Depressed older individuals have a higher mortality than older persons without depression. Depression is associated with physical inactivity, and low levels of physical activity have been shown in ...some cohorts to be a partial mediator of the relationship between depression and cardiovascular events and mortality.
A cohort of 5888 individuals (mean 72.8 ± 5.6 years, 58% female, 16% African-American) from four US communities was followed for an average of 10.3 years. Self-reported depressive symptoms (10-item Center for Epidemiological Studies Depression Scale) were assessed annually and self-reported physical activity was assessed at baseline and at 3 and 7 years. To estimate how much of the increased risk of cardiovascular mortality associated with depressive symptoms was due to physical inactivity, Cox regression with time-varying covariates was used to determine the percentage change in the log HR of depressive symptoms for cardiovascular mortality after adding physical activity variables.
At baseline, 20% of participants scored above the cut-off for depressive symptoms. There were 2915 deaths (49.8%), of which 1176 (20.1%) were from cardiovascular causes. Depressive symptoms and physical inactivity each independently increased the risk of cardiovascular mortality and were strongly associated with each other (all p < 0.001). Individuals with both depressive symptoms and physical inactivity had greater cardiovascular mortality than those with either individually (p < 0.001, log rank test). Physical inactivity reduced the log HR of depressive symptoms for cardiovascular mortality by 26% after adjustment. This was similar for persons with (25%) and without (23%) established coronary heart disease.
Physical inactivity accounted for a significant proportion of the risk of cardiovascular mortality due to depressive symptoms in older adults, regardless of coronary heart disease status.
Introduction
Cardiac adaptation to sustained exercise in the athletes is established. However, exercise‐associated effect on the cardiac function of the elderly has to be elucidated. The aim of this ...study was to analyse left (LV) and right ventricular (RV) characteristics at different levels of chronic exercise in the senior heart.
Materials and methods
We studied 178 participants in the World Senior Games (mean age 68 ± 8 years, 86 were men; 48%). Three groups were defined based on the type and intensity of sports: low‐, moderate‐ and high‐intensity level. Exclusion criteria were coronary artery disease, atrial fibrillation, valvular heart disease or uncontrolled hypertension. LV and RV size and function were evaluated with an echocardiogram.
Results
LV trans‐mitral inflow deceleration time decreased in parallel to the intensity of chronic exercise: 242 ± 54 ms in low‐, 221 ± 52 ms in moderate‐ and 215 ± 58 ms in high‐intensity level, p = .03. Left atrial volume index (LAVI) was larger in high‐intensity group, p = .001. The LAVI remained significantly larger when adjusting for age, gender, heart rate, hypertension and diabetes (p = .002). LV and RV sizes were larger in the high‐intensity group. LV ejection fraction and RV systolic function evaluated by tissue Doppler velocity, atrioventricular plane displacement and strain did not differ between groups.
Conclusion
Left ventricular diastolic filling is not only preserved, but may also be enhanced in long‐term, top‐level senior athletes. Moreover, LV and RV systolic function remain unchanged at different levels of exercise. This supports the beneficial effects of endurance exercise participation in senior hearts.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
To examine the strength and consistency of the evidence on the relationship between depression and adherence to antihypertensive medications.
The MEDLINE, CINAHL, PsycINFO, Embase, SCOPUS, and ISI ...databases were searched from inception until 11 December 2009 for published studies of original research that assessed adherence to antihypertensive medications and used a standardized interview, validated questionnaire, or International Classification of Diseases Ninth Revision code to assess depression or symptoms of depression in patients with hypertension. Manual searching was conducted on 22 selected journals. Citations of included articles were tracked using Web of Science and Google Scholar. Two investigators independently extracted data from the selected articles and discrepancies were resolved by consensus.
Eight studies were identified that included a total of 42,790 patients. Ninety-five percent of these patients were from one study. Only four of the studies had the assessment of this relationship as a primary objective. Adherence rates varied from 29 to 91%. There were widely varying results within and across studies. All eight studies reported at least one significant bivariate or multivariate negative relationship between depression and adherence to antihypertensive medications. Insignificant findings in bivariate or multivariate analyses were reported in six of eight studies.
All studies reported statistically significant relationships between depression and poor adherence to antihypertensive medications, but definitive conclusions cannot be drawn because of substantial heterogeneity between studies with respect to the assessment of depression and adherence, as well as inconsistencies in results both within and between studies. Additional studies would help clarify this relationship.
Background
Accurate assessment of cardiac structures, ventricular function, and hemodynamics is essential for any echocardiographic laboratory. Quality improvement (QI) processes described by the ...American Society of Echocardiography (ASE) and the Intersocietal Commission (IAC) should be instrumental in reaching this goal.
