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on behalf of the Reduction of Atherothrombosis for Continued Health (REACH) Registry Investigators* Background-Peripheral artery disease (PAD) is common and imposes a high risk of major systemic and limb ischemic events. The REduction of Atherothrombosis for Continued Health (REACH) Registry is an international prospective registry of patients at risk of atherothrombosis caused by established arterial disease or the presence of Ն3 atherothrombotic risk factors. Methods and Results-We compared the 2-year rates of vascular-related hospitalizations and associated costs in US patients with established PAD across patient subgroups. Symptomatic PAD at enrollment was identified on the basis of current intermittent claudication with an ankle-brachial index (ABI) Ͻ0.90 or a history of lower-limb revascularization or amputation. Asymptomatic PAD was diagnosed on the basis of an enrollment ABI Ͻ0.90 in the absence of symptoms. Overall, 25 763 of the total 68 236 -patient REACH cohort were enrolled from US sites; 2396 (9.3%) had symptomatic and 213 (0.8%) had asymptomatic PAD at baseline. One-and cumulative 2-year follow-up data were available for 2137 (82%) and 1677 (64%) of US REACH patients with either symptomatic or asymptomatic PAD, respectively. At 2 years, mean cumulative hospitalization costs, per patient, were $7445, $7000, $10 430, and $11 693 for patients with asymptomatic PAD, a history of claudication, lower-limb amputation, and revascularization, respectively (Pϭ0.007). A history of peripheral intervention (lower-limb revascularization or amputation) was associated with higher rates of subsequent procedures at both 1 and 2 years. Conclusions-The economic burden of PAD is high. Recurring hospitalizations and repeat revascularization procedures suggest that neither patients, physicians, nor healthcare systems should assume that a first admission for a lower-extremity PAD procedure serves as a permanent resolution of this costly and debilitating condition. (Circ Cardiovasc Qual Outcomes. 2010;3:642-651.)

Background-Among patients with acute myocardial infarction (AMI), depression is both common and underrecognized.The association of different manifestations of depression, somatic and cognitive, with depression recognition and long-term prognosis is poorly understood. Methods and Results-Depression was confirmed in 481 AMI patients enrolled from 21 sites during their index hospitalization with a Patient Health Questionnaire (PHQ-9) score Ն10. Within the PHQ-9, separate somatic and cognitive symptom scores were derived, and the independent association between these domains and the clinical recognition of depression, as documented in the medical records, was evaluated. In a separate multisite AMI registry of 2347 patients, the association between somatic and cognitive depressive symptoms and 4-year all-cause mortality and 1-year all-cause rehospitalization was evaluated. Depression was clinically recognized in 29% (nϭ140) of patients. Cognitive depressive symptoms (relative risk per SD increase, 1.14; 95% CI, 1.03 to 1.26; Pϭ0.01) were independently associated with depression recognition, whereas the association for somatic symptoms and recognition (relative risk, 1.04; 95% CI, 0.87 to 1.26; Pϭ0.66) was not significant. However, unadjusted Cox regression analyses found that only somatic depressive symptoms were associated with 4-year mortality (hazard ratio [HR] per SD increase, 1.22; 95% CI, 1.08 to 1.39) or 1-year rehospitalization (HR, 1.22; 95% CI, 1.11 to 1.33), whereas cognitive manifestations were not (HR for mortality, 1.01; 95% CI, 0.89 to 1.14; HR for rehospitalization, 1.01; 95% CI, 0.93 to 1.11). After multivariable adjustment, the association between somatic symptoms and rehospitalization persisted (HR, 1.16; 95% CI, 1.06 to 1.27; Pϭ0.01) but was attenuated for mortality (HR, 1.07; 95% CI, 0.94 to 1.21; Pϭ0.30). Conclusions-Depression after AMI was recognized in fewer than 1 in 3 patients. Although cognitive symptoms were associated with recognition of depression, somatic symptoms were associated with long-term outcomes. Comprehensive screening and treatment of both somatic and cognitive symptoms may be necessary to optimize depression recognition and treatment in AMI patients. (Circ Cardiovasc Qual Outcomes. 2009;2:328-337.)

This study examined the association between patient-reported anxiety and post-cardiac surgery mortality and major morbidity. Frailty ABC'S was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals between 2008 and 2009. Patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale (HADS), a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was high levels of anxiety, defined by HADS score ≥11. The main outcome measure was all-cause mortality or major morbidity (stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for Society of Thoracic Surgeons (STS) predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the HADS-A. High levels of preoperative anxiety were present in 7% of patients. There were no differences in type of surgery and STS predicted risk across preoperative levels of anxiety. After adjusting for Society of Thoracic Surgeons predicted risk, age, gender, and symptoms of depression, preoperative anxiety remained independently predictive of postoperative mortality or major morbidity (OR 5.1; 95% CI 1.3, 20.2; p=0.02). In conclusion, although high levels of anxiety were present in a minority of patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.

