Unique female indicators of coronary heart disease: do they exist?
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Comorbidity↗
Biomedical subjects
A Appels
Publications and source records attributed to A Appels.
The nature of the depressive symptomatology preceding myocardial infarction.
Little is known about the nature of the depressive symptomatology preceding myocardial infarction (MI). Specification of the depressive symptomatology is important for the development of hypotheses about the biological mechanisms relating depressive symptoms to MI. To test the hypothesis that feelings of fatigue and loss of energy have the strongest predictive power of all depressive symptoms, the authors reanalyzed data from a prospective study of 3877 healthy men aged 40 to 65 years. The men's mental state was assessed using the Maastricht Questionnaire, a scale that measures vital exhaustion, which is characterized by unusual fatigue and lack of energy, increased irritability, and depressive symptoms, including demoralization. Oblique factor analysis was used to validate these dimensions. Results of Cox's regression analyses showed that the fatigue subscale has the strongest predictive power for incident MI and that depression and irritability subscales lose their predictive power when controlled for fatigue.
Adult↗
Vital exhaustion as a risk factor of myocardial infarction: a case-control study in Venezuela.
In this study, 32 first myocardial infarction (MI) cases and 42 healthy controls were compared with respect to vital exhaustion (VE), a state characterized by loss of energy, increased irritability, and feelings of demoralization. This state has been found to precede the onset of cardiac events. Participants also responded to questionnaires on Type A behavior, anger expression (Anger In, Anger Out, and Anger Control), and positive and negative self-concept. Results showed that VE discriminated well between MI patients and controls (Odds Ratio [OR] = 15.42, 95% confidence interval = 3.92-60.67) even when controlling for age, smoking, and exercise. The odds ratio decreased to 12.34 when controlling for socioeconomic status. Groups also differed in Anger In but not in Anger Control, Anger Out, negative or positive self-concept. Anger In was correlated to VE in all participants pointing to the relevance of withholding emotions in relation to exhaustion. Exhaustion was strongly associated with negative self-concept in the MI cases group only but significantly discriminated between cases and controls when adjusted for negative self-concept. Summarizing, the results show that, as has previously been found in other countries, in Venezuela VE is a precursor of MI.
Journal Article↗
Inflammation and the mental state before an acute coronary event.
Feelings of exhaustion have been found to belong to the precursors of acute coronary events. Guided by the current views of the pathogenesis of acute coronary syndromes, a two-stage model describing a feedback relationship between mental state and the disease process is presented. According to the presented model prolonged exposure to stress results in a state of exhaustion leading to increased susceptibility to inflammatory diseases. Inflammation, in turn, amplifies feelings of exhaustion and malaise through cytokine release. Results of a study of 15 exhausted and 15 nonexhausted angioplasty patients, showing elevated levels of interleukin-1beta and tumour necrosis factor-alpha in the exhausted patients, give empirical support to this model.
Case-Control Studies↗
The effect of a psychological intervention program on the risk of a new coronary event after angioplasty: a feasibility study.
Restenosis after successful percutaneous coronary angioplasty (PTCA) is a major problem because it occurs in 25% to 35% of all patients. Because psychological factors, especially anger and vital exhaustion, have been found to increase the risk of new cardiac events after PTCA, a behavioral intervention might contribute to the reduction of the risk of restenosis. To investigate the operational and methodological aspects of a behavioral intervention, and to estimate the effect size of the risk reduction, we did a feasibility study of angioplasty patients who remained exhausted after PTCA. Breathing therapy was used as the main method for intervention. Thirty patients who participated in the intervention program and 65 controls were followed during an average period of 16 and 18 months, respectively. It was observed that the intervention resulted in a significant decrease of the mean exhaustion scores and reduced the risk of a new coronary event (cardiac death, coronary artery bypass grafting, myocardial infarction, rePTCA, restenosis) by 50% (chi = 2.19; p = 0.13). These results indicate that a clinical trial to test the hypothesis that a reduction of vital exhaustion and hostility reduces the risk of a new cardiac event after PTCA, is feasible and merits the efforts required.
Analysis of Variance↗
Depression and coronary heart disease: observations and questions.
The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes and influences the course of disease after their manifestation is accumulating. However, we still are far short of proof that depression has a causal role in the etiology and pathogenesis of coronary heart disease (CHD). Some unsolved questions concern the causes and the nature of the depression preceding a first or recurrent cardiac event, the biological mechanisms relating depression and CHD, the time window of the exposure-disease association, and the power of therapy programs for depression to reduce the risk of a first or recurrent cardiac event.