Methods
All patients undergoing transthoracic echocardiogram (TTE) followed by cardiac catheterization within 24 hours at Christiana Care Health System in 2011 and 2012 were identified, with 126 and 133 cases, respectively. Hemodynamic parameters of diastolic function and pulmonary artery systolic pressure (PASP) on TTE correlated poorly with catheterization in 2011. An educational process was developed and implemented at quarterly QI meetings based on ASE and IAC recommendations to target frequently encountered errors and provide methods for improved performance. The hemodynamic parameters were then reexamined in 2012 postintervention.
Results
Following the QI process, there was significant improvement in the correlation between invasive and echocardiographic hemodynamic measurements in both systolic and diastolic function, and PASP. This reflected in significant better correlations between echo and cath LVEF R = 0.88, ICC = 0.87 vs. R = 0.85, ICC = 0.85; P < 0.001, average E/E′ and of left ventricle end‐diastolic pressure (LVEDP) R = 0.62 vs. R = 0.09, P = 0.006 and a better correlation for PASP R = 0.77, ICC = 0.77 vs. R = 0.30, ICC = 0.31; P = 0.05 in 2012 compared to 2011.
Conclusion
The QI process, as recommended by ASE and IAC, can allow for identification as well as rectification of quality issues in a large regional academic medical center hospital.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Many critical treatment decisions are based on the medical history of patients with an acute coronary syndrome (ACS). Discrepancies between the medical history documented by a health professional and ...the patient's own report may therefore have important health consequences.
Medical histories of 117 patients with an ACS were documented. A questionnaire assessing the patient's health history was then completed by 62 eligible patients. Information about 13 health conditions with relevance to ACS management was obtained from the questionnaire and the medical record. Concordance between these two sources and reasons for discordance were identified.
There was significant variation in agreement, from very poor in angina (kappa < 0) to almost perfect in diabetes (kappa = 0.94). Agreement was substantial in cerebrovascular accident (kappa = 0.76) and hypertension (kappa = 0.73); moderate in cocaine use (kappa = 0.54), smoking (kappa = 0.46), kidney disease (kappa = 0.52) and congestive heart failure (kappa = 0.54); and fair in arrhythmia (kappa = 0.37), myocardial infarction (kappa = 0.31), other cardiovascular diseases (kappa = 0.37) and bronchitis/pneumonia (kappa = 0.31). The odds of agreement was 42% higher among individuals with at least some college education (OR = 1.42; 95% CI, 1.00 - 2.01, p = 0.053). Listing of a condition in medical record but not in the questionnaire was a common cause of discordance.
Discrepancies in aspects of the medical history may have important effects on the care of ACS patients. Future research focused on identifying the most effective and efficient means to obtain accurate health information may improve ACS patient care quality and safety.
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CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract only Healthy Community Initiatives is a means of directly impacting the health and well-being of the cities and communities served by the Cleveland Clinic. The Health Challenge is the ...signature program of the Cleveland Clinic Healthy Community Initiatives. It is a collaborative effort between Cleveland Clinic and community partners to engage individuals in the community to help manage chronic conditions and promote a healthier lifestyle. The population is the Cleveland Clinic Central region and other nearby neighborhoods impacting 59 zip codes. Each Health Challenge lasted 8 weeks. Neighborhood participants representing each area acquired points by attending health and wellness classes and events held at the Cleveland Clinic community center and partner locations. Individuals are awarded points for participation and improvement in biometric results and/or completion of a clinical appointment. Data was collected by summing up scores received from the different events in the health challenges as noted : Pre-Program Health Screening (1 point), Post-Program Health Screening (1 point), Decrease in BMI at End of Program (1 Point), Decrease in Blood Pressure at End of Program (1 point), Attend classes, programs, or exercise sessions at partner organizations (1 point), Attend classes, programs, or exercise sessions (2 points), mammography (5 points) and Women's Clinic Appointment (5 points) at the Cleveland Clinic Community Center. The winner of individual health challenge was determined by a point system based on participation and completion percentage. There were 17 eight week Health Challenges held in 2018 and 2019 in which a total of 1889 participants enrolled. Average age was 60 years. Average participant attended 9.4 classes/programs or exercise sessions during the 8 week program - total number attended by all the participants was 7,433. The completion percentage was 47.6%. From 2018 to 2019, enrollment increased by 24.9%, weight (by pounds) decreased by 27.7% (a net total of 2,133.7 pounds lost). However, completion rate decreased by 6.6%. Blood pressure abnormality (number of participants with stage 2 blood pressure abnormality decreased from 33% to 23% (national average 28.3%) ; initial lack of physical activity decreased from 51.2% to 32.2% (national average 25.4%) , initial lack of sleep decreased from 50.2% to 41% (national average 29.2%). The main objective of this report is to show how community health interventions such as these have positive impact on the health and well-being of both individuals and community at large. It is anticipated that dissemination of the positive outcomes of these community health interventions will encourage and consolidate healthy behaviors. It may also create incentives for both community and institutional investment and support in such beneficial health focused activities at the grassroots level.
