Glycaemic control and self-management behaviours in Type 2 diabetes: results from a 1-year longitudinal cohort study.

AIM: To better understand the associations between changes in self-management behaviours and glycaemic control. METHODS: We conducted a prospective observational study of 295 adult patients with Type 2 diabetes evaluated at baseline, 6 and 12 months. Four self-management behaviours were evaluated using the Summary of Diabetes Self-Care Activities instrument, which assesses healthy diet, physical activity, medication taking and self-monitoring of blood glucose. Using hierarchical linear regression models, we tested whether changes in self-management behaviours were associated with short-term (6-month) or long-term (12-month) changes in glycaemic control, after controlling for demographic and clinical characteristics. RESULTS: Improved diet was associated with a decrease in HbA1c level, both at 6 and 12 months. Improved medication taking was associated with short-term improvement in glycaemic control, while increased self-monitoring of blood glucose frequency was associated with a 12-month improvement in HbA1c . Completely stopping exercise after being physically active at baseline was associated with a rise in HbA1c level at 6-month follow-up. Interaction analysis indicated that a healthy diet benefitted all participant subgroups, but that medication taking was associated with glycaemic control only for participants living in poverty and more strongly for those with lower educational levels. Finally, a higher self-monitoring of blood glucose frequency was associated with better glycaemic control only in insulin-treated participants. CONCLUSIONS: Even after adjusting for potential confounders (including baseline HbA1c ), increased frequency of healthy diet, medication taking and self-monitoring of blood glucose were associated with improved HbA1c levels. These self-management behaviours should be regularly monitored to identify patients at risk of deterioration in glycaemic control. Barriers to optimum self-management should be removed, particularly among socio-economically disadvantaged populations.

Relationship between n-3 and n-6 plasma fatty acid levels and insulin resistance in coronary patients with and without metabolic syndrome.

BACKGROUND AND AIMS: Animal studies show that ecosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are effective for the prevention and treatment of insulin resistance (IR). Data from human studies are contradictory. We sought to determine whether the relationships between plasma n-3 and n-6 polyunsaturated fatty acid (FA) levels and IR differ according to the presence or absence of metabolic syndrome (MS) in a coronary heart disease sample. METHOD AND RESULTS: Clinical, metabolic parameters, plasma phospholipid FA profiles and indirect measurement of IR (homeostatic model assessment-HOMA) were measured in 734 subjects, 8 weeks following acute coronary syndrome. FA levels and their correlations with IR were compared in subjects with and without MS. MS patients had higher saturated (16:0, 18:0) and n-6 (18:3n-6, 20:3n-6, 22:4n-6, 22:5n-6) FA levels, and lower EPA and DHA levels. HOMA-IR correlated positively with total saturated (r=0.13, P=0.017) and n-6 (r=0.17, P=0.001) FA levels and negatively with total n-3 FA levels (r=-0.13, P=0.012), in MS subjects only. Total n-3 and n-6 FAs and n-6/n-3 ratio were associated with HOMA-IR levels in MS subjects independent of total saturated FA levels, age, sex, sedentary behaviour, smoking, waist circumference, triglycerides, HDL-cholesterol, and systolic blood pressure. CONCLUSIONS: Relationships between polyunsaturated FA type and IR vary according to the presence or absence of MS. N-3 FAs including EPA and DHA are associated with lower HOMA-IR, while the opposite is true for n-6 FAs. Prospective studies are required to address the potential effects of intermediate dose EPA and DHA on glucose handling in MS patients.

[Impact of psychiatric disturbances on the outcome of coronary bypass surgery]. / Impact des troubles psychiques sur les suites d'un pontage coronaire.

The influence of anxiety and depression on the development and prognosis of coronary disease seems to be well established but there are few studies of the effects of these disturbances on the postoperative outcome of coronary surgery. The object of this review of the literature was to present recent data on this subject and to suggest therapeutic strategies for patients referred for coronary bypass surgery to improve their quality of life and even cardiovascular prognosis.

Alexithymia following myocardial infarction: psychometric properties and correlates of the Toronto Alexithymia Scale.

