questionnaires on the QoL (SF36), physical well-being (FEW16) and depression (PHQ-D). RESULTS: The FEW16 showed good values for Cronbachs' alpha coefficients (0.85-0.93). The cross-validity with SF36 and PHQ-D was highly significant but more so for psychological aspects. At baseline, the FEW16 score correlated with age, the subscale resilience with age and the 6 min walking distance test. At follow-up, the total and resilience scores had improved in the training group. In contrast to the SF36, the FEW16 did not detect differences between the groups in Ex-DHF­P. DISCUSSION: The FEW16 questionnaire showed good internal consistency and correlation with SF36, its total score and resilience had improved after training; however, it did not reflect different changes between the study groups. The FEW16 is therefore more suited to assess general/mental well-being than the subjective physical well-being.

[Psychocardiology: clinically relevant recommendations regarding selected cardiovascular diseases]. / Psychokardiologie: praxisrelevante Erkenntnisse und Handlungsempfehlungen.

Psychosocial risk factors (work stress, low socioeconomic status, impaired social support, anger, anxiety and depression), certain personality traits (e.g. hostility) and post-traumatic stress disorders may negatively influence the incidence and course of multiple cardiovascular disease conditions. Systematic screening for these factors may help to adequately assess the psychosocial risk pattern of a given patient and may also contribute to the treatment of these patients. Recommendations for treatment are based on current guidelines. The physician-patient interaction should basically follow the principle of a patient centered communication and should gender and age specific aspects into consideration. Integrated biopsychosocial care is an effective, low threshold option to treat psycho-social risk factors and should be offered on a regular basis. Patients with high blood pressure may profit from relaxation programs and biofeedback procedures (however with moderate success). An individually adjusted multimodal treatment strategy should be offered to patients with coronary heart disease, heart failure and after heart surgery. It may incorporate educational tools, exercise therapy, motivational modules, relaxation and stress management programs. In case of affective comorbidity, psychotherapy may be indicated. Anti-depressant pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) in the first line should only be offered to patients with at least moderate severe depressive episodes. Psychotherapy and SSRIs, particularly sertraline, have been proven to be safe and effective with regard to improvements of the patient's quality of life. A prognostic benefit has not been clearly proven so far. Patients with an implanted cardioverter/defibrillator (ICD) should receive psychosocial support on a regular basis. Concomitant psychotherapy and/or psychopharmacotherapy (SSRIs) should be offered in case of a severe mental comorbidity. Generally, tricyclic antidepressants should be avoided in cardiac patients because of adverse side effects.

[Psychosomatic aspects of chronic heart failure. Nothing but depression?]. / Psychosomatik der Herzinsuffizienz. Alles nur Depression?

Psychosocial factors are bi-directionally associated with the pathophysiology, symptoms, and prognosis observed in heart failure. Cardiac symptom severity is both dependent on psychological appraisal processes and causally related to feelings of exhaustion and distress. Distress and depression have been shown to affect physiological processes involved in the pathogenesis and course of chronic heart failure as well as illness behaviors. Conversely, physiological consequences of heart failure such as inflammatory activation may lead to sickness behavior and depression. However, there are some indications that the secretion of natriuretic peptides observed in response to cardiac overload may also have beneficial psychological effects (e.g., anxiolysis). Quality of life is typically reduced in heart failure but functional impairment and psychological maladjustment seem to be more important for quality of life than cardiac severity markers such as systolic or diastolic function per se. Current guidelines therefore recommend complementing optimal medical care with good communication, the creation of a trustful physician-patient relationship, patient education and partnership building, as well as specialized mental health care in cases of severe or enduring mental disorders or inappropriate illness behavior. While the evidence for antidepressant drug treatment in heart failure appears inconclusive, behavioral treatments such as exercise and psychotherapy may be more promising in treating comorbid anxiety and depression.

[Psychosomatic aspects of coronary heart disease]. / Psychosomatik der koronaren Herzkrankheit.

Coronary heart disease is one of the most frequent causes of death in Germany. Psychosocial factors can be considered cofactors in the development of coronary heart disease. These factors also play a particularly important role in triggering acute coronary syndrome or acute myocardial infarction. Heart disease itself can result in manifest anxiety, tendencies toward denial, and depressive disorders. Especially the latter worsen the disease course and prognosis. In addition to somatic treatment, behavioral interventions to control risk factors are available as well as psychotherapy and antidepressants. The aim of this contribution is to describe the psychosomatic aspects of coronary heart disease and to delineate the principles of a holistic approach to treatment.

Association of glucose metabolism with diastolic function along the diabetic continuum.

