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   Table of Contents - Current issue
Coverpage
October-December 2022
Volume 6 | Issue 4
Page Nos. 209-289

Online since Friday, December 16, 2022

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EDITORIAL  

Stressors and cardiovascular disease p. 209
Ismail Laher
DOI:10.4103/hm.hm_56_22  
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REVIEW ARTICLES Top

Psychosocial stressors in psychosomatic cardiology: A narrative review p. 211
Töres Theorell
DOI:10.4103/hm.hm_26_22  
The definition of a psychosocial stressor and reactions to it is discussed in relation to individual and environmental factors. The relation of this model to psychophysiological stress reactions and regeneration, as well as its significance for cardiovascular diseases, is described. Three classes of psychosocial stressors (life changes, work conditions, and family conflicts) are then described in relation to cardiovascular illness and risk factors. Particular emphasis is on longitudinal studies of patients. Heart contractility and urinary adrenaline excretion are discussed in detail. Epidemiological data on psychosocial stressors and cardiovascular disease outcomes (mainly myocardial infarction) are also discussed.
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Does psychosocial stress lead to spontaneous coronary artery dissection? A review of the evidence p. 219
Simon W Rabkin
DOI:10.4103/hm.hm_36_22  
Spontaneous coronary artery dissection (SCAD) is the acute development of a false lumen within the coronary artery wall by the spontaneous formation of an intramural hematoma which may compromise coronary (blood) flow by compression of the true lumen. Psychological factors have been implicated in its pathophysiology, but a synthesis of available data has not been previously undertaken. A literature search was conducted with the terms coronary artery dissection or spontaneous coronary artery dissection AND the terms psychological stress, anxiety, or depression. Initial studies in the field reported that psychological stress, anxiety, or depression was associated with SCAD and that acute stress may have a role in producing the SCAD. Recent studies with control groups of either acute coronary syndromes or acute myocardial infarction have produced discordant results. A meta-analysis of these studies, in this review, using a fixed effects model, showed that there was no significant association between SCAD and either moderate-to-high psychological stress or moderate-to-severe depression. However, one study reported that patients with SCAD were two-fold more likely to have experienced an emotional precipitant in the 24 h prior to the event. Assessment of patients with SCAD found long-term psychological consequences, and in some cases similar to posttraumatic stress disorder. In conclusion, chronic psychological stress, anxiety, or depression is not associated with the development of SCAD, however acute emotional stress may be a factor precipitating SCAD in some patients. Further research is necessary to examine the biological basis for SCAD and how acute stress might play a role in its pathogenesis.
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Is noise exposure a risk factor for cardiovascular diseases? A literature review p. 226
Andre Faria, Ana Clara Caldas, Ismail Laher
DOI:10.4103/hm.hm_48_22  
We are exposed to noise on a daily basis, and noise pollution is increasingly becoming more intense, especially with more people living in the urban areas. Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide and of global public health concern. Preventing and treating CVDs requires a better understanding of the associated risk factors. There is emerging evidence that noise pollution, especially related to the various forms of transport, is likely a contributor to the pathogenesis and aggravation of CVDs. We review key epidemiological data that address the link between excessive noise exposure and CVDs in humans and present proposed pathophysiological mechanisms underlying this association.
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A narrative review on obstructive sleep apnea in China: A sleeping giant in disease pathology p. 232
Yuxi Wei, Yu Liu, Najib Ayas, Ismail Laher
DOI:10.4103/hm.hm_49_22  
We review the aspects of obstructive sleep apnea (OSA), which is the most common respiratory disorder of sleep in China. Approximately 176 million people in China have apnea/hypopnea index ≥5/h, ranking first among the ten countries with the highest prevalence rates. Two-thirds of patients do not receive treatment at all or withdraw after only brief treatment in a survey nested in two centers in China. Drowsiness and progressive cognitive impairment related to OSA decrease work performance and add to workplace errors and accidents. Many patients with OSA remain undiagnosed. Untreated OSA increases the risk of developing cardiovascular diseases and metabolic diseases. Undiagnosed and untreated OSA patients place a great burden on healthcare costs and services, and thus enormous economic burdens across most countries across the world, due to the global epidemic of obesity, an important contributor to OSA. Continuous positive airway pressure is the first-line treatment for OSA in China; however, adherence levels are poor. Effective and less labor-intensive methods that improve adherence need to be further investigated. Traditional Chinese medicine and acupuncture are promising treatments but with unproven efficacy.
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Loneliness and health: An umbrella review p. 242
Nima Rezaei, Amene Saghazadeh
DOI:10.4103/hm.hm_51_22  
Loneliness has been associated with different health outcomes in the following domains: general health, well-being, physical health, mental health, sleep, and cognitive function. However, the most significant associations fall into mental health- and well-being-related outcomes. Moreover, loneliness is an identified risk factor for all-cause mortality. This article overviews the systematic and meta-analytic studies, which have investigated epidemiology and etiology, associated medical and neuropsychiatric conditions, and interventions for loneliness. Meta-analyses have associated higher levels/prevalence of loneliness with pathological conditions, including physical (cardiovascular diseases, obesity, and cancer) and mental health conditions (dementia, cognitive impairment, depression, anxiety, suicide, substance abuse, frailty, and addiction). Furthermore, loneliness commonly occurs to people during particular physiological conditions, for example, childhood, adulthood, elderly, pregnancy, and taking care of others. Moreover, young adults commonly experience transient loneliness. For all these pathological/physiological conditions, COVID-19 has been confirmed as a loneliness-worsening condition. Genetic background, in addition to environmental factors, plays a role in the etiology of loneliness. Biomarkers mainly include neural correlates, including aberrations in the structure/function of cognitive or emotional control-related brain regions, inflammatory correlates, and anthropometric measures. The current interventions for loneliness alleviation are mostly focused on older people, for whom the evidence derived from systematic or meta-analytic studies shows none-to-moderate benefits and substantial heterogeneity across studies. The evidence is not adequate to conclude about the effectiveness of interventions in youth. In addition to the need for pathology- and population-specific interventions for loneliness reduction/prevention, there is a need to survey loneliness longitudinally to examine the causality of loneliness-health associations.
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ORIGINAL ARTICLES Top