Coronary Disease↗
Behavioral-neuroendocrine-immunologic interactions in myocardial infarction.
An enduring state of exhaustion as opposed to chronic hostility-a long-term risk factor-has been found to be a more proximal precursor of myocardial infarction. The strength of the association with exhaustion suggests that this behavioral factor reflects not only a breakdown in adaptation to chronic stressors but also the disease process itself. Recent research on the pathogenesis of myocardial infarction lends credence to a role for immunological factors. herein, we outline a two-stage theoretical model, postulating a feedback relationship between behavior, associated neuroendocrine changes, immunological responses, and the pathogenesis of this disease. We propose a long-term first stage consisting of chronic hostility, prolonged occupational over-exertion, and exposure to other life stressors, terminating eventually in a much shorter second stage of 'vital exhaustion'. Stressor-associated neuroendocrine changes result in immunosuppression leading to reactivation of latent, systemic infections (such as cytomegalovirus) and potentially to autoimmune reactions as well. The consequent release of pro-inflammatory cytokines exacerbates fatigue and induces a stimulus for cytokine production in brain. This cytokine production stimulates a chronically activated, over-compensated limbic-hypothalamic-pituitary-adrenal axis, resulting in a dampened response, continued exhaustion, and a potential 'reverberating circuit' between behavior, neuroendocrine change, cytokine release and coronary artery occlusion, culminating in myocardial infarction.
Anti-Bacterial Agents↗
Exhausted subjects, exhausted systems.
A state of 'vital exhaustion', characterized by unusual tiredness, increased irritability and feelings of demoralization has been found to preceed the onset of myocardial infarction and to increase the risk of a new coronary event after angioplasty. Probably this state reflects a decreased activity of the hypothalamic-pituitary-adrenal axis as part of an homeostatic reaction to prolonged stress and inflammation.
Adult↗
Why do imminent victims of a cardiac event feel so tired?
A state of vital exhaustion, characterised by unusual tiredness and lack of energy, increased irritability and feelings of demoralisation, has been found to be one of the precursors of myocardial infarction and other cardiac events. These feelings probably reflect decreased activity of the hypothalamic-pituitary-adrenal axis. Treatment of the conditions leading to this state of vital exhaustion might decrease the risk of a cardiac event.
Adult↗
Self-rated health and mortality in a Lithuanian and a Dutch population.
The hypothesis that the evaluation of one's health as poor is associated with mortality, independent of the results of a standardized medical examination, was tested in the Kaunas-Rotterdam Follow-Up Study. In this study two cohorts, one consisting of 2452 Lithuanian males and one of 3365 Dutch males, aged 45-60, were screened for cardiovascular risk factors in 1973, using identical protocols, and were followed for about ten years. Self-rated health was assessed by two direct questions: 'How would you assess your own health?' and 'What do you think of your own health compared to that of other men of your age?' as well as by a Semantic Differential Test of 'My Health'. In both cohorts a negative evaluation of one's health was associated with mortality, controlling for past or present heart disease, cardiovascular risk factors, parental life span, socio-economic and marital status. Especially the data with regard to the comparative question indicate that self-rated health is associated with mortality in men living in two different socio-cultural systems. The date suggest that a weak sense of mastery may explain the association between health perception and mortality.
Adult↗
Educational level of spouses and risk of mortality: the WHO Kaunas-Rotterdam Intervention Study (KRIS).
BACKGROUND: A 9.5-year follow-up of the Kaunas-Rotterdam Intervention Study (KRIS) provided the opportunity of investigating whether the educational level of wives was associated with their husbands' risk of mortality and coronary heart disease (CHD), independently of the educational level of the husbands themselves. METHODS: The data represent populations consisting of 2452 Lithuanian men and 3365 Dutch men. These men were extensively screened for cardiovascular risk factors in the period 1972-1974. During the follow-up 303 Kaunasians and 350 Rotterdammers died. We used the Cox proportional hazards and the logistic regression models to analyse the data. RESULTS: We found that men whose spouses had little education apparently had an increased risk of all-cause mortality, even when their own educational level was taken into account. The relative risks (RR) were 1.57 in Kaunas and 2.15 in Rotterdam. The results for fatal and non-fatal myocardial infarctions were compatible with this finding, especially in Rotterdam. The prevalence of smoking was higher among men whose wives had primary schooling only. Nonetheless, adjusting the effect of the wife's educational level on her husband's mortality risk for all coronary risk factors in the husband only partially explained the association. CONCLUSIONS: The spouse's educational level appears to have independent effects on a man's risk of mortality in both eastern and western European communities. The results strongly suggest that including characteristics of the socioeconomic status of an individual's spouse would improve studies of socioeconomic differences in health.