AIMS/HYPOTHESIS: Hyperglycaemia and insulin resistance have been linked to diastolic dysfunction experimentally. We investigated the association between glucose metabolism and diastolic function along the whole spectrum of glucose metabolism states. METHODS: In the observational Diagnostic Trial on Prevalence and Clinical Course of Diastolic Dysfunction and Diastolic Heart Failure (DIAST-CHF) study, patients with risk factors for heart failure were included. We analysed data including comprehensive echocardiography from a subgroup of patients classified by OGTT and history as normal (n = 343), prediabetic (n = 229) and non-insulin treated (n = 335) or insulin-treated (n = 178) type 2 diabetic. RESULTS: While ejection fraction did not differ, markers of diastolic function significantly worsened across groups. Prediabetes represented an intermediate between normal glucose metabolism and diabetes with regard to echocardiography changes. Prevalence and severity of diastolic dysfunction increased significantly (p < 0.001) along the diabetic continuum. Glucose metabolism status was significantly associated with prevalence of diastolic dysfunction on multivariate logistic regression analysis. In the whole cohort, HbA(1c) correlated with early diastolic mitral inflow velocity (E):early diastolic tissue Doppler velocity at mitral annulus (e') ratio (E:e') (r = 0.20, p < 0.001). HbA(1c) was significantly associated with E:e' on multivariate analysis. Similarly, glucose metabolism status was significantly associated with E:e' on multivariate analysis. The distance walked in 6 min decreased along the diabetic spectrum and was significantly correlated with E:e' and grade of diastolic dysfunction. CONCLUSIONS/INTERPRETATION: Glucose metabolism is associated with diastolic dysfunction across the whole spectrum. Our data extend previous observations into the prediabetic and normal range, and may be relevant to preventive approaches, as no effective treatment has been identified for diastolic heart failure once established.

Nasal manifestations of self-destructive behaviour.

Self-destructive behaviour is prevalent in a variety of different psychiatric disorders. Most common manifestations are self-inflicted cuts to the skin, especially the skin of the forearms. Manifestations of self-destructive behaviour involving the nasal area are rather rare. A series of cases is presented in which nasal diseases were initially misinterpreted, but could finally be identified as factitious disorders. Presented symptoms were foreign body insertions, hemodynamically relevant epistaxis and impetiginous inflammations of the paravestibular skin of the nose. Factitious disorders of the nose should be identified as such for the following reasons: avoiding unnecessary operations, adequate symptomatic rhinologic therapy and the initiation of psychiatric consultation.

Angiotensin II blockers in obstructive pulmonary disease: a randomised controlled trial.

In chronic obstructive pulmonary disease (COPD), the sympathetic nervous system, as well as the renin-angiotensin system, is activated with possible negative systemic effects on skeletal muscles. Angiotensin II type-1 receptor blockers inhibit the sympathetic and renin-angiotensin systems and might improve skeletal and respiratory muscle strength in patients in whom these systems are activated. The effects of the angiotensin receptor blocker irbesartan given over 4 months was evaluated in 60 patients with COPD and a forced expiratory volume in one second of <50% of the predicted value and without obvious cardiovascular disease that would necessitate the administration of an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Irbesartan was well tolerated, but did not exert a significant effect on the primary end-point maximum inspiratory pressure. Spirometric results were not affected, but total lung capacity was reduced. Irbesartan led to a significant decrease in haematocrit (46.4+/-3.6 to 43.9+/-4.3% versus 47.5+/-2.4 to 48.7+/-3.0% with placebo). In conclusion, respiratory muscle strength in chronic obstructive pulmonary disease patients was not influenced by angiotensin II receptor blockade. However, the changes in haematocrit and total lung capacity following irbesartan raise the possibility that well-known cardiovascular drugs can produce unanticipated beneficial effects in chronic obstructive pulmonary disease patients.

[Psychosocial factors in coronary heart disease -- scientific evidence and recommendations for clinical practice]. / Psychosoziale Faktoren bei koronarer Herzkrankheit -- wissenschaftliche Evidenz und Empfehlungen für die klinische Praxis.

Psychosocial risk factors like low socio-economic status, lack of social support and social isolation, chronic work or family stress, as well as negative emotions, e. g. depression and hostility, contribute significantly to the development and adverse outcome of coronary heart disease (CHD). Negative effects of psychosocial risk factors are conveyed via behavioural pathways including unhealthy lifestyle, e. g. food choice, smoking, sedentary life, inadequate utilisation of medical resources, and psychobiological mechanisms like disturbed autonomic and hormonal regulation: all these factors contribute to metabolic dysfunction and inflammatory and haemostatic processes, which are directly involved in the pathogenesis of CHD. Interventions to improve pychosocial factors are available and have demonstrated positive effects on risk factors and - at least in part - on CHD morbidity and mortality. The prevention of CHD should therefore include screening for psychosocial risk factors and adequate interventions. Recommedations for the screening of risk factors, behavioural change and further management of psychosocial risk factors in clinical practice are pointed out.

[A set of questionnaires for the assessment (screening) of psychological disorders and social problems in cardiac rehabilitation patients]. / Ein Fragebogenset zur Erfassung (Screening) psychischer Störungen und sozialer Probleme von Patienten in der kardiologischen Rehabilitation.

