Context Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown. Objective To determine why depressive symptoms are associated with an increased risk of cardiovascular events. Design and Participants The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years. Setting Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008. Main Outcome Measures Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators. Results A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score ≥10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16–1.95; P=.002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00–1.71; P=.04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94–1.63; P=.12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79–1.40; P=.75). Conclusion In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.

Background-Fetuin-A is a multifunctional hepatic secretory protein that inhibits the action of insulin in experimental animals. We evaluated the association between human serum fetuin-A and the metabolic syndrome (MetS) in a cohort of persons with coronary artery disease. Methods and Results-We defined MetS by the National Cholesterol Education Program criteria among 711 nondiabetic outpatients with coronary artery disease. The mean age was 67 years, and 82% were male. We divided participants into quartiles by serum fetuin-A concentrations. A total of 45% of participants (80 of 177) in the highest quartile of fetuin-A had MetS compared with 24% of participants (42 of 177) in the lowest quartile (odds ratio, 2.7; 95% confidence interval, 1.7 to 4.2; PϽ0.001). This association persisted after adjustment for potential confounding variables, including hypertension, body mass index, and inflammatory biomarkers (adjusted odds ratio, 2.0; 95% confidence interval, 1.1 to 3.5; Pϭ0.02). Higher fetuin-A quartiles were also strongly and independently associated with higher low-density lipoprotein, non-high-density lipoprotein (HDL), and triglyceride concentrations and lower HDL concentrations (all PϽ0.01). Conclusions-Higher

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We found no evidence that current depression is associated with greater inflammation in outpatients with CHD. Inflammation is unlikely to explain the adverse cardiovascular outcomes associated with depression in patients with established CHD.

The predictive value of left atrial (LA) dilatation in ambulatory adults with coronary artery disease is not known. It was hypothesized that echocardiographic LA volume index (LAVI) predicts heart failure (HF) hospitalization and mortality with similar statistical power as left ventricular ejection fraction (LVEF) in ambulatory adults with coronary artery disease. We measured LAVI in 935 adults without atrial fibrillation, atrial flutter, or significant mitral valve disease in the Heart and Soul Study. LAVI was calculated using the biplane method of disks. Outcomes included HF hospitalization and mortality. Logistic regression odds ratios (ORs) were calculated and adjusted for age, demographics, medical history, left ventricular mass, diastolic function, and LVEF. Mean LAVI was 32 ± 11 ml/ m 2 , and mean LVEF was 62 ± 10%. Sixty-six patients (7%) had LAVI >50 ml/m 2 . There were 108 HF hospitalizations and 180 deaths at 4.3 years of follow-up. C statistics calculated as the area under the receiver-operator characteristic curve were the same (0.60) for LAVI and LVEF in predicting mortality. The unadjusted OR for HF hospitalization was 4.4 for LAVI > 50 ml/m 2 and 5.3 for LVEF <45% (p <0.001). In those with normal LVEF, the ORs for LAVI >50 ml/m 2 were 5.2 for HF hospitalization (p <0.0001) and 2.5 for mortality (p = 0.006). After multivariate adjustment, LAVI > 50 ml/m 2 was predictive of HF hospitalization (OR 2.4, p = 0.02), and LAVI >40 ml/m 2 was predictive of mortality (OR 1.9, p = 0.005). In conclusion, LAVI had similar predictability as LVEF for HF hospitalization and mortality in ambulatory adults with coronary artery disease.Left atrial (LA) dilatation occurs in the setting of both systolic and diastolic dysfunction. [1][2][3] The American Society of Echocardiography recommended LA volume index (LAVI), the value of LA volume divided by body surface area, to measure LA size. 4 Increased LAVI was shown to predict mortality after acute myocardial infarction (MI), 5,6 but the predictive power of degrees of LAVI dilatation has not been established in the frequently encountered clinical setting of ambulatory adults with coronary artery disease. We hypothesized that LAVI predicts heart failure (HF) hospitalization and mortality with similar statistical power as left ventricular ejection fraction (LVEF) in ambulatory adults with coronary artery disease. MethodsThe Heart and Soul Study was a prospective cohort study of psychosocial factors and health outcomes in patients with coronary disease. Methods and objectives have been described previously. 7 Criteria for enrollment were (1) history of MI, (2) angiographic evidence of ≥50% diameter stenosis in ≥1 coronary vessel, (3) evidence of exercise-induced ischemia using treadmill electrocardiogram or stress nuclear perfusion imaging, or (4) history of coronary revascularization. Patients were excluded if they deemed themselves unable to walk 1 block, were within 6 months of an acute coronary syndrome, or were planning to move out of the local area within 3 ...

Objective-To examine the relationship between cardiac self-efficacy and health status, including symptom burden, physical limitation, quality of life, and overall health among outpatients with stable coronary heart disease (CHD). We hypothesized that lower self-efficacy would predict worse health status, independent of CHD severity and depression.Methods-We performed a cross-sectional study of 1024 outpatients with CHD, who were recruited between 2000 and 2002 for the Heart and Soul Study. We administered a validated measure of cardiac self-efficacy, assessed cardiac function using exercise treadmill testing with stress echocardiography, and measured depressive symptoms using the Patient Health Questionnaire. Health status outcomes (symptom burden, physical limitation, and quality of life) were assessed using the Seattle Angina Questionnaire, and overall health was measured as fair or poor (versus good, very good, or excellent).Results-After adjustment for CHD severity and depressive symptoms, each standard deviation (4.5-point) decrease in self-efficacy score was independently associated with greater symptom burden (adjusted odds ratio (OR) = 2.1, p = .001), greater physical limitation (OR = 1.8, p < .0001), worse quality of life (OR = 1.6, p < .0001), and worse overall health (OR = 1.9, p < .0001). Depressive symptoms and poor treadmill exercise capacity were also associated with poor health status, but left ventricular ejection fraction and ischemia were not.Conclusions-Among patients with CHD, low cardiac self-efficacy is associated with poor health status, independent of CHD severity and depressive symptoms. Further study should examine if selfefficacy constitutes a useful target for cardiovascular disease management interventions.

