Cardiac medication use in patients with suspected ischaemia without obstructive coronary arteries: sex differences and psychological distress.

BACKGROUND: Ischaemia without obstructive coronary arteries (INOCA) is more prevalent in women and associated with psychological distress. Pharmacological treatment goals are angina relief and cardiovascular risk management. The present study aims to examine sex differences in cardiac and non-cardiac medication use, as well as medication and sex differences related to consistent psychological distress in patients with suspected INOCA. DESIGN: A TweeSteden mild stenosis observational cohort study in patients with suspected INOCA as detected by ischaemic reason for referral and non-obstructive arteries based on coronary angiography or computed tomography. METHODS: Medication documented in the hospital records of 488 patients (53% women) was coded as angina relief medication, blood-pressure-lowering medication, antithrombotics, statins, and non-cardiac medication, using the Anatomical Therapeutic Chemical code. Depressive symptoms and anxiety were recoded as 'consistent distress' (above the cut-off score for depression and anxiety on validated questionnaires), 'inconsistent distress' (above the cut-off for depression or anxiety) or 'no distress' (below the cut-off). RESULTS: No sex differences were observed in cardiac medication use. Women used anxiolytic benzodiazepines more often (12% vs 4%, p = 0.002) compared to men. Consistent distress was more prevalent in women (22% vs 15%, p = 0.004) and was related to the use of more angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and diuretics in women and to calcium antagonist use as well as lower adherence levels in men. Women who reported chest pain more often received angina relief medication and blood-pressure-lowering medication than men. CONCLUSION: No sex differences were observed in cardiac medication use in patients with suspected INOCA. Psychological distress may reflect hypertension and subsequent medication use in women, and experiencing chest pain and subsequent medication use in men.

Psychological and clinical characteristics of female patients with spontaneous coronary artery dissection.

AIMS: Spontaneous coronary artery dissection (SCAD) is increasingly recognised as a cause of myocardial infarction, but psychological characteristics of patients with SCAD have not yet been extensively investigated. We assessed the prevalence of a broad range of psychological and clinical factors, and their inter-relationships in patients with a history of SCAD. Furthermore, we investigated whether specific clusters of patients with SCAD can be identified. METHODS: Participants were recruited between March and May 2019 from a Dutch SCAD database and completed online questionnaires. Clinical information was verified by review of medical records. Participants were predominantly female (172/183; 94%). Analyses focused on the 172 female patients (mean age 52.0 ± 7.5 years, 37% postmenopausal). RESULTS: The most common comorbidities of SCAD were migraine (52%), fibromuscular dysplasia (FMD; 29%), chronic pain (29%), and tinnitus (28%). Six women (3%) had pregnancy-associated SCAD. Traditional cardiovascular risk factors were rare (<10%), except for hypertension (31%). Psychological assessment indicated high levels of perceived stress (PSS-10 ≥14; 50%), fatigue (FAS-10 ≥22; 56%), and a frequent history of burnout (25%). The prevalence of depression (9%) and anxiety (12%) was relatively low. Three clusters were identified: (A) FMD and chronic non-ischaemic conditions (tinnitus, chronic pain, and irritable bowel syndrome); (B) migraine; and (C) none of these conditions. CONCLUSION: This study shows that perceived stress and fatigue are common in patients with SCAD, in addition to prevalent comorbid FMD, migraine, tinnitus, and non-ischaemic pain conditions. These factors may add to developing tailored rehabilitation programmes for patients with SCAD.

Personality subtypes and chest pain in patients with nonobstructive coronary artery disease from the TweeSteden Mild Stenosis study: mediating effect of anxiety and depression.

BACKGROUND: Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing <60%) are at risk for emotional distress and future events. We aimed to examine the association of personality subtypes with persistent chest pain, and investigated the potential mediating effects of negative mood states. METHODS: Any chest pain in the past month was the primary outcome measure reported by 523 patients with nonobstructive CAD (mean age 61.4 years, SD = 9.4; 48% men), who participate in the TweeSteden Mild Stenosis (TWIST) observational cohort. Personality was categorized into a 'reference group', a high social inhibition ('SI only'), a high negative affectivity ('NA only') and a 'Type D' (NA and SI) group. Negative mood states included symptoms of depression and anxiety (Hospital Anxiety and Depression Scale) and cognitive and somatic depression (Beck Depression Inventory). The PROCESS macro was used to examine the relation between personality subtypes and chest pain presence, with the negative mood states as potential mediators. RESULTS: Persistent chest pain was present in 44% of the patients with nonobstructive CAD. Type D personality (OR = 1.91, 95% CI 1.24-2.95), but not the 'NA only' (OR = 1.48, 95% CI 0.89-2.44) or the 'SI only' (OR = 0.93, 95% CI 0.53-1.64) group was associated with chest pain, adjusted for age and sex. Negative mood states mediated the association between personality and chest pain. CONCLUSIONS: Type D personality, but not negative affectivity or social inhibition, was related to chest pain in nonobstructive CAD, which was mediated by negative mood states.

The association between diabetes and an episode of depressive symptoms in the 2002 World Health Survey: an analysis of 231,797 individuals from 47 countries.

AIMS: Depression is common in people with diabetes and increases the risk of poor health outcomes, including premature mortality. We explored the association between diabetes and an episode of depressive symptoms in a cross-sectional multinational study, which included a large number of low- and middle-income non-Western countries. METHODS: Data from 47 countries of the 2002 World Health Organization World Health Survey were used, including 231,797 adults (mean age 41 years, 53% female). Diabetes was assessed by self-report of diagnosis or treatment. The presence of an episode of depressive symptoms was assessed by self-report using an algorithm based on DSM-IV criteria. Odds ratios and 95% confidence intervals were calculated to quantify associations between diabetes and episodes of depressive symptoms in the entire sample and for countries aggregated into four continents: Africa, South America, Asia and Europe. Odds ratios were adjusted for age, sex, education, BMI, smoking and physical activity level. RESULTS: The prevalence of diabetes (mean 3.6%, range 0.2-13%) and episodes of depressive symptoms (mean 7.9%, range 0.4-38%) differed widely across countries. Globally, individuals with diabetes had increased odds of an episode of depressive symptoms compared with those without diabetes (adjusted odds ratio 2.36, 95% confidence interval 1.91-2.92). Similar associations were found in South America, Asia and Europe (odds ratio > 1.97), but not in Africa (odds ratio 0.86, 95% confidence interval 0.54-1.37). CONCLUSIONS: Globally, diabetes is associated with a twofold increased prevalence of an episode of depressive symptoms, except in Africa. Given the worldwide rise in diabetes in the coming decades, and the increased risk of poor diabetes outcomes associated with co-morbid depression, studies examining mechanisms and interventions are necessary.