Showing papers by "Alan Rozanski published in 2005"

Prognostic Significance of Dyspnea in Patients Referred for Cardiac Stress Testing

Abstract: Background Although dyspnea is a common symptom, there has been only limited investigation of its prognostic significance among patients referred for cardiac evaluation. Methods We studied 17,991 patients undergoing myocardial-perfusion single-photon-emission computed tomography during stress and at rest. Patients were divided into five categories on the basis of symptoms at presentation (none, nonanginal chest pain, atypical angina, typical angina, and dyspnea). Multivariable analysis was used to assess the incremental prognostic value of symptom categories in predicting the risk of death from cardiac causes and from any cause. In addition, the prognosis associated with various symptoms at presentation was compared in subgroups selected on the basis of propensity analysis. Results After a mean (±SD) follow-up of 2.7±1.7 years, the rate of death from cardiac causes and from any cause was significantly higher among patients with dyspnea (both those previously known to have coronary artery disease and those...

Psychologic functioning and physical health: a paradigm of flexibility.

Abstract: Recent evidence suggests that positive psychologic factors may be protective against coronary artery disease (CAD). We consider this possibility through a paradigm that explores three interrelated factors that may promote healthy psychologic functioning: vitality, emotional flexibility, and coping flexibility. Vitality is a positive and restorative emotional state that is associated with a sense of enthusiasm and energy. Flexibility is related both to the ability to regulate emotions effectively and cope effectively with challenging daily experiences. A variety of factors may diminish vitality, including chronic stress and negative emotions. Pathophysiologically, chronic stress and negative emotional states can both invoke a "chronic stress response" characterized by increased stimulation of the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, with resultant peripheral effects, including augmented heart rate and blood pressure responsiveness and delayed recovery to stressful stimuli. Research indicates a wide array of stressful conditions--associated with either elements of relative inflexibility in psychologic functioning and/or relatively unabated stressful stimulation--that are associated with this type of exhausting hyperarousal. Conversely, new data suggest that positive psychologic factors, including positive emotions, optimism, and social support, may diminish physiological hyperresponsiveness and/or reduce adverse clinical event rates. Still other positive factors such as gratitude and altruistic behavior have been linked to a heightened sense of well-being but have not yet been tested for beneficial physiological effects. Pending further study, these observations could serve as the basis for expanding the potential behavioral interventions that may be used to assist patients with psychosocial risk factors for CAD.

The clinical impact of negative psychological states: expanding the spectrum of risk for coronary artery disease

Abstract: Objectives Research has demonstrated a gradient relationship between depression and the risk of adverse cardiovascular events among both initially healthy individuals and those with known cardiac disease. Moreover, recent investigators have demonstrated that adverse outcomes are even associated with the presence of relatively mild symptoms, as measured by self-report scales like the Beck Depression Inventory. The association between even mild depressive symptoms and sequelae of cardiac disease raises the following question: Is the spectrum of psychological factors associated with cardiac disease greater than previously recognized? Methods To address this issue, we consider a small but emerging literature that has focused on effects of other negative psychologic states on cardiovascular health. Results Five negative states that have been linked in varying degrees to cardiovascular disease or disturbances are identified, including hopelessness, pessimism, rumination, anxiety, and anger. Considering a broader spectrum of risk may help to understand more fully the mechanisms by which depression and other negative affective states influence coronary heart disease risk.

Metabolic Syndrome and Diabetes Are Associated With an Increased Likelihood of Inducible Myocardial Ischemia Among Patients With Subclinical Atherosclerosis

Abstract: OBJECTIVE—Coronary artery calcification (CAC) is associated with cardiac events and the likelihood of inducible myocardial ischemia. Because metabolic syndrome contributes to atherosclerosis, we assessed whether it also influences the relationship between CAC levels and myocardial ischemia. RESEARCH DESIGN AND METHODS—We evaluated 1,043 patients without known coronary artery disease (CAD) who underwent stress myocardial perfusion scintigraphy (MPS) and computed tomography. Metabolic syndrome was defined by modified National Cholesterol Education Program criteria. Metabolic abnormalities were present in 313 patients (30%), including 140 with diabetes (with or without metabolic syndrome) and 173 who had metabolic syndrome without diabetes. RESULTS—Although CAC scores CONCLUSIONS— Among patients with CAC scores ≥100, metabolic abnormalities, and even metabolic syndrome in the absence of diabetes predicted a higher likelihood of inducible ischemia. These findings suggest the need for assessment of metabolic status when interpreting the results of CAC imaging among patients undergoing such testing because of suspected CAD.

Social network and coronary artery calcification in asymptomatic individuals.