Cardiovascular Diseases↗
Vital exhaustion, extent of atherosclerosis, and the clinical course after successful percutaneous transluminal coronary angioplasty.
It has been observed that vital exhaustion, a state characterized by unusual tiredness, increased irritability and feelings of demoralization not uncommonly precedes myocardial infarction in apparently healthy individuals. This observation raised the question as to whether vital exhaustion is a marker of subclinical coronary disease. To answer that question the condition was assessed in 105 male patients (mean age 54.8 year) before and 2 weeks after successful percutaneous transluminal coronary angioplasty (PTCA) by the Maastricht questionnaire. Vital exhaustion was found to be significantly correlated with the number of diseased vessels before PTCA and to decrease significantly after PTCA. However, the association was rather modest (R2 = 0.08) and most patients remained exhausted after PTCA. During a follow-up period of 1.5 years, 32 patients (30%) experienced a new cardiac event (cardiac death, myocardial infarction, coronary artery bypass grafting, repeat PTCA, a new coronary lesion or recurrent angina with documented ischaemia). Univariate and multivariate analyses showed that the number of diseased vessels, hypercholesterolaemia, and vital exhaustion were independently associated with future events. The odds ratios were 3.74 (P = 0.02), 3.08 (P = 0.08) and 3.07 (P = 0.04), respectively. It is concluded that the tiredness preceding a cardiac event is only modestly associated with the extent of coronary artery disease and that a state of exhaustion after PTCA increases the risk for a new cardiac event.
Adult↗
Psychosocial risk factors for cardiovascular disease in women: the role of social support.
Lack of social support is becoming increasingly important as a psychosocial risk factor in the study of coronary heart disease (CHD). There may also be an association between vital exhaustion and lack of social support. Because most research has focused on men, we decided to explore the associations between structural and functional social support and first myocardial infarction (MI) in women. Subjects were 79 women hospitalized with a First MI (mean age 59.3; SD = 9.3) and 90 women hospitalized with an acute surgical event (mean age 57.4: SD = 9 1). MI cases reported more vital exhaustion than did controls (p < ,040), and exhausted women reported less structural (p < .001) and functional support (p < .000). After controlling for age, hypertension, diabetes, menopausal status, smoking, nonanginal pain, and vital exhaustion, multiple logistic regression analysis showed that poor structural support was associated with an increased risk for MI. These results suggest that social support is associated with vital exhaustion, which is a well-known risk factor for CHD. Furthermore, it is suggested that women with only a few confidants are more at risk for MI even after adjustment for well-known risk factors for CHD.
Journal Article↗
Differences in mortality and coronary heart disease between Lithuania and The Netherlands: results from the WHO Kaunas-Rotterdam Intervention Study (KRIS).
BACKGROUND: A 9.5-year follow-up of the Kaunas-Rotterdam Intervention Study (KRIS) provided an opportunity to compare mortality patterns and rates in a population from Lithuania, one of the former republics of the Soviet Union, with a population from the Netherlands. These populations consisted of 2452 and 3365 males, respectively, aged 45-60 years. In 1972-1974, these males were extensively screened for cardiovascular risk factors, using uniform methods. METHODS AND RESULTS: During the follow-up, 303 males in Kaunas (Lithuania) and 350 males in Rotterdam (the Netherlands) died. Using Cox proportional hazards and logistic regression analysis, it was found that all-cause mortality rates during follow-up were 30% higher in Kaunas; this was mainly due to higher mortality rates from external causes (relative risk = 6.69), stomach cancer (RR = 2.78), stroke (RR = 2.30) and infectious diseases (RR = 12.43). The risk of fatal and non-fatal coronary heart disease (CHD) was, however, smaller in Kaunas (RR = 0.72). This lower risk closely corresponded with the Lithuanian risk profile which could be described by less smoking, lower cholesterol levels, and higher physical activity. As Lithuanians had a more advantageous cardiovascular risk profile, the higher Lithuanian all-cause mortality rates could not be explained by this risk profile. CONCLUSIONS: The results provide evidence for geographical differences in mortality and morbidity between Lithuania and the Netherlands. Population-specific health behaviours were shown to be involved in differences in the risk of CHD. The lower CHD rates in Eastern European communities in the 1970s, in this study confirmed for Lithuania, suggests that the apex of the CHD epidemic had not yet reached the Lithuanian population.