OBJECTIVE: The purpose was to explore the psychometrics and correlates of the Toronto Alexithymia Scale (TAS-20) after myocardial infarction (MI). METHODS: The TAS-20 and other self-report measures were administered 3-6 months after discharge to 1443 patients. RESULTS: Good internal reliability was confirmed for the total TAS-20 and two subscales (F1 and F2). The F3 showed low internal consistency linked to negatively keyed items. The prevalence of alexithymia was 30.2% at the first interview. Alexithymics were older, less educated, more likely to have previous MIs and had higher scores on all measures of negative emotions. Six-month test-retest reliability was.47 (n=167). Residual change score analysis showed patients with more education and a first MI had greater decreases in alexithymia than expected. CONCLUSIONS: The TAS-20 has adequate internal consistency in post-MI patients, and its correlates are similar to other reports. Low temporal stability suggests that secondary alexithymia is important after MI.

Clinical implications of a reduction in psychological distress on cardiac prognosis in patients participating in a psychosocial intervention program.

OBJECTIVE: The objective of this secondary analysis was to examine the relationships between a reduction in psychological distress and long-term cardiac and psychological outcomes in post-myocardial infarction patients who participated in a randomized trial of home-based psychosocial nursing interventions (the Montreal Heart Attack Readjustment Trial [M-HART]). Gender differences were considered. METHODS: We studied 433 patients (36.0% women) from the M-HART treatment group who received two home visits after achieving a high psychological distress score (ie, > or =5) on the General Health Questionnaire (GHQ). Short-term GHQ success was determined by a return to a normal GHQ score (<5) or a reduction of > or =50% after the two visits. Patients with short-term successful and unsuccessful GHQ outcomes were compared for mid-term maintenance of success, 1-year death and readmission rates, and 1-year depression and anxiety symptoms. RESULTS: Patients with short-term GHQ success were more likely to show mid-term GHQ success (p < .001), marginally less likely to die of any causes (p = .087), less likely to die of cardiac causes (p = .043), less likely to be readmitted for any reason (p < .001) and for cardiac reasons (p < .001), and less likely to have high depression (p < .001) and anxiety (p < .001) at 1-year than patients with short-term unsuccessful GHQ outcomes. Results held for men and women and were not altered by controlling for potential confounders. However, the number of deaths prevented analysis with statistical controls. CONCLUSIONS: Post-myocardial infarction interventions that reduce psychological distress have the potential to improve long-term prognosis and psychological status for both men and women.

Psychosocial factors as predictors of functional status at 1 year in patients with left ventricular dysfunction.

Chronic heart failure patients often experience significant functional impairments. A better understanding of the biopsychosocial correlates of functional status may lead to interventions that improve quality of life in this population. Social isolation, mood disturbance, low socioeconomic status, and non-White ethnicity were evaluated as possible correlates of impaired functional status in 2,992 U.S. patients with left ventricular ejection fractions (LVEFs)

Depression in patients with cardiac disease: a practical review.

Some degree of depression affects at least 30% of hospitalized patients with coronary artery disease (CAD), and is associated with increased risks of mortality and continuing depression over at least the first year following hospital discharge. Despite its consequences for prognosis and quality of life, depression is underrecognized and undertreated in cardiac patients. The diagnosis of depression is complicated in patients with medical illness. Their symptoms can reflect physical as well as psychological complaints. Many CAD patients resist the idea of additional medications, and drug interactions can be problematic for those willing to accept antidepressant treatment. Finally, depression tends to recur. Its successful treatment requires a long-term commitment from both physician and patient. This article examines the special challenges involved in diagnosing depression in patients with CAD, outlines available psychotherapeutic and pharmacological treatments, and considers the issues involved in deciding which patients to treat, with what approach, and for how long.

Depression and health-care costs during the first year following myocardial infarction.