A set of questionnaires for the assessment (screening) of psychological and social problems in cardiac rehabilitation patients is analyzed for its psychometric properties. The test battery had before been consented by a task force of the German Association for the Prevention and Rehabilitation of Cardiovascular Disease, DGPR. It integrates generally approved and well-tried assessments for depression/anxiety, social isolation (vocational) stress, and subjective vocational disability. The questionnaire was administered to a convenience sample of 426 patients undergoing inpatient cardiac rehabilitation. Results on the psychometric properties, a comparison of the cardiac sample to the general population, as well as distributions of quartile ranges are reported. Also, a preliminary appraisal of the need for further assessment or treatment is made. The results confirm that the short test battery is suited for assessing psychological and social problems in cardiac rehabilitation patients.

[Anxiety and depression in cardiology patients: how to diagnose, how to treat?]. / Angst und Depressivität bei Herzpatienten--wie erkennen, wie behandeln?

IMPORTANCE: Anxiety and depression are frequent problems in patients with heart diseases. Prevalences vary between 15 and 50%, depending on diagnostic criteria as well as on sociodemographic and medical patient characteristics. During the last 10-15 years, a large number of studies have shown that anxiety and depression strongly affect overall well-being, cardiac and non-specific symptom reporting and overall quality of life. This leads to increased health care utilization, early retirement and imposes a financial burden on individuals and social security systems. In addition, anxious and especially depressed patients with heart disease tend to exhibit unhealthy illness behavior, low compliance and suboptimal risk factor control. Together with the known physiological effects of negative affect on cardiac autonomic balance, inflammation and platelet function, these behavioral mechanisms may lead to the frequently observed increase of cardiac event and mortality rates in depressed patients wit coronary artery disease. DIAGNOSIS: Despite their clinical relevance and unsatisfactory spontaneous remission rate, anxiety and depression still go unrecognized and undertreated in most cardiac patients. Case-identification can be improved by a graded approach. In the first step, symptoms of anxiety and depression should explicitly be asked for as part of a routine cardiological work-up. As an adjunct, validated self-rating questionnaires can be used for screening purposes. Patients screened positive should receive a thorough diagnostic interview and a criteria-based diagnosis. TREATMENT: Once a diagnosis has been obtained, several treatment options are available: In less severe cases (minor depression or adjustment disorders), supportive care by primary care physicians or cardiologists may be sufficient. Patients with major depression or panic disorder should receive structured psychotherapy and/or antidepressant medication. Exercise training can also improve symptoms of anxiety and depression. Although both psychotherapy and antidepressants, especially if integrated in a concept of comprehensive cardiac care, can be expected to result in marked subjective benefit for the majority of patients, the impact of these treatments on cardiac event and mortality rates still needs to be determined.

Depressed mood, physician-rated prognosis, and comorbidity as independent predictors of 1-year mortality in consecutive medical inpatients.

OBJECTIVE: To determine the independent effects of depressed mood and markers of medical disease severity on mortality in consecutive medical inpatients. METHODS: Consecutive general medical inpatients were asked to complete the Hospital Anxiety and Depression Scale (HADS) at admission. Prognostic indicators were obtained from patients' records and physicians' ratings. The study endpoint was mortality from all causes at 1 year. RESULTS: The baseline assessment was completed by 575 patients (87.7%). Survival data were available for 572 of these (86 deaths). HADS depression scores and several physical risk indicators predicted mortality. In multivariate analyses, physicians' rating of prognosis was the best predictor of mortality [adjusted odds ratio (OR) 3.6; 95% confidence interval (CI), 2.5--5.4]. Other independent predictors included a principal diagnosis of hemato-oncological disease, comorbidity scores, and HADS depression (adjusted OR 1.75; 95% CI, 1.10--2.79). CONCLUSION: Our data demonstrate an independent prognostic effect of depressed mood on mortality in general medical inpatients. Screening for depression may improve risk stratification in these patients over and above that obtained by routinely available physical parameters and physicians' clinical judgement.

[Not Available]. / Biopsychosoziale Faktoren in Genese und Manifestation der koronaren Herzkrankheit/ Biopsychosocial factors in pathogenesis and manifestation of coronary heart disease.

Psychosocial factors have always been considered important causes of heart disease. Because of its extraordinary epidemiological and political relevance, coronary heart disease (CHD) has received Special scientific attention in this field. However, the abundance of literature dealing with its biological, psychological and social precursors is in sharp contrast with a lack of comprehensive modeis trying to integrate the results of different scientific traditions. This paper gives a brief overview of the present State of psychosocial research on etiological factors in CHD. Instead of solely relying on attempts to identify supposedly independent risk factors, it emphasizes the importance of dynamic biopsychosocial processes, which finally lead to manifest coronary disease. The paper outlines an approach which integrates clinical and empirical findings in a bio-psycho-sociodynamic model. This model is open to future extension. It may be helpful for better understanding individual patients as well as scientific findings. By providing hypotheses, which are suggested to go beyond the still predominating reductionistic, linear modeis, it may furthermore be a basis for future research in psychosocial cardiology.