Depression symptom patterns as predictors of metabolic syndrome and cardiac events in symptomatic women with suspected myocardial ischemia: The women's ischemia syndrome evaluation (WISE and WISE-CVD) projects p. 254
Nicole E Virzi, David S Krantz, Vera A Bittner, C Noel Bairey Merz, Steven E Reis, Eileen M Handberg, Carl J Pepine, Viola Vaccarino, Thomas Rutledge
DOI:10.4103/hm.hm_35_22  
Background: Ischemic heart disease (IHD) risk in women includes biomedical, behavioral, and psychosocial contributors. The purpose of this study was to build upon previous research suggesting that in women, somatic symptoms (SS) of depression may be important to the development of IHD risk factors and major adverse cardiovascular events (MACE). Based on previous findings, we hypothesized that: (1) SS would be associated with robust biomedical predictors of heart disease and functional capacity, while cognitive symptoms (CS) of depression would not, and (2) SS would independently predict adverse health outcomes while CS would not. Methods: We examined the relationships between symptoms of depression (SS/CS), metabolic syndrome (MetS), inflammatory markers (IM), coronary artery disease (CAD) severity, and functional capacity in two independent cohorts of women with suspected IHD. In the Women's Ischemia Syndrome Evaluation (WISE), we also examined these variables as predictors of all-cause mortality (ACM) + MACE over a median 9.3-year follow-up. The WISE sample included 641 women with suspected ischemia with or without obstructive CAD. The WISE-Coronary Vascular Dysfunction (WISE-CVD) sample consisted of 359 women with suspected ischemia and no obstructive CAD. All study measures were collected uniformly at baseline. Depressive symptoms were measured via the Beck Depression Inventory. MetS was assessed according to Adult Treatment Panel III (ATP-III) criteria. Results: In both studies, SS was associated with MetS (Cohen's d = 0.18, 0.26, P < 0.05, respectively), while CS was not. Within WISE, using Cox Proportional Hazard Regression, SS (Hazard ratio [HR] = 1.08, 95% confidence interval [CI] = 1.01–1.15; HR = 1.07, 95% CI = 1.00–1.13) and MetS (HR = 1.89, 95% CI = 1.16–3.08; HR = 1.74, 95% CI=1.07–2.84) were independent predictors of ACM + MACE after controlling for demographics, IM, and CAD severity, while CS was not. Conclusions: In two independent samples of women undergoing coronary angiography due to suspected ischemia, SS but not CS of depression were associated with MetS, and both SS and MetS independently predicted ACM and MACE. These results add to previous studies suggesting that SS of depression may warrant specific attention in women with elevated cardiovascular disease (CVD) risk. Future research evaluating the biobehavioral basis of the relationship between depression, MetS, and CVD is needed.
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Perceived stress and cardiovascular disease in a community-based population p. 262
Yasi Zhang, Aijie Zhang, Jianbang Xiang, Yiqiang Zhan
DOI:10.4103/hm.hm_55_22  
Background: Perceived stress plays an important role in the pathogenesis of cardiovascular diseases (CVDs). Their associations with CVDs in the Chinese population are less investigated. The present study aims to investigate the associations of perceived stress with well-defined CVDs in a population-based survey in Shenzhen, China. Methods: In the community-based survey, we recruited 2,287 participants aged 18 years and over from 8 communities in Shenzhen, China. Perceived stress was assessed using the modified Chinese version of the Perceived Stress Scale with 14 items and a five-point Likert scale. CVDs including coronary heart disease, heart failure, and atrial fibrillation were ascertained from electronic health records and confirmed by family physicians. Potential confounders included age, sex, educational attainment, occupation, smoking, and alcohol-drinking habits. Multivariable logistic regression models were employed to estimate the magnitude of the associations. Results: Overall, the average perceived stress