OBJECTIVE: Depression in the hospital after myocardial infarction (MI) has been associated with a substantial increase in the long-term risk of cardiac mortality, but little is known about other outcomes. This study uses Quebec Medicare data to examine the relationship between post-MI depression and physician costs, including both out-patient care and hospital readmissions. METHODS: The sample consists of 848 1-year survivors of an acute MI who had completed the Beck Depression Inventory (BDI) in hospital. Two hundred sixty subjects had BDI scores of >/=10 (30.7%), indicative of mild to moderate symptoms of depression. Quebec Medicare data during the index admission for an acute MI and during the year following discharge were compared for the patients with elevated BDI scores and those with normal scores. RESULTS: Total costs, in Canadian dollars (out-patient physician charges plus physician costs during admissions plus estimates of associated direct costs), were about 41% higher (p = 0.004) for patients with elevated BDI scores. The difference was primarily related to out-patient and emergency room visits and readmission costs associated with longer stays in hospital wards, and was not accounted for by use of psychiatric services or readmissions for revascularization. CONCLUSION: Results suggest that, in addition to the survival risks associated with post-MI depression, there are increased health care costs linked to both readmissions and out-patient contacts among depressed patients who survive the first post-MI year. The extent to which the increased use of health care may have reduced depression and enhanced survival remains unclear.

Depression and 1-year prognosis in unstable angina.

BACKGROUND: Depression is common after acute myocardial infarction and is associated with an increased risk of mortality for at least 18 months. The prevalence and prognostic impact of depression in patients with unstable angina, who account for a substantial portion of acute coronary syndrome admissions, have not been examined. METHODS: Interviews were carried out in hospital with 430 patients with unstable angina who did not require coronary artery bypass surgery before hospital discharge. Depression was assessed using the 21-item self-report Beck Depression Inventory and was defined as a score of 10 or higher. The primary outcome was 1-year cardiac death or nonfatal myocardial infarction. RESULTS: The Beck Depression Inventory identified depression in 41.4% of patients. Depressed patients were more likely to experience cardiac death or nonfatal myocardial infarction than other patients (odds ratio, 4.68; 95% confidence interval, 1.94-11.27; P<.001). The impact of depression remained after controlling for other significant prognostic factors, including baseline electrocardiographic evidence of ischemia, left ventricular ejection fraction, and the number of diseased coronary vessels (adjusted odds ratio, 6.73; 95% confidence interval, 2.43-18.64; P<.001). CONCLUSIONS: Depression is common following an episode of unstable angina and is associated with an increased risk of major cardiac events during the following year.

Social support, depression, and mortality during the first year after myocardial infarction.

BACKGROUND: We previously reported that depression after myocardial infarction (MI) increases the long-term risk of cardiac mortality. Other research suggests that social support may also influence prognosis. This article examines the interrelationships between baseline depression and social support in terms of cardiac prognosis and changes in depression symptoms over the first post-MI year. METHODS AND RESULTS: For this study, 887 patients completed the Beck Depression Inventory (BDI) and the Perceived Social Support Scale (PSSS) at about 7 days after MI. Some 32% had BDIs > or =10, indicating mild to moderate depression. One-year survival status was determined for all patients. Follow-up interviews, including the BDI, were conducted with 89% of survivors. There were 39 deaths (35 cardiac). Elevated BDI scores were related to cardiac mortality (P=0.0006), but PSSS scores and other measures of social support were not. There was a significant interaction between depression and the PSSS (P=0. 016). The relationship between depression and cardiac mortality decreased with increasing support. Furthermore, residual change score analysis revealed that among 1-year survivors who had been depressed at baseline, higher baseline social support was related to more improvement in depression symptoms than expected. CONCLUSIONS: Post-MI depression is a predictor of 1-year cardiac mortality, but social support is not directly related to survival. However, very high levels of support appear to buffer the impact of depression on mortality. Furthermore, high levels of support predict improvements in depression symptoms over the first post-MI year in depressed patients. High levels of support may protect patients from the negative prognostic consequences of depression because of improvements in depression symptoms.

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.

Gender, depression, and one-year prognosis after myocardial infarction.