Objective-The authors sought to evaluate the association of self-efficacy with objective measures of cardiac function, subsequent hospitalization for heart failure (HF), and all-cause mortality.Design-Observational cohort of ambulatory patients with stable CHD. The authors measured selfefficacy using a published, validated, 5-item summative scale, the Sullivan Self-Efficacy to Maintain Function Scale. The authors also performed a cardiac assessment, including an exercise treadmill test with stress echocardiography.Main Outcome Measures-Hospitalizations for HF, as determined by blinded review of medical records, and all-cause mortality, with adjustment for demographics, medical history, medication use, depressive symptoms, and social support.Results-Of the 1,024 predominately male, older CHD patients, 1013 (99%) were available for follow-up, 124 (12%) were hospitalized for HF, and 235 (23%) died during 4.3 years of follow-up. Mean cardiac self-efficacy score was 9.7 (SD 4.5,, corresponding to responses between "not at all confident" and "somewhat confident" for ability to maintain function. Lower self-efficacy predicted subsequent HF hospitalization (OR per SD decrease = 1.4, p = 0006), and all-cause mortality (OR per SD decrease = 1.4, p < .0001). After adjustment, the association of cardiac selfefficacy with both HF hospitalization and mortality was explained by worse baseline cardiac function.Conclusion-Among patients with CHD, self-efficacy was a reasonable proxy for predicting HF hospitalizations. The increased risk of HF associated with lower baseline self-efficacy was explained by worse cardiac function. These findings indicate that measuring cardiac self-efficacy provides a rapid and potentially useful assessment of cardiac function among outpatients with CHD. As mortality from coronary heart disease (CHD) improves in the acute setting, improving care and outcomes for those with stable CHD assumes greater importance for public health. Avoiding hospitalization for heart failure (HF) is an important goal for this population, and understanding predictors of HF is the first step toward targeted prevention measures. In addition to cardiac physiology, psychosocial factors may contribute to HF hospitalizations (HowieEsquivel & Dracup, 2007;Jiang et al., 2007;Sherwood et al., 2007), through both increased physiologic stress and through patient behaviors such as inadequate medication adherence (Murray et al., 2007;Tu et al., 2005). KeywordsSelf-efficacy is a psychological construct based on social-cognitive theory, which describes the interaction between behavioral, personal, and environmental factors in health and chronic disease (Bandura, 1977(Bandura, , 1997Lorig & Holman, 2003). The theory of self-efficacy proposes that patients' confidence in their ability to perform certain health behaviors influences their engagement in and actual performance of those behaviors (e.g., diet and exercise adherence), which in turn influence health outcomes. Indeed, the construct of self-efficacy has extended far beyond...

Context Posttraumatic stress disorder (PTSD) is increasingly recognized as a cause of substantial disability. In addition to its tremendous mental health burden, PTSD has been associated with worse physical health status and an increased risk of cardiovascular disease. Objective To determine whether PTSD is associated with cardiovascular health status in patients with heart disease and whether this association is independent of cardiac function. Design Cross-sectional study. Setting The Heart and Soul Study, a prospective cohort study of psychological factors and health outcomes in adults with stable cardiovascular disease. Participants One thousand twenty-two men and women with coronary heart disease. Main Outcome Measures Posttraumatic stress disorder was assessed using the Computerized Diagnostic Interview Schedule for DSM-IV. Cardiac function was measured using left ventricular ejection fraction, treadmill exercise capacity, and inducible ischemia on stress echocardiography. Disease-specific health status was assessed using the symptom burden, physical limitation, and quality of life subscales of the Seattle Angina Questionnaire. We used ordinal logistic regression to evaluate the association of PTSD with health status, adjusted for objective measures of cardiac function. Results Of the 1022 participants, 95 (9%) had current PTSD. Participants with current PTSD were more likely to report at least mild symptom burden (57% vs 36%), mild physical limitation (59% vs 44%), and mildly diminished quality of life (62% vs 35%) (all P≤.001). When adjusted for cardiovascular risk factors and objective measures of cardiac function, PTSD remained independently associated with greater symptom burden (odds ratio, 1.9; 95% confidence interval, 1.2-2.9; P=.004); greater physical limitation (odds ratio, 2.2; 95% confidence interval, 1.4-3.6; P=.001); and worse quality of life (odds ratio, 2.5; 95% confidence interval, 1.6-3.9; P<.001). Results were similar after excluding participants with depression. Conclusions Among patients with heart disease, PTSD is more strongly associated with patient-reported cardiovascular health status than objective measures of cardiac function. Future studies should explore whether assessing and treating PTSD symptoms can improve function and quality of life in patients with heart disease.