score was 37.2 (standard error: 7.2 and range: 14–70) among the participants. The prevalence of CVDs was 2.7%. After controlling for age, sex, educational attainment, occupation, smoking, and alcohol-drinking habits, a higher perceived stress score was significantly associated with higher risks of CVDs (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.01–1.55). The associations were comparable among men (OR: 1.20, 95% CI: 1.01–1.43) and women (OR: 1.29, 95% CI: 1.02–1.63). We also examined the potential nonlinear relationship using restricted cubic spines and found that the relationship was almost linear. Conclusions: Our analysis showed that higher perceived stress was associated with higher risks of CVDs among adults. Future studies are warranted to clarify the biological mechanisms and shed light on these associations.
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Medical maximizing-minimizing preferences and health beliefs associated with emergency department patients' intentions to take a cardiac stress test after receiving information about testing p. 267
Andrew J Foy, Ashley Bucher, Lauren J Van Scoy, Laura D Scherer
DOI:10.4103/hm.hm_48_21  
Purpose: The Medical Maximizer-Minimizer Scale (MMS) has been validated to predict preferences for health-care service use on hypothetical vignettes in nonclinical cohorts. Using mixed methods, we sought to determine whether it would predict preferences for cardiac stress testing in a cohort of emergency department (ED) patients with low-risk chest pain within the context of the Health Belief Model (HBM). Design: Patients who met the definition for low-risk chest pain and who were eligible to take a cardiac stress test before being discharged from the hospital were recruited to participate. Each participant provided demographic information and completed the MMS-10 paper-and-pencil scale. They then watched a 7-min informational video on an iPad tablet that provided information about the condition of “low-risk chest pain” and the probabilities of results and outcomes following a cardiac stress test. After the video, participants answered a one-question survey on their intention-to-take (ITT) a cardiac stress test or not and were then interviewed about factors that influenced their decision-making. Interviews were interpreted using a HBM lens. Results: Sixty participants were enrolled in the study who were between the ages of 29 and 80 years with a mean age of 53 (± 10.8); 58% were women and 90% were white. The mean MMS score was 4.6 (± 0.8) and ranged from 2.6 to 6.8. Minimizers accounted for 25% (n = 15) of the cohort while maximizers accounted for 75% (n = 45). MMS scores followed a normal distribution and were found to be mildly correlated with ITT scores (r = 0.25; P = 0.051). The mean ITT scores for individuals with MMS scores in the 1st and 4th quartiles were 3.9 ± 2.2 and 5.9 ± 1.7, respectively. After watching the informational video, individuals' perceptions related to the: (1) low threat posed by the condition, (2) low utility (low benefits + significant barriers) of taking a cardiac stress test, and (3) high benefits of taking a cardiac stress test were all strongly associated with ITT scores in a directional manner. No direct connection was found between minimizer-maximizer preferences and health beliefs after watching the informational video. This may have been due to sample size and underrepresentation of minimizers in the cohort. Conclusions: MMS and health beliefs predicted preferences for cardiac stress testing in ED patients with low-risk chest pain after viewing an informational video on the topic. However, we did not find direct evidence that the relationship between MMS and decision-making is mediated through the formation of perceptions of threat and utility consistent with the HBM. More research is needed to establish this connection and understand how framing of information in the health-care space may interact with stable personality traits to influence decision-making.
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CASE REPORTS Top

