Omega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder.

Depression is associated with elevated rates of cardiovascular morbidity and mortality. This elevation seems to be due to a significantly increased risk of coronary artery disease and myocardial infarction and, once the ischemic heart disease is established, sudden cardiac death. Recent data suggest that the increased rates of cardiovascular disease in patients with depression may be the result of one or more still-unrecognized underlying physiological factors that predispose a patient to both depression and cardiovascular disease. Two possibly related factors that may have a causal relation with both depressive disorders and cardiovascular disease are an omega-3 fatty acid deficiency and elevated homocysteine levels. We present the available data connecting cardiovascular disease, depression, omega-3 fatty acids, and homocysteine. In addition, we suggest research strategies and some preliminary treatment recommendations that may reduce the increased risk of cardiovascular mortality in patients with major depressive disorder.

Respiratory symptoms and lung function in workers in heavy and highway construction: a cross-sectional study.

BACKGROUND: Occupational exposures for workers in heavy and highway (HH) construction include cement-containing dusts and diesel exhaust (DE). To investigate possible health effects, respiratory symptoms and lung function were examined in laborers, tunnel workers (TW), and operating engineers (OE) in HH and tunnel construction. The principal outcome of interest was airways disease. METHODS: Subjects were recruited through their unions. Medical and occupational histories and flow-volume loops were obtained. Based on self-report, asthma and chronic bronchitis were categorized as (1) physician-diagnosed or (2) for asthma, undiagnosed likely, and (3) for chronic bronchitis, symptomatic. Trade and time in the union were used as surrogates of exposure. Prevalence of asthma and chronic bronchitis, lung function outcome, and relationships with exposure variables were examined. RESULTS: Data were obtained on 389 workers: 186 laborers, 45 TWs, and 158 OEs. Prevalence of asthma was 13 and 11.4% for laborers (including TW) and OEs, respectively, and of symptomatic chronic bronchitis, 6.5 and 1.9%, respectively. Odds ratios (OR) for undiagnosed asthma likely were significantly elevated in TWs compared to OEs, and marginally elevated for chronic bronchitis. Inverse relationships were observed between time in the union, and risk for asthma and chronic bronchitis. Asthma (physician-diagnosed or undiagnosed likely) predicted lower FEV(1). Current cigarette use was associated with chronic bronchitis but not asthma. CONCLUSIONS: TWs, laborers, and OEs in HH construction are at increased risk for asthma. TWs also appear to be at increased risk for chronic bronchitis. Our data suggest that symptomatic workers are self-selecting out of their trade. Asthma was associated with lower lung function in those affected.

Psychosocial factors: role in cardiac risk and treatment strategies.

Recent epidemiologic research has identified several psychosocial factors that impact unfavorably on prognosis among patients with established coronary heart disease (CHD). Several biologic and behavioral characteristics have been identified in patients with these psychosocial risk factors that are biologically plausible mediators of their adverse impact on prognosis. Several small-scale clinical trials offer encouraging evidence that both behavioral and pharmacologic interventions have the potential to ameliorate the health-damaging effects of psychosocial risk factors in patients with CHD. In this article we review the evidence on these points and offer recommendations as to how incorporation of this new knowledge into clinical care of the patient with CHD can lead to reduced mortality and morbidity rates in this population.

Lack of effect of exercise training on dehydroepiandrosterone-sulfate.