Abstract: Background Psychosocial factors are associated with the development of coronary artery disease. However, studies examining psychosocial factors as risk indicators for coronary artery calcification (CAC) have been inconclusive. Methods Seven hundred eighty-three participants (mean age 57.4 +/- 9.3 years, 47% female) underwent CAC imaging using electron beam tomography. Psychosocial measures included social network (number of people in the household, marital status), socioeconomic status (education, income, and work status), history of depression, and current depressive symptoms as assessed with the Center for Epidemiologic Studies Depression (CES-D) scale. Assessments were also made for lipid profile, blood glucose, blood pressure, and health behaviors (smoking status, exercise, and diet). Results Calcification was present in 351 (44.8%) participants (CAC score range 0-3022; mean 111.5 +/- 307.2). Indicators of social isolation (being single or widowed) were independently associated with elevated risk for the presence of CAC, even after adjustment for age, sex, systolic blood pressure, blood glucose, and low-density lipoprotein (adjusted odds ratios 1.80, 95% confidence interval [CI] = 1.05-3.10, and 2.48, 95% CI = 1.02-6.03, respectively). By contrast, health behaviors, socioeconomic status, and depressive symptoms were not related to CAC. Conclusions Social network indices such as being single or widowed are associated with CAC, independent of age and coronary risk factors. Because coronary calcification has been identified as a potential marker of early atherosclerosis, these findings may partially explain the predictive value of limited social networks for future adverse cardiovascular health outcomes.

Integrating psychologic approaches into the behavioral management of cardiac patients.

Abstract: Despite increasing evidence that depression and other psychologic risk factors promote atherosclerosis and adverse cardiac events, practice guidelines for integrating psychologic considerations into the management of cardiac patients are currently lacking. This review explores how application of psychologic principles may help physicians to implement three basic approaches for improving the behavioral management of cardiac patients. The first is the identification and reduction of barriers to following behavioral recommendations, including the presence of negative mood states and other psychologic factors. Patients often self-manage negative moods through unhealthy behaviors such as smoking or eating. However, replacement of these behaviors with more health-promoting behaviors such as exercise and stress management techniques is often difficult and may require active assistance. Second, physicians should help provide patients with external support systems such as referral to support groups or telephone follow ups, when necessary. Such external supports, however, often require other approaches for long-term maintenance of new health behaviors. Third, a motivational literature suggests that physicians can promote patient self-management by formulating health goals in a manner that satisfies "basic psychologic needs" such as the needs for autonomy and competency. Satisfaction of these needs increases "vitality" (a positive state of energy and enthusiasm). Motivation can also be enhanced by creating an emotional attachment to health goals. A case example is provided to illustrate the application of these concepts in clinical practice, and future directions are discussed, including a potential healthcare model that could make the behavioral management of patients more feasible in cardiac practice.

From Feeling Blue to Clinical Depression: Exploring the Pathogenicity of Depressive Symptoms and Their Management in Cardiac Practice

Abstract: INTRODUCTION This issue of Psychosomatic Medicine includes the first supplement for this journal in nearly 40 years. Why have we chosen to do one now? Evidence is growing that a variety of psychosocial factors are strongly linked to coronary artery disease (CAD), including such factors as depression, poor social support, low socioeconomic status, and various forms of chronic stress (1). Such data should be of interest to the community of internists and cardiologists who take care of patients at risk for heart disease. Mastering this literature, however, is difficult, because articles covering such topics appear in a large number and diverse array of journals: medical psychology journals such as our own, general internal medicine journals, and cardiology subspecialty journals, to name just a few categories. We have chosen to focus on depression and heart disease because both are associated with substantial morbidity and mortality. Depression is observed quite commonly within cardiac populations, with a prevalence three to four times that of the general population. Moreover, our understanding of how depression is related to CAD is rapidly evolving. The goal of this supplement is to summarize recent advances in the understanding of the pathogenicity of depressive symptoms and their management in cardiac practice. The articles in this supplement address four topics, including delineating the epidemiology that links depressive syndromes to coronary artery disease (CAD), defining the pathophysiology that mediates this association, evaluating the efficacy of treatment options for depression among cardiac patients, and reviewing potential ways in which cardiologists and other physicians can enhance behavioral intervention in clinical practice.

Translation of critical pathways for acute coronary syndrome and for acute heart failure into admission forms and discharge planning.

Abstract: We have recently developed and published 2 care pathways: 1 for the management of acute coronary syndrome and the other for acute heart failure. Our pathways are designed to optimize care for patients using clinical evidence models and to teach physicians in training consensus evaluation and management strategies. To implement our pathways to improve our patient care, we have developed unique admission and discharge forms derived from these pathways. These forms serve as reminders of key points of the pathways, as data collection devices, and most importantly as a health care agreement on discharge between patients and their healthcare providers.