Necklace pattern left ventricular noncompaction cardiomyopathy with plethora of paradoxic septal premature ventricular complexes: A case report and literature review p. 276
Debasish Das, Abhinav Kumar, Anindya Banerjee, Tutan Das, Shashikant Singh, Manaranjan Dixit
DOI:10.4103/hm.hm_69_21  
We report an extremely rare case of left ventricular noncompaction (LVNC) cardiomyopathy sparing the anterior ventricular wall in an interesting “necklace” pattern in parasternal short axis view in a 76-year-old female with frequent palpitation and shortness of breath for the last 6 months. Interestingly, the patient had a plethora of basal septal premature ventricular complexes (PVCs) both from the anterior and posterior aspects of the paradoxically thinned-out basal septum and they were not from the segment of noncompacted (NC) myocardium. Our case is unique and the first to describe the LVNC in an interesting shape of “necklace” sparing the left ventricular anterior, anteroseptal, and anterolateral wall and paradoxically arising plethora of septal PVCs from the thinned-out basal septum deteriorating the left ventricular function rapidly in an elderly female in her seventh decade of life. Although commonly in LVNC, the PVCs arise from the NC segment, in this unique case plethora of PVCs paradoxically arising from the basal septum were contributing toward rapid deterioration of left ventricular systolic function in an elderly patient in her seventh decade of life without the presence of conventional risk factors.
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A case report of iatrogenic radial artery pseudoaneurysm: Avoidable complication with the need of early intervention p. 282
Anshuman Darbari, Rahul Sharma, Rahul Dev, Ruhi Sharma
DOI:10.4103/hm.hm_17_22  
It is crucial to clinically differentiate true aneurysms from pseudoaneurysms. Here, we are reporting a case of postintervention, iatrogenic distal radial artery pseudoaneurysm, which was successfully managed surgically. The present case scenario signifies the clinical features of pseudoaneurysm and relevant discussion with early treatment needs for this iatrogenic complication.
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OPINION Top

Existential suffering, futility, and the mental stress of moral distress in health care p. 285
Philip Crowell
DOI:10.4103/hm.hm_30_22  
This article explores the relationship of existential suffering and moral distress by examining life-threatening medical situations and the distress on persons engaged in medical ethics decision-making. The aim and focus are to articulate how existential suffering experienced by the patient and family generates moral distress in the health-care team as they perceive ongoing treatments as futile. Suffering and existential suffering pose a challenge ethically and therapeutically on a number of levels, first in terms of determining what a patient wants to be addressed or what a substitute decision-maker needs to consider in fulfilling the best interests of the patient who is suffering. Second, when there are unrelenting and intolerable sufferings, a difficult medical assessment is sometimes made that any further treatments are “futile,” which leads to conflict with the family and moral distress for the medical team. Moral distress and mental stress have physiological, psychological, social/behavioral, and existential-spiritual dimensions. Existential suffering consists of a constellation of factors, not only severe pain but also the inclusion of harms from the illness, which are irreversible, irremediable, and unrelenting, adding to the total suffering. This article argues that the existential suffering of the patient and family has a special moral status that significantly and legitimately guides decisions at the end of life, and addressing the existential suffering of the patient/family can relieve levels of moral distress for the health-care team.
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