Context Little is known about how health insurance status affects decisions to seek care during emergency medical conditions like acute myocardial infarction (AMI). Objective To examine the association between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation (prehospital delays) during AMI. Design, Setting and Patients Multicenter, prospective registry of 3721 AMI patients enrolled between April, 2005 and December, 2008 from 24 U.S. hospitals. Health insurance status was categorized as uninsured, insured with financial concerns about accessing care, and insured without financial concerns. Insurance information was determined from medical records while financial concerns among those with health insurance were determined from structured interviews. Main Outcome Measure Prehospital delay times (≤2 hours, >2 to 6 hours, >6 hours), adjusted for demographic, clinical, social and psychological factors using hierarchical ordinal regression models. Results Of 3,721 patients, 738 (19.8%) were uninsured, and 689 (18.5%) were insured with financial concerns, and 2294 (61.7%) were insured without financial concerns. Uninsured and insured patients with financial concerns were more likely to delay seeking care during AMI, with prehospital delays >6 hours among 48.6% of uninsured patients, 44.6% of insured patients with financial concerns, and 39.3% of insured patients without financial concerns, as compared with prehospital delays of <2 hours among 27.5%, 33.5%, and 36.6% of those who were uninsured, insured with financial concerns, and insured without financial concerns, respectively (P <.001). After adjusting for potential confounders, both insurance with financial concerns and lack of insurance were associated with prehospital delays: insurance without financial concerns (reference); insurance with financial concerns, adjusted odds ratio [OR)], 1.21; 95% confidence interval [CI]: 1.05-1.41, P=.01; no insurance, adjusted OR 1.38, 95% CI: 1.17-1.63, P <.001. Conclusions Lack of health insurance and financial concerns about accessing care among those with health insurance were each associated with delays in seeking emergency care for AMI.

Background Chronic stress has been shown to be associated with the development of cardiovascular disease and, in the case of particular types of stress such as job and marital strain, with recurrent adverse events after acute myocardial infarction (AMI). Little is known, however, about the association of chronic stress with mortality and adverse health status outcomes in a general AMI population. Objectives To determine the association of chronic stress with long-term adverse outcomes after AMI. Methods In a cohort of 4204 AMI patients from 24 U.S. hospitals completing the Perceived Stress Scale-4 (sum scores ranging from 0-16) during hospitalization, moderate/high stress over the prior month was defined as scores in the top 2 quintiles (scores 6-16). Detailed data on sociodemographics, psychosocial status, and clinical characteristics were collected at baseline. Outcomes included patients’ 1-year health status—assessed with the Seattle Angina Questionnaire, Short Form-12, and EuroQol Visual Analog Scale—and 2-year mortality. Results AMI patients with moderate/high stress had increased 2-year mortality as compared with those having low levels of stress (12.9% vs. 8.6%; p<0.001). This association persisted after adjusting for sociodemographics, clinical factors (including depressive symptoms), revascularization status, and GRACE discharge risk scores (HR 1.42, 95% CI 1.15 to 1.76). Furthermore, moderate/high stress was independently associated with poor 1-year health status, including a greater likelihood of angina, worse disease-specific and generic health status, and worse perceived health (p<0.01 for all). Conclusions Moderate/high perceived stress at the time of an AMI is associated with adverse long-term outcomes, even after adjustment for important confounding factors. Future studies need to examine whether stress mediates observed racial and socio-economic disparities, and whether novel interventions targeting chronic stress and coping skills can improve post-AMI outcomes.

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Background Depression is known to increase the risk of coronary artery disease, but few studies have evaluated the association between depression and peripheral artery disease (PAD). We examined the association of depression with PAD and evaluated potential mediators of this association. Methods and Results We used data from the Heart and Soul Study, a prospective cohort of 1024 men and women with coronary artery disease recruited in 2000–2002 and followed for a mean of 7.2±2.6 years. Depressive symptoms were assessed with the validated 9‐item Patient Health Questionnaire. Prevalent PAD at baseline was determined by self‐report. Prospective PAD events were adjudicated on the basis of review of medical records. We used logistic regression and Cox proportional‐hazards models to estimate the independent associations of depressive symptoms with prevalent PAD and subsequent PAD events. At baseline, 199 patients (19%) had depressive symptoms (Patient Health Questionnaire ≥10). Prevalent PAD was reported by 12% of patients with depression and 7% of those without depression (base model adjusted for age and sex: odds ratio 1.79, 95% confidence interval 1.06–3.04, P=0.03; full model adjusted for comorbidities, medications, PAD risk factors, inflammation, and health behaviors: odds ratio 1.59, 95% confidence interval 0.90–2.83, P=0.11). During follow‐up, PAD events occurred in 7% of patients with depression and 5% of those without depression (base model adjusted for age and sex: hazard ratio 2.09, 95% confidence interval 1.09–4.00, P=0.03; full model adjusted for comorbidities, medications, PAD risk factors, inflammation, and health behaviors: hazard ratio 1.33, 95% confidence interval 0.65–2.71, P=0.44). Factors explaining >5% of the association between depression and incident PAD events included race/ethnicity, diabetes, congestive heart failure, high‐density lipoprotein, triglyceride levels, serum creatinine, inflammation, smoking, and levels of physical activity. Conclusions Depressive symptoms were associated with a greater risk of PAD. Because the association was explained partly by modifiable risk factors, our findings suggest that more aggressive treatment of these risk factors could reduce the excess risk of PAD associated with depression.