Although functions of dehydroepiandrosterone (DHEA) and its sulfate ester are unknown, investigators have found an inverse relation between DHEA-sulfate levels and coronary artery disease, suggesting its importance as an inverse coronary risk factor. In previous studies, where behavioral therapy was used to try to reduce stress and social isolation, DHEA levels increased--although other confounding factors, including enhanced physical activity, also were affected. To determine the influence of physical activity alone on plasma DHEA-sulfate levels in patients with coronary artery disease, the authors studied the effects of exercise training by measuring plasma DHEA-sulfate levels and other parameters in 96 patients at baseline and after 12 weeks of cardiac rehabilitation and exercise training. They confirmed that DHEA-sulfate levels decreased with age (r = 0.41; P < 0.0001) and that DHEA-sulfate levels correlated with body mass index (r = 0.32; P < 0.001), but not with other baseline risk factors. Exercise training during cardiac rehabilitation resulted in a 43% increase in exercise capacity (P < 0.0001) and was associated with improvement in other cardiac risk factors; however, there were no significant changes in plasma DHEA-sulfate levels (106 +/- 77 micrograms/dL versus 102 +/- 76 micrograms/dL). Although behavior therapy in combination with exercise training was shown to lead to concomitant increases in DHEA-sulfate and physical activity, exercise training alone has no significant impact on DHEA-sulfate, thereby strengthening the suggested role of behavioral changes in modifying this hormone.

Sexual functioning post-myocardial infarction: effects of beta-blockers, psychological status and safety information.

Impaired sexual functioning limits the quality of life of 34-75% of post-myocardial infarction (MI) patients. This study examined the effects of three factors: (a) beta-blocker intake, (b) psychological distress, and (c) information about safety of sexual activity, on post-MI decreased sexual functioning. Sixty-three male post-MI, post-cardiac rehabilitation patients and their spouses participated in the study. Analyses of partial variance were conducted to test for the effect of each factor on sexual functioning. Controlling for age, results revealed that patients' psychological distress explained uniquely 24% of the variance on decreased post-MI sexual activity (p < 0.002). Beta-blocker intake and message received with regard to sexual activity safety were not significant predictors of observed changes. Interdisciplinary assessments and interventions are recommended.

Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly.

OBJECTIVES: The aim of this study was to determine the effects of cardiac rehabilitation and exercise training on plasma lipids, indexes of obesity and exercise capacity in the elderly and to compare the benefits in elderly patients with coronary heart disease with benefits in a younger cohort. BACKGROUND: Despite the well proved benefits of cardiac rehabilitation and exercise training, elderly patients with coronary heart disease are frequently not referred or vigorously encouraged to pursue this therapy. In addition, only limited data are available for these elderly patients on the benefits of cardiac rehabilitation on plasma lipids, indexes of obesity and exercise capacity. METHODS: At two large multispecialty teaching institutions, baseline and post-rehabilitation data including plasma lipids, indexes of obesity and exercise capacity were compared in 92 elderly patients (> or = 65 years, mean age 70.1 +/- 4.1 years) and 182 younger patients (< 65 years, mean 53.9 +/- 7.4 years) enrolled in phase II cardiac rehabilitation and exercise programs after a major cardiac event. RESULTS: At baseline, body mass index (26.0 +/- 3.9 vs. 27.8 +/- 4.2 kg/m2, p < 0.001), triglycerides (141 +/- 55 vs. 178 +/- 105 mg/dl, p < 0.01) and estimated metabolic equivalents (METs) (5.6 +/- 1.6 vs. 7.7 +/- 3.0, p < 0.0001) were lower and high density lipoprotein cholesterol was greater (40.4 +/- 12.1 vs. 37.5 +/- 10.4 mg/dl, p < 0.05) in the elderly than in younger patients. After rehabilitation, the elderly demonstrated significant improvements in METs (5.6 +/- 1.6 vs. 7.5 +/- 2.3, p < 0.0001), body mass index (26.0 +/- 3.9 vs. 25.6 +/- 3.8 kg/m2, p < 0.01), percent body fat (24.4 +/- 7.0 vs. 22.9 +/- 7.2%, p < 0.0001), high density lipoprotein cholesterol (40.4 +/- 12.1 vs. 43.0 +/- 11.4 mg/dl, p < 0.001) and the ratio of low density to high density lipoprotein cholesterol (3.6 +/- 1.3 vs. 3.3 +/- 1.0, p < 0.01) and a decrease in triglycerides that approached statistical significance (141 +/- 55 vs. 130 +/- 76 mg/dl, p = 0.14) but not in total cholesterol or low density lipoprotein cholesterol. Improvements in functional capacity, percent body fat and body mass index, as well as lipids, were statistically similar in the older and younger patients. CONCLUSIONS: Despite baseline differences, improvements in exercise capacity, obesity indexes and lipids were very similar in older and younger patients enrolled in cardiac rehabilitation and exercise training. These data emphasize that elderly patients should not be categorically denied the psychosocial, physical and risk factor benefits of secondary coronary prevention including formal cardiac rehabilitation and supervised exercise training.

