Effects of aerobic conditioning on cardiovascular sympathetic response to and recovery from challenge.

Exercise has widely documented cardioprotective effects, but the mechanisms behind these effects are still poorly understood. Here, we test the hypothesis that aerobic training lowers cardiovascular sympathetic responses to and speeds recovery from challenge. We conducted a randomized, controlled trial contrasting aerobic versus strength training on indices of cardiac (pre-ejection period, PEP) and vascular (low-frequency blood pressure variability, LF-BPV) sympathetic responses to and recovery from psychological and orthostatic challenge in 149 young, healthy, sedentary adults. Aerobic and strength training did not alter PEP or LF-BPV reactivity to or recovery from challenge. These findings, from a large randomized, controlled trial using an intent-to-treat design, show that moderate aerobic exercise training has no effect on PEP and LF-BPV reactivity to or recovery from psychological or orthostatic challenge. In healthy young adults, the cardioprotective effects of exercise training are unlikely to be mediated by changes in sympathetic activity.

Hair analysis versus conventional methods of drug testing in substance abusers seeking organ transplantation.

As substance abusers need to demonstrate abstinence prior to transplant, valid/reliable drug tests are needed. Patients may deny use, fearing surgery will be delayed. Breath, blood and urine tests have brief detection windows that allow patients to evade detection. Routine laboratory tests do not include all substances of abuse. Hair analysis overcomes these barriers, increasing the likelihood that active users will be identified. This study compared results for alcohol, opioids and cocaine based on 445 self-report, breath, urine and hair samples from 42 patients who had been denied a transplant due to recent substance abuse. Compared to hair toxicology, sensitivity for conventional drug tests was moderate for cocaine and opioids, but poor for alcohol. Of positive hair tests, only half were corroborated through other tests. In contrast, specificity was high across tests and substances, with positive findings from conventional tests confirmed through hair toxicology. Based on a 90-day detection window for hair analysis, two negative tests suggest 6 months of continuous abstinence. Hair testing should be considered as an alternative approach for monitoring substance use in the transplant population, either as a routine procedure or when the veracity of findings from conventional tests is in doubt.

Relation between depression after coronary artery bypass surgery and 12-month outcome: a prospective study.

BACKGROUND: The association of depression with cardiac events has been investigated mainly in community cohorts, in patients undergoing catheterisation, or in patients who have had myocardial infarction. We have assessed the effect of depression on outcomes after coronary artery bypass graft (CABG) surgery. METHODS: In a prospective study, we followed up for 1 year 207 men and 102 women, who had undergone coronary artery bypass graft surgery. We assessed depression with a structured psychiatric interview (diagnostic interview schedule) and a questionnaire (Beck depression inventory) before discharge. Cardiac events included angina or heart failure that needed admission to hospital, myocardial infarction, cardiac arrest, percutaneous transluminal coronary angioplasty, repeat CABG, and cardiac mortality. Non-cardiac events consisted of all other reasons for mortality or readmission. FINDINGS: 63 patients (20%) met modified diagnostic statistical manual IV criteria for major depressive disorder. At 12 months, 17 (27%) of these patients had a cardiac event compared with 25 of 246 (10%) who were not depressed (p<0.0008). Five variables had significant univariate associations with cardiac events: sex, living alone, low ejection fraction (<0.35), length of hospital stay, and depression. In a Cox proportional-hazard model with these five and two other variables of cardiac severity, major depressive disorder (risk ratio 2.3 [95% CI 1.17-4.56]), low ejection fraction (2.3 [1.07-5.03]), and female sex (2.4 [1.24-4.44]) were associated with adverse outcomes. Depression did not predict deaths or admissions for non-cardiac events. INTERPRETATION: Depression is an important independent risk factor for cardiac events after CABG surgery.

Hostility, gender, and cardiac autonomic control.

OBJECTIVE: Although considerable evidence implicates hostility in the development of coronary artery disease (CAD), the pathogenic mechanisms remain poorly understood. We have developed a psychophysiological model that holds that altered autonomic nervous system function links psychological traits with CAD outcomes. In laboratory studies, stressors reduce high-frequency (HF) heart period variability, an index of cardiac vagal modulation. With ambulatory electrocardiographic recording, we demonstrated in a predominantly male sample that hostility was inversely associated with HF power, but only during waking hours. These findings are consistent with the hypothesis that hostile individuals experience multiple stressful interpersonal transactions each day, resulting in overall lower HF power during the day but not at night. METHODS: To further evaluate this hypothesis, we screened 96 subjects using the Cook-Medley Hostility Scale and selected 15 men and 15 women representing a wide distribution of hostility. These subjects were studied in a laboratory session assessing reactivity to psychological and orthostatic challenges with continuous electrocardiographic, blood pressure, and respiration monitoring. We predicted that for men and women, hostility would be inversely related to reductions in HF power in response to challenge. RESULTS: In response to mental stressors, all measures of heart period variability change were inversely related to hostility as predicted. No such relationships were found for responses to tilt. The data suggested a possible effect of gender on these relationships. CONCLUSIONS: These data add to the growing body of evidence showing that hostility influences vagal modulation of the cardiovascular system and suggest that altered autonomic control is a pathogenic mechanism linking hostility and CAD.

