Monday, March 9, 2009
Depression linked to cardiac death
Healthy women with severe depression have double the risk of sudden cardiac death, as well as higher risk for fatal coronary heart disease.
Depression and heart disease are linked by cardiovascular risk factors such as high blood pressure, diabetes, high cholesterol and smoking, which are more common among severely depressed women. Possible explanations could be autonomic dysfunction, higher resting heart rates and reduced heart rate variability.
Researchers prospectively studied 63,469 women from the Nurses Health Study with no evidence of prior heart disease or stroke between 1992 and 2004. They used self-reported symptoms of depression and antidepressant use, and then examined those with the most severe symptoms on a mental health index or those regularly using antidepressants. They reported their results in the Journal of the American College of Cardiology.
Low mental health index scores were associated with an increased risk of heart disease, with a hazard ratio of 1.5 after controlling for other risk factors. Sudden coronary death risk was 3.3 times greater in subjects who took antidepressants, more so than the mental health index scores, causing an editorial writer to raise the specter of needing further research into this drug class while emphasizing that the benefits outweigh the risk. As usual, one study raises more questions to answer. In the meantime, doctors should closely monitor patients with depression for risk factors for coronary heart disease.
Labels: cardiology, depression, heart, heart disease, heart failure
posted by Ryan DuBosar at
5:01 PM
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Wednesday, November 12, 2008
Power to the patient! (with your encouragement)
The theme of several late-breaking trials today seems to be, very loosely, patient empowerment. To wit:
One study compared atrial fib/heart valve patients on warfarin who were monitored monthly at a clinic with those who did weekly home INR testing. There was no difference in the primary outcome-- time to death, major bleed or stroke.
This is a case where a negative outcome isn't really bad. It's good to know, the author said, that patients can test at home just as well as in a clinic, especially for those who live in remote areas or have other barriers to getting to a clinic. Plus, patients were happier with the home testing approach, and Medicare covers it for AF, heart valve and VTE patients.
Next comes a sub-study of yesterday's HF-Action study on exercise and heart failure (see earlier post for main study). This one found patients who did exercise training reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years.
Quality of life is important in heart failure patients, because HF is a chronic, incurable disease, discussant Anne Taylor, MD said. She noted that in this study, the subjects were receiving optimal medical therapy, and were 59 years old on average-- while in the general population, heart failure patients don't always get OMT, and are older. Study author Ileana Pina, MD, responded that the group did plan to analyze the results in an older cohort, so stay tuned.
Finally, Lori Mosca, MD, reported on her group's creative study in which researchers screened and counseled the relatives of hospitalized patients about their health risk factors. The control group got a handout about reducing risks, while the intervention group got immediate feedback on screening tests, and a year of diet and exercise counseling.
LDL levels declined in both groups after a year-- a testament to how motivating it is to see a loved on get sick, Dr. Mosca said-- but there was no difference between groups. The intervention group had a significantly better diet score and exercised more, and their HDL went up slightly, while the control group's HDL declined. Both groups significantly decreased their saturated and trans fat consumption.
Given that both groups improved their behaviors after some level of intervention, hospitals have a unique opportunity to educate, motivate and help patients' relatives, observers noted. A lot of these relatives were unaware they had CV risks, Dr. Mosca said, and that awareness alone might have spurred them to action.
Labels: AHA Sessions, exercise, heart failure
posted by Jessica Berthold at
1:41 PM
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Tuesday, November 11, 2008
Heart failure, part two
Now it's time for the bummer news about heart failure (HF).
Historically, there's been no treatment that improves outcomes for those HF patients who have an ejection fraction of greater than or equal to 45%. And, we learned today, there still isn't.
Researchers studied whether treating these patients with irbesartan (an ARB) might lower death and hospitalizations for HF, MI, stroke and arrhythmia. It was the largest study of an ARB for this condition, ever, with 4,128 subjects and a 4.5 year follow-up. The average patient age was 72 years and 60% were women-- appropriate given that that this condition mostly affects women and older folks.
There was a difference in those who took irbesartan vs. placebo, but it wasn't significant. At least, the researchers said, the study showed the drug was safe, which means it could be a good substitute for patients who can't tolerate other hypertension drugs. But, as Philip Poole-Wilson, MD, said in his inimitable English accent about the exercise and heart failure study: "Safety without benefit is a bit dull, really."
Labels: AHA Sessions, heart failure
posted by Jessica Berthold at
2:16 PM
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Heart failure and exercise
It's heart failure day at AHA Scientific Sessions-- at least in terms of the late-breaking trials.
During a press conference about some of these trials, several physicians bemoaned the fact that the general public knows little about the common problem of heart failure. Milton Packer, MD, of the Univ. of Texas Southwestern Medical Center, quipped "We've been trying to find spokespeople for heart failure, but they are too short of breath to speak!" (Maybe that was funnier in person.)
One study looked at whether structured exercise training for HF patients reduced hospitalization or death rates. The results weren't statistically significant in the main analysis, but an adjusted analysis showed an 11% reduction in deaths/hospitalization, and a 15% reduction for CV mortality or HF hospitalization (a secondary endpoint).
The regimen in the study involved 36 supervised sessions of 30 mins of exercise 3x/week. At the 18th session, patients began to transition into exercising at home for 40 mins 5x/week by giving them a treadmill or exercise bike (wonder if they got to keep them once the study ended?) All patients were receiving optimal medication therapy.
There was some debate about how seriously to take the results, given that they were only significant after adjustment. The author, Dr. Christopher O'Connor of Duke, argued that since the adjustments were pre-specified, the analysis was "fair". He and several others also discussed how much more difficult it is to measure the effects of lifestyle interventions than, say, a drug-- suggesting one should cut this kind of study a little slack.
Dr. O'Connor also noted that the hazard ratios weren't much different in the two primary analyses: HR of 0.93 for main and 0.89 for adjusted. (The variables in the adjusted analysis, by the way, were CPX exercise duration, LVEF, Beck Depression Inventory and history of HF.)
It's also important to note there were no more adverse events-- like heart attack, angina or arrhythmia-- in the HF patients who exercised vs. those who got usual care. Both doctors and patients are often wary of prescribing exercise for HF patients, for fear of bad consequences, O'Connor said, so this provides some reassurance.
Labels: AHA Sessions, heart failure
posted by Jessica Berthold at
11:39 AM
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