Healthcare is of such vital importance to every individual that it is considered by some to be a human right applicable to all human beings. Unfortunately, given this infinite demand, healthcare ...resources are limited even in rich countries and therefore need to be distributed efficiently to avoid waste. Thus, the relative value of a health intervention - cost compared with its effectiveness - needs to be taken into consideration when deciding which interventions to adopt. Cost-effectiveness analysis provides the crucial information that guides these decisions. As the field of medicine and indeed cardiology move forward with innovations that are effective but often expensive, it becomes imperative to employ these cost-effectiveness analytic tools, not with the intention of denying vital health services but to ascertain what society is willing to pay for.
CONTEXT Several practice guidelines recommend that depression be evaluated and treated in patients with cardiovascular disease, but the potential benefits of this are unclear. OBJECTIVE To evaluate ...the potential benefits of depression screening in patients with cardiovascular disease by assessing (1) the accuracy of depression screening instruments; (2) the effect of depression treatment on depression and cardiac outcomes; and (3) the effect of screening on depression and cardiac outcomes in patients in cardiovascular care settings. DATA SOURCES MEDLINE, PsycINFO, CINAHL, EMBASE, ISI, SCOPUS, and Cochrane databases from inception to May 1, 2008; manual journal searches; reference list reviews; and citation tracking of included articles. STUDY SELECTION We included articles in any language about patients in cardiovascular care settings that (1) compared a screening instrument to a valid major depressive disorder criterion standard; (2) compared depression treatment with placebo or usual care in a randomized controlled trial; or (3) assessed the effect of screening on depression identification and treatment rates, depression, or cardiac outcomes. DATA EXTRACTION Methodological characteristics and outcomes were extracted by 2 investigators. RESULTS We identified 11 studies about screening accuracy, 6 depression treatment trials, but no studies that evaluated the effects of screening on depression or cardiovascular outcomes. In studies that tested depression screening instruments using a priori-defined cutoff scores, sensitivity ranged from 39% to 100% (median, 84%) and specificity ranged from 58% to 94% (median, 79%). Depression treatment with medication or cognitive behavioral therapy resulted in modest reductions in depressive symptoms (effect size, 0.20-0.38; r2, 1%-4%). There was no evidence that depression treatment improved cardiac outcomes. Among patients with depression and history of myocardial infarction in the ENRICHD trial, there was no difference in event-free survival between participants treated with cognitive behavioral therapy supplemented by an antidepressant vs usual care (75.5% vs 74.7%, respectively). CONCLUSIONS Depression treatment with medication or cognitive behavioral therapy in patients with cardiovascular disease is associated with modest improvement in depressive symptoms but no improvement in cardiac outcomes. No clinical trials have assessed whether screening for depression improves depressive symptoms or cardiac outcomes in patients with cardiovascular disease.
The Patient Navigator Program: Focus MI was a 2-year QI initiative for post-MI care from 2017-2019. Resources and national expert support were provided to optimize patient care and outcomes. An ...aldosterone blocking agent (ABA) is recommended in post-MI in patients with LVEF ≤40%. One component of the Patient Navigator Program: Focus MI QI initiative was assessment of ABA prescription at discharge in 3 hospital groups: participation in ACC's NCDR Chest Pain - MI Registry™ but not Focus-MI, Focus-MI as a non-diplomat site (less intensive QI activities; lack of in person expert support), and Focus-MI as a diplomat site (was previously involved in the initial Patient Navigator Program from 2015-2017). Aims of this analysis were to examine differences in ABA prescription by groups and time (pre Focus-MI baseline, 2017, and year 1 and 2, 2018-2019).
Focus-MI involved 773 participating hospitals. De-identified data from Diplomat (n=15), non-diplomat (n=57), and non-participating sites (n=712) who did not receive Focus-MI registry support were compared. Multivariable models were used to assess ABA prescription at discharge by group and time effect after adjusting for differences between groups.
Diplomat sites were more likely to be University-based teaching hospitals. Of 376,421 patients, median (IQR) age was similar between groups (64 55, 74) years and 66.7% (n=251,397) were male. The ABA prescription rate was highest in diplomat sites vs. non-diplomat and non-participating sites at baseline (22.96% vs. 18.74% vs. 15.53%) and 2 years after post-Focus-MI program initiation (33.2% vs. 26.91% vs. 17.32%). After adjusting for factors that differed by group, the odds of ABA prescription (95% CI) were higher in diplomat and non-diplomat hospitals compared to non-Focus-MI sites; 2.26 (1.38-3.70; p=.0001) and 1.53 (1.19-1.98, p=.0001), respectively (Figure). By time (baseline compared to year 1 and year 2), the greatest increase in ABA prescription at discharge was from baseline through year 1 of program implementation (p<.0001).
Among post-MI patients with LVEF ≤40%, participation in the Focus-MI program was associated with increased prescription of ABA; although improvement slowed after year 1. Further studies are needed to identify how best to increase and sustain closure of gaps in ABA prescription over time.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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