Long-term use of a left ventricular assist device for end-stage heart failure.

BACKGROUND: Implantable left ventricular assist devices have benefited patients with end-stage heart failure as a bridge to cardiac transplantation, but their long-term use for the purpose of enhancing survival and the quality of life has not been evaluated. METHODS: We randomly assigned 129 patients with end-stage heart failure who were ineligible for cardiac transplantation to receive a left ventricular assist device (68 patients) or optimal medical management (61). All patients had symptoms of New York Heart Association class IV heart failure. RESULTS: Kaplan-Meier survival analysis showed a reduction of 48 percent in the risk of death from any cause in the group that received left ventricular assist devices as compared with the medical-therapy group (relative risk, 0.52; 95 percent confidence interval, 0.34 to 0.78; P=0.001). The rates of survival at one year were 52 percent in the device group and 25 percent in the medical-therapy group (P=0.002), and the rates at two years were 23 percent and 8 percent (P=0.09), respectively. The frequency of serious adverse events in the device group was 2.35 (95 percent confidence interval, 1.86 to 2.95) times that in the medical-therapy group, with a predominance of infection, bleeding, and malfunction of the device. The quality of life was significantly improved at one year in the device group. CONCLUSIONS: The use of a left ventricular assist device in patients with advanced heart failure resulted in a clinically meaningful survival benefit and an improved quality of life. A left ventricular assist device is an acceptable alternative therapy in selected patients who are not candidates for cardiac transplantation.

Cerebral activation, hostility, and cardiovascular control during mental stress.

OBJECTIVE: Hostility has been established as a risk factor for the development of coronary artery disease. Putatively pathogenic hemodynamic and neuroendocrine responses to psychological stressors are associated with hostility, but the cerebral effects of hostility and their relationship to these responses are unknown. This pilot study examined cardiovascular and cerebral blood flow responses to stress in subjects with high and low levels of trait hostility. METHODS: Regional cerebral blood flow was measured by single-photon emission computed tomography (SPECT) during a control condition and in response to mental arithmetic stress. RESULTS: The stressor was associated with reduced blood flow to the prefrontal cortex, and this reduction was greater in the high hostility subjects. CONCLUSION: These preliminary findings support the hypothesis that mental arithmetic stress is associated with reduced blood flow to prefrontal cortex, and that trait hostility is associated with a stronger effect.

An open-label preliminary trial of sertraline for treatment of major depression after acute myocardial infarction (the SADHAT Trial). Sertraline Anti-Depressant Heart Attack Trial.

BACKGROUND: Depression occurs frequently in patients with acute myocardial infarction and is associated with increased mortality rates. It is not known whether serotonin reuptake inhibitors would be safe and effective for patients with depression after myocardial infarction and whether such treatment would reduce mortality rates. METHODS AND RESULTS: We conducted a multicenter, open-label, pilot study of sertraline treatment in patients with major depressive disorder identified 5 to 30 days after admission for acute myocardial infarction. Outcome measures included cardiovascular and hemostatic function, adverse events, and mood ratings. Twenty-six patients were enrolled in the study. During treatment there were no significant changes in heart rate, blood pressure, cardiac conduction, or left ventricular ejection fraction, and there was a trend toward reduced ventricular ectopic activity. There were no changes in coagulation measures. Bleeding time increased in 12 patients, decreased in 4 patients, and was unchanged in 2 patients. Three (12%) patients withdrew from treatment prematurely because of adverse events. Significant improvements in mood ratings occurred over the course of treatment. CONCLUSIONS: Sertraline treatment was associated with clinical improvement and was well tolerated in >85% of the patients in this open-label treatment trial for patients with major depression after myocardial infarction. These results encourage further controlled trials to establish the effects of treatment for this high-risk population.

The REMATCH trial: rationale, design, and end points. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure.