Prevention of disability due to cardiovascular diseases.

Emotional distress and interpersonal stress are extremely common in patients after myocardial infarction and typically lessen over several months. However, it is important for physicians to screen patients with CAD for certain conditions that may need further assessment and possible treatment by a mental health professional. The examination of the patient with CAD involves assessment of psychological functioning, including the patient's level of denial, anxiety, and depression; the presence of panic anxiety or depressive disorder; and neuropsychological functioning, including memory and concentration. Evaluation for the presence of persistent or excessive interpersonal strife, marital conflict, and sexual dysfunction is also important. Those with symptomatic anxiety, depression, or social or sexual dysfunction should be referred to a mental health professional who has expertise in working with CAD patients and is knowledgeable about a variety of psychosocial and psychopharmacological treatments. Patients with CAD who are unable to modify their cardiovascular risk factors satisfactorily after guidelines are clearly articulated should be referred to a center designed to help patients identify the obstacles to behavior change and to facilitate and maintain long-term adherence to these changes. Patients with CAD who are physiologically able to work but have marked work stress or a marked reluctance to return to work should be evaluated by a mental health professional.

Physiologic benefits of a stress reduction program for healthy middle-aged Army officers.

Stress reduction programs (SRPs) can reduce morbidity and mortality in patients with coronary artery disease (CAD). This study evaluated the effect of an SRP on metabolic and hormonal risk factors for CAD. Twenty army officers participating in an SRP, Group I, and a comparison group of seventeen SRP nonparticipants, Group C, volunteered to undergo measurement of dehydroepiandrosterone-sulfate (DHEA-S), cortisol, DHEA-S/cortisol ratio, testosterone, apolipoprotein-A1, apolipoprotein-B, triglycerides, cholesterol, fibrinogen, and leukocyte count both before and after the SRP period. No differences in the changes in biochemical risk factors for CAD were found between participant and nonparticipant except for DHEA-S. While Group C had a marked reduction in DHEA-S levels, Group I had a small increase. Previous studies indicate DHEA-S is inversely associated with extent of CAD and age-adjusted DHEA-S levels below 3.78 mumol/l confer an increased risk for CAD mortality. SRP participation appears to effect DHEA-S levels, possibly partially accounting for the benefits observed in SRPs among CAD patients.

Review of psychosomatic aspects of cardiovascular disease.

This review deals with the clinically most relevant psychosomatic aspects of cardiovascular disease. Smoking cessation, the role of physical activity in the prevention and rehabilitation of cardiac disease, the relationship of cholesterol to behavior, depression and heart disease, the pharmacotherapy of depression in this specific patient population, the psychiatric risk factors for coronary artery disease, and the treatment of hostility, stress and type A behavior are discussed.

Buspirone therapy for Type A behavior, hostility, and perceived stress in cardiac patients.

Hostility is considered to be a risk factor for coronary artery disease. Despite the findings of reduced serotonergic function and effectiveness of treatment with serotonergic agents in similar symptom complexes, there have been no attempts at using serotonergic psychopharmacologic agents to treat this population. We conducted an 8-week open trial of 10 type A, irritable men with coronary artery disease and no diagnosable psychiatric (axis I) condition to examine the effects of buspirone on these subjects. Buspirone appears to significantly reduce type A behavior, hostility, anxiety, impatience, and perceived stress.