OBJECTIVE: The purpose of this study was to assess gender differences in the impact of depression on 1-year cardiac mortality in patients hospitalized for an acute myocardial infarction (MI). METHODS: Secondary analysis was performed on data from two studies that used the Beck Depression Inventory (BDI) to assess depression symptoms during hospitalization: a prospective study of post-MI risk and a randomized trial of psychosocial intervention (control group only). The sample included 896 patients (283 women) who survived to discharge and received usual posthospital care. Multivariate logistic regression analysis was used to assess the risk of 1-year cardiac mortality associated with baseline BDI scores. RESULTS: There were 290 patients (133 women) with BDI scores > or =10 (at least mild to moderate symptoms of depression); 8.3% of the depressed women died of cardiac causes in contrast to 2.7% of the nondepressed. For depressed men, the rate of cardiac death was 7.0% in contrast to 2.4% of the nondepressed. Increased BDI scores were significantly related to cardiac mortality for both genders [the odds ratio for women was 3.29 (95% confidence interval (CI) = 1.02-10.59); for men, the odds ratio was 3.05 (95% CI = 1.29-7.17)]. Control for other multivariate predictors of mortality in the data set (age, Killip class, the interactions of gender by non-Q wave MI, gender by left ventricular ejection fraction, and gender by smoking) did not change the impact of the BDI for either gender. CONCLUSIONS: Depression in hospital after MI is a significant predictor of 1-year cardiac mortality for women as well as for men, and its impact is largely independent of other post-MI risks.

Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction.

BACKGROUND: Increases in life stress have been linked to poor prognosis, after myocardial infarction (MI). Previous research suggested that a programme of monthly screening for psychological distress, combined with supportive and educational home nursing interventions for distressed patients, may improve post-MI survival among men. Our study assessed this approach for both men and women. We aimed to find out whether the programme would reduce 1-year cardiac mortality for women and men. METHODS: We carried out a randomised, controlled trial of 1376 post-MI patients (903 men, 473 women) assigned to the intervention programme (n = 692) or usual care (n = 684) for 1 year. All patients completed a baseline interview that included assessment of depression and anxiety. Survivors were also interviewed at 1 year. FINDINGS: The programme had no overall survival impact. Preplanned analyses showed higher cardiac (9.4 vs 5.0%, p = 0.064) and all-cause mortality (10.3 vs 5.4%, p = 0.051) among women in the intervention group. There was no evidence of either benefit or harm among men (cardiac mortality 2.4 vs 2.5%, p = 0.94; all-cause mortality 3.1 vs 3.1%, p = 0.93). The programme's impact on depression and anxiety among survivors was small. INTERPRETATION: Our results do not warrant the routine implementation of programmes that involve psychological-distress screening and home nursing intervention for patients recovering from MI. The poorer overall outcome for women, and the possible harmful impact of the intervention on women, underline the need for further research and the inclusion of adequate numbers of women in future post-MI trials.

Major depression before and after myocardial infarction: its nature and consequences.

The prevalence and prognostic impact of previous depression, depression in the hospital, and depression after discharge were studied in 222 patients admitted for acute myocardial infarction (MI). Patients were interviewed 1 week, 6 months, and 12 months after the index MI using a modified version of the Diagnostic Interview Schedule (DIS); patients also completed the Beck Depression Inventory (BDI). Patients or family members were recontacted at 18 months to determine survival. Some 27.5% of patients had at least one episode of major depression before their MI, but only 7.7% were depressed at some point during the year preceding the infarct. Overall, 31.5% of patients experienced depression in the hospital or during the year postdischarge. Some 35 patients were depressed in the hospital, 30 became depressed between discharge and 6 months, and five more between 6 and 12 months after the MI. History of depression increased the risk of depression in the hospital and after discharge. Depression in the hospital was associated with an increased risk of mortality over 18 months. Patients who experienced a recurrent depression in the hospital were at particularly high risk. Although patients who became depressed after discharge differed from those who remained depression-free in terms of age, history of depression, BDI scores, and the number of depression symptoms on the DIS in the hospital, a model including these variables identified only 14.7% of the patients who became depressed after returning home. Post-MI depression is common and largely unrelated to medical and psychosocial factors.

The impact of negative emotions on prognosis following myocardial infarction: is it more than depression?

This study examine the importance of major depression symptoms, history of major depression, anxiety, anger-in, anger-out, and perceived social support, measured in the hospital after a myocardial infarction (MI), in predicting cardiac events over the subsequent 12 months in a sample of 222 patients. Cardiac events included both recurrences of acute coronary syndromes (unstable angina admissions and survived and nonsurvived MI recurrences) and probable arrhythmic events (survived cardiac arrests and arrhythmic deaths). Major depression, depressive symptoms, anxiety, and history of major depression all significantly predicted cardiac events. Multivariate analyses showed that depressive symptoms, anxiety, and history of major depression each had an impact independent of each other, as well as of measures of cardiac disease severity.