BACKGROUND: Because left ventricular assist devices have recently been approved by the Food and Drug Administration to support the circulation of patients with end-stage heart failure awaiting cardiac transplantation, these devices are increasingly being considered as a potential alternative to biologic cardiac replacement. The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial is a multicenter study supported by the National Heart, Lung, and Blood Institute to compare long-term implantation of left ventricular assist devices with optimal medical management for patients with end-stage heart failure who require, but do not qualify to receive cardiac transplantation. METHODS: We discuss the rationale for conducting REMATCH, the obstacles to designing this and other randomized surgical trials, the lessons learned in conducting the multicenter pilot study, and the features of the REMATCH study design (objectives, target population, treatments, end points, analysis, and trial organization). CONCLUSIONS: We consider what will be learned from REMATCH, expectations for expanding the use of left ventricular assist devices, and future directions for assessing clinical procedures.

Cardiac autonomic control buffers blood pressure variability responses to challenge: a psychophysiologic model of coronary artery disease.

This article presents a model that identifies effects of blood pressure variability (BPV) as a possible mechanism by which psychological/psychiatric factors and health behaviors confer increased risk of coronary artery disease (CAD) and acute coronary syndromes. Recent research in vascular biology and dynamics of coronary artery blood flow suggests that BPV may have pathogenic effects on the coronary endothelium, plaque formation, and plaque stability. Thus, BPV may be a risk factor for cardiovascular disease independent of mean arterial pressure. The model proposes that autonomic control of the heart exerts a buffering or inhibitory influence on oscillations in blood pressure. Established psychological/behavioral risk factors for CAD, such as depression, hostility, and anxiety, as well as physical deconditioning and aging, are associated with diminished autonomic control of the heart, which may disinhibit pathogenic BPV. Together, these data suggest a coherent, testable psychophysiological model of CAD. In this article, we review these data and make recommendations for research to examine the model.

Comparing the perception of dentists and lay people to altered dental esthetics.

PURPOSE: This study was designed to determine the perceptions of lay people and dental professionals with respect to minor variations in anterior tooth size and alignment and their relation to the surrounding soft tissues. MATERIALS AND METHODS: Smiling photographs were intentionally altered with one of eight common anterior esthetic discrepancies in varying degrees of deviation, including variations in crown length, crown width, incisor crown angulation, midline, open gingival embrasure, gingival margin, incisal plane, and gingiva-to-lip distance. Forty images were randomized in a questionnaire and rated according to attractiveness by three groups: orthodontists, general dentists, and lay people; 300 questionnaires were distributed. RESULTS: The response rate was 88.2% for orthodontists, 51.8% for general dentists, and 60.6% for lay people. The results demonstrated threshold levels of noticeable difference between the varying levels of discrepancy. A maxillary midline deviation of 4 mm was necessary before orthodontists rated it significantly less esthetic than the others. However, general dentists and lay people were unable to detect even a 4-mm midline deviation. All three groups were able to distinguish a 2-mm discrepancy in incisor crown angulation. An incisal plane cant of 1 mm as well as a 3-mm narrowing in maxillary lateral incisor crown width were required by orthodontists and general dentists to be rated significantly less esthetic. Lay people were unable to detect an incisal plane asymmetry until it was 3 mm, or a lateral incisor narrowing until it reached 4 mm. Threshold levels for open gingival embrasure and gingiva-to-lip distance were both at 2 mm for the orthodontic group. Open gingival embrasure became detectable by the general dentists and lay people at 3 mm, whereas gingiva-to-lip distance was classified by these groups as noticeably unattractive at 4 mm. CLINICAL SIGNIFICANCE: The results of this study show that orthodontists, general dentists, and lay people detect specific dental esthetic discrepancies at varying levels of deviation, which may aid the dental professional in making specific treatment recommendations.

The use of antidepressant drugs in patients with heart disease.

Both depression and cardiovascular disease are common as people age and are, therefore, likely to coexist. It has become evident recently that the rate of this comorbidity exceeds substantially what is expected by chance. A major problem arises in that there is increasing evidence that the tricyclic antidepressants (TCAs) carry more risk than originally thought in patients with ischemic heart disease. This risk increases the importance of understanding both the safety and efficacy of the serotonin selective reuptake inhibitors (SSRIs) in this population. Three recent studies on safety data in patients with overt heart disease are now available: although the total of 94 patients limits the ability to make generalizations, the data that are available give little evidence of harm and even suggest that SSRIs may have beneficial effects in ischemic heart disease.

Effect of presurgical incisor extrusion on stability of anterior open bite malocclusion treated with orthognathic surgery.