Blood Pressure↗
Vital exhaustion as risk indicator for myocardial infarction in women.
To test the hypothesis that 'vital exhaustion' (VE), a state characterized by unusual fatigue, increased irritability, and feelings of demoralization, precedes the onset of myocardial infarction (MI) in females, 79 females hospitalized with a first MI (mean age: 59.3; SD = 9.3) and 90 females hospitalized in the departments of general and orthopaedic surgery (mean age: 57.4; SD = 9.1), were compared on the retrospective form of the Maastricht Questionnaire (MQ). Defining 'exhaustion' as a score above the median of the MQ, 63% of the cases and 39% of the controls were exhausted before hospitalization (chi 2 = 10.02; p < 0.00). The relative risk associated with exhaustion, after controlling for age, smoking, coffee consumption, diabetes, hypertension, non-anginal pain, and menopausal status, was estimated as 2.75 (95% CI:I.28-5.81; p < 0.01), thus corroborating the hypothesis. Exploratory analyses of the origins of exhaustion in these females showed that of all biographical characteristics, holding a job and simultaneously taking care of the household was most strongly associated with elevated exhaustion scores.
Adult↗
[Exhausted awakening as a risk factor for coronary heart disease].
In a prospective study of 3877 males, aged 39-65, the predictive power of complaints indicating problems falling or staying asleep and of the feeling of waking up exhausted was investigated. It was hypothesized that especially those who wake up exhausted but do not complain about problems falling or staying asleep are at increased risk of myocardial infarction. After controlling for age, blood pressure, smoking, cholesterol and the use of anti-hypertensive drugs, the relative risk was found to be 2.74 (95% confidence interval 1.28-5.83) for a years follow-up and 6.50 for the first year of follow-up. These findings indicate that waking up exhausted belongs to the short-term risk indicators of myocardial infarction.
Adult↗
Vital exhaustion and perception of sleep.
Sleep complaints and unusual sleep durations have been found to increase the risk for coronary heart disease. One explanation states that insomnia and excess fatigue on final waking are predictive for myocardial infarction because they are part of a state of 'vital exhaustion'. Sleep complaints and sleep durations, however, are usually assessed with retrospective self-report procedures. Such procedures must be interpreted with reserve because in insomniacs, a consistent disparity in the perception of habitual and current sleep has been observed. This caused us to question whether this phenomenon is present in exhausted males also. Two approaches were used. The first one consisted of a retrospective assessment of subjective sleep characteristics, the second one of self-monitoring these sleep characteristics during 21 days. In the second week, subjects slept in a laboratory. No disparity was found in how exhausted males perceive their habitual and current sleep. It appeared that sleep quality is worse and sleep duration is shorter in exhausted males. They also feel more sleepy and take longer naps during the day, indicating that their daytime functioning is impaired. Sleeping in a laboratory reduced time asleep and midsleep wake. Sleep quality, however, was essentially the same as at home. These findings made us conclude that it is not the intrusion of nocturnal wake times per se but more likely the impaired daytime functioning which is the reason for exhausted males to complain about their sleep.
Cardiovascular Diseases↗
Exhaustion as precursor of cardiac death.
Excess fatigue is the most prevalent precursor of sudden cardiac death. This state may reflect prolonged tension or heart disease. In order to test the first explanation a prospective study was done among 3365 males, aged 45-59 years. This cohort was followed during an average period of 9.5 years. Exhaustion was assessed by the statement: 'At the end of the day I am completely exhausted mentally and physically'. Among those free of coronary heart disease at the beginning, 69 subjects died because of myocardial infarction. Data were analysed using Cox's regression analysis. The results showed a highly significant interaction between duration of follow-up and exhaustion upon the risk of cardiac death. The hazard ratios for exhaustion were 8.96, 6.33, 4.47 and 3.16 for the first 10, 20, 30 and 40 months of follow-up respectively. Thereafter the association between exhaustion and cardiac death is no more significant. It is argued that exhaustion before cardiac death does not reflect manifest heart disease but that an interaction between prolonged tension and subclinical levels of ischaemia may increase the risk of cardiac death.
Death, Sudden, Cardiac↗