The records of 40 nongrowing open bite patients treated with orthodontics and maxillary surgery were divided into two groups and evaluated. The extrusion group (n = 19) included those patients who had presurgical maxillary incisor extrusion of at least 1.5 mm. In the nonextrusion group (n = 21), the maxillary incisors were maintained or intruded prior to surgery. Statistical analysis showed no relationship between presurgical extrusion of the maxillary incisors and the stability of open bite correction; the maxillary incisors were generally stable long term in both groups. Overbite decreased a mean of -0.97 mm in the extrusion group and -0.67 mm in the nonextrusion group during the mean 5-year 10-month follow-up period after appliance removal. Twenty-five percent (10 of 40, 5 from each group) of the sample had no incisal overlap long term. These findings suggest that a moderate amount of presurgical incisor extrusion or lack of extrusion are stable long term and have little influence on posttreatment stability of open bites. The decrease in overbite observed after treatment may result from the influence of various dental, skeletal, and soft tissue factors rather than from any single factor.

Depression and the course of coronary artery disease.

Literature and folk wisdom have long linked depression and death; however, only recently have scientific studies examined the relation between them. Beginning in the 1970s, investigators compared mortality among patients treated for major depression and the general population. Nine of ten studies found an increased mortality from cardiovascular disease among depressed patients. However, such studies confound the relation between depression and its treatment. Community surveys circumvent this difficulty, but as these studies began to appear, other investigations revealed the strong association between depression and cigarette smoking, which made obvious a need to control for smoking. The first study to do this appeared in 1993, and not only did a relation between depression and mortality persist, but a relation between depression and the development of ischemic disease was revealed. In the past 2 years, six more community surveys have followed populations initially free of disease, and five have observed an increased risk of ischemic heart disease among depressed persons. Another research strategy is to start with subjects who have preexisting cardiovascular disease. Here, too, depression has consistently been associated with a worse outcome. In one well-designed study, patients with depression in the period immediately after a myocardial infarction were 3.5 times more likely to die than nondepressed patients. The basis of this association remains speculative. However, it is likely that the changes in the autonomic nervous system and platelets that are seen in depression account for a substantial portion of the association.

A 3-year follow-up study of various types of orthodontic canine-to-canine retainers.

The present study was performed to test the tendency for plaque and calculus build-up along the wire of different types of bonded orthodontic canine-to-canine retainers, whether the presence of such retainers causes any damage to the teeth involved, the failure rate of the retainers, and any changes in incisor alignment during a 3-year period of retention. The four test groups received either retainers made of thick plain wire bonded only to the canines (n = 11); thick spiral wire bonded only to the canines (n = 13); thin, flexible spiral wire bonded to each tooth (n = 11); or removable retainers (n = 14). Accumulation of plaque and calculus along the gingival margin, gingival inflammation and probing attachment level were scored in lingual areas from canine to canine at the time of fixed appliance removal and again 3 years after retainer insertion. Incisor irregularity was measured on plaster models made at the same time periods. Accumulation of plaque and calculus and development of caries along the wire were scored at follow-up. Retainer failures were recorded whenever they occurred. The results revealed no intergroup differences in changes between baseline and follow-up examinations or status along the retainer wire for any of the variables. Gingival inflammation and plaque accumulation were scored less frequently after 3 years in retention than at the time of debonding. No signs of caries were seen adjacent to the wire. Failures were observed of one, four and three of the fixed retainer types, respectively. These patients showed a greater increase in incisor irregularity than the other patients.

Blood pressure variability responses to tilt are buffered by cardiac autonomic control.

Variability in blood pressure (BPV) is influenced by vascular sympathetic drive as well as autonomic control of the heart. Evidence suggests that elimination of cardiac autonomic control, as measured by heart period variability (HPV), produces a reduction in BPV at rest but an increase in BPV during challenge. We recently showed that the BPV response to psychological challenge, which principally produces cardiac parasympathetic withdrawal, was inversely related to the subject's level of cardiac control. In the current study we examined the BPV response to orthostatic tilt, a sympathetic stressor. Subjects were 22 healthy men and women who differed in cardiac control due in part to differences in aerobic capacity. HPV and BPV were measured noninvasively on a beat-to-beat basis. Tilt produced significant increases in heart rate and diastolic blood pressure and a significant decrease in high frequency HPV. As predicted, changes in BPV in response to tilt were inversely related to resting HPV. Results are interpreted in terms of a model of cardiovascular control which holds that BPV originates from feedforward effects of central control of the heart, feedback effects mediated through the baroreflexes, and direct sympathetic vascular effects.

Cardiac autonomic control is inversely related to blood pressure variability responses to psychological challenge.

Blood pressure exhibits variability (BPV) at low (0.02- to 0.07-Hz), mid (0.07- to 0.15-Hz)-, and high (0.15- to 0.50-Hz) frequencies. Evidence suggests that BPV responses to challenge are inversely related to cardiac autonomic control. We tested this hypothesis by examining the BPV responses to psychological stressors in 22 normal subjects who differed in cardiac control, operationalized as resting heart period variability (HPV). HPV and BPV were measured noninvasively or a beat-to-beat basis. The stressors produced a significant increase in heart rate and a small but significant increase in diastolic blood pressure. As predicted, the changes in BPV in response to the stressors were inversely related to resting HPV. The results are interpreted in terms of a model of cardiovascular control that holds that BPV originates from feedforward effects of central control of the heart, feedback effects mediated through the baroreflexes, and direct sympathetic vascular effects.

Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial.

OBJECTIVE: The role of complementary medicine techniques has generated increasing interest in today's society. The purpose of our study was to evaluate the effects of one technique, self-hypnosis, and its role in coronary artery bypass surgery. We hypotesize that self-hypnosis relaxation techniques will have a positive effect on the patient's mental and physical condition following coronary artery bypass surgery. EXPERIMENTAL DESIGN: A prospective, randomized trial was conducted. Patients were followed beginning one day prior to surgery until the time of discharge from the hospital. SETTING: The study was conducted at Columbia Presbyterian Medical Center, a large tertiary care teaching institution. PATIENTS: All patients undergoing first-time elective coronary artery bypass surgery were eligible. A total of 32 patients were randomized into two groups. INTERVENTIONS: The study group was taught self-hypnosis relaxation techniques preoperatively, with no therapy in the control group. MEASURES: Outcome variables studied included anesthetic requirements, operative parameters, postoperative pain medication requirements, quality of life, hospital stay, major morbidity and mortality. RESULTS: Patients who were taught self-hypnosis relaxation techniques were significantly more relaxed postoperatively compared to the control group (p=0.032). Pain medication requirements were also significantly less in patients practising the self-hypnosis relaxation techniques that those who were noncompliant (p=0.046). No differences were noted in intraoperative parameters, morbidity or mortality. CONCLUSION: This study demonstrates the beneficial effects self-hypnosis relaxation techniques on patients undergoing coronary artery bypass surgery. It also provides a framework to study complementary techniques and the limitations encountered.

Left ventricular assist devices. Psychosocial burden and implications for heart transplant programs.

Left ventricular assist devices (LVADs) driven by external sources and capable of sustaining life over weeks to months as a bridge to heart transplantation have been implanted in over 300 patients in the United States. Because of the limited availability of organs for transplantation, the remarkable degree to which LVADs reverse end-organ dysfunction, and patient acceptance, proposals for home LVAD treatment and for use of the LVAD as a permanent treatment for heart failure are being considered. LVAD therapy is associated with characteristic psychiatric and psychosocial problems, however, which must be addressed to optimize results. Among the first 30 LVAD patients treated at our center, psychiatric interventions were frequently required for family stress, major depression, organic mental syndromes, and serious adjustment disorders. Psychiatric problems most often occurred in patients with ongoing medical complications following LVAD implantation, and often significantly impaired rehabilitation. Both depression and organic mental syndromes were frequently associated with preexisting cerebrovascular disease, which was sometimes occult, and with strokes complicating LVAD therapy. Aggressive treatment of depression played a major role in improving functional status. LVADs may decompress heart transplant waiting lists and make it possible to optimize patients' physiological and functional status before transplantation. With increased LVAD use, however, neuropsychiatric factors can be expected to play a large role in determining quality of life and outcome both before and after heart transplantation.

Psychiatric aspects of cardiovascular disease.

The co-occurrence of psychiatric and cardiac disease in many patients exemplifies the complexity of psychosomatic medicine, with both psychosomatic and somatopsychic effects. Psychological factors including depression, anxiety, and hostility influence the development, clinical expression, and prognosis of coronary heart disease. Depression and anxiety are especially common problems complicating cardiac disease. The physician must approach the patient with an appreciation of the confounding aspects of diagnosis and a readiness to think flexibly about the nature of the problems encountered. SSRIs play an increasingly prominent role in psychopharmacotherapy of this population. Innovative treatments in cardiology, such as heart transplantation, defibrillators and mechanical ventricular assist devices are associated with characteristic psychiatric problems for which psychiatrists must devise treatment strategies.