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Objective: This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders., Methods: This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist., Results: The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms., Conclusions: The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: Both N-terminal pro B-type natriuretic peptide (NT-pro BNP) and depressive symptoms independently predict cardiac events in heart failure (HF) patients. However, the relationship among NT-pro BNP, depressive symptoms, and cardiac event is unknown., Methods and Results: Blood was drawn to measure NT-pro BNP and depressive symptoms were measured by the Patient Health Questionnaire 9 (PHQ-9) among 210 patients with HF. Data about cardiac event-free survival were collected for the average follow-up period of 397 days. Cox proportional hazards regression with survival curves were used to determine the relationship of NT-pro BNP and depressive symptoms to cardiac event-free survival. Higher NT-pro-BNP confers greater risk of cardiac events among those with depressive symptoms than those without depressive symptoms (P for the interaction = .029). Patients with NT-pro BNP > 581 pg/mL and total PHQ-9 score >/= 10 had a 5.5 times higher risk for cardiac events compared with patients with NT-pro BNP

Few investigators have compared health-related quality of life (HRQOL) in heart failure (HF) patients from different countries.The purposes of this study were to compare HRQOL between American (n = 87) and Taiwanese (n = 88) HF patients and to determine factors associated with HRQOL in both groups. In this cross-sectional survey, HRQOL was measured using the Minnesota Living with Heart Failure Questionnaire. American patients rated their HRQOL worse than Taiwanese patients did. Sociodemographics, disease severity, and symptom severity were associated with HRQOL, accounting for 42.4% of the variance in HRQOL in Americans and 57.3% in Taiwanese. Symptom severity was the most important predictor of HRQOL in both groups. Interventions targeting symptom severity could improve HF patients' HRQOL.

Background: : Anxiety is not routinely assessed in patients hospitalized for acute myocardial infarction (AMI). Failure to identify and treat patients who are anxious after AMI makes them more vulnerable to the adverse effects of anxiety, including higher complication rates. The anxiety subscale of the Brief Symptom Inventory (BSI) is a simple, reliable measure of anxiety with minimal patient burden. However, there is limited evidence of reliability and validity of the BSI as a measure of anxiety in patients hospitalized for AMI., Objective: : The aim of this study was to provide evidence for the reliability and validity of the BSI in hospitalized AMI patients., Method: : A total of 536 patients admitted for AMI (62 +/- 14 years of age, 66% men, 85% white, 27% with previous myocardial infarction) completed the BSI and the state portion of the State Anxiety Inventory (SAI) within 72 hours of admission. Internal consistency reliability, criterion-related validity, and construct validity of the BSI were tested., Results: : There was sufficient evidence of internal consistency (Cronbach alpha = .87), which supported the reliability of the BSI. There was evidence of criterion-related validity based on the Spearman rho correlation coefficient of 0.70 (P < .001) between BSI and SAI scores. Anxious patients had higher complication rates than did nonanxious patients (BSI, 1.31 +/- 0.13 vs 0.82 +/- 0.08, respectively, P < .001; SAI, 1.34 +/- 0.13 vs 0.80 +/- 0.07, respectively, P < .001), demonstrating adequate construct validity. In a logistic regression, BSI scores were independent predictors of in-hospital complications after controlling for sociodemographic and clinical variables, which further supported construct validity., Conclusion: : These results provide support for the BSI as a reliable, valid instrument for measuring anxiety in patients hospitalized for AMI.

Background: Depressive symptoms are a well-known predictor of mortality in patients with heart failure, and positive spousal support is associated with improved outcomes in these patients. However, in the context of depressive symptoms, the effect on survival of having a spouse is unknown., Objective: To determine the effect of marital status on event-free survival in patients with heart failure who did or did not have depressive symptoms., Methods: Depressive symptoms were assessed by using the Beck Depression Inventory-II in patients with heart failure who were followed-up for up to 4 years to collect data on mortality and hospitalizations. Patients were grouped according to the presence and absence of depressive symptoms by using the standard cutoff score of 14 on the Beck Depression Inventory-II. Kaplan-Meier and Cox regression analyses were used to compare event-free survival for married and nonmarried patients who were stratified according to the presence or absence of depressive symptoms., Results: Of 166 patients, 56% were married, and 33% had depressive symptoms. Levels of depressive symptoms were similar between married and nonmarried patients (10.9 vs 12.1; P = .39). Married patients experienced longer event-free survival than did nonmarried patients (P = .009), even with stratification according to depressive symptoms (P = .01)., Conclusions: Patients with a spouse had longer event-free survival than nonmarried patients did, even in the context of depressive symptoms.

Background: Trait anger, hostility, and serum level of homocysteine are associated with recurrent cardiac events after percutaneous coronary interventions. However, whether trait anger or hostility influences the association between serum level of homocysteine and recurrent cardiac events is unknown., Objectives: To examine the relationships among trait anger, hostility, serum level of homocysteine, and recurrent cardiac events after percutaneous coronary interventions., Methods: This prospective study included 135 consecutive patients (68% male, mean age 61 [SD, 10] years) undergoing percutaneous coronary interventions during an index hospitalization. Trait anger and hostility were measured with the Spielberger Trait Anger Scale and the Cynical Hostility Scale, respectively. Blood samples were obtained to measure serum levels of total cholesterol, triglycerides, high- and low-density lipoprotein cholesterol, and homocysteine. Recurrent cardiac events (emergency department visits and rehospitalization) were noted for 6 months after discharge and confirmed by review of hospital records. Hierarchical Cox hazard regression was used for statistical analysis., Results: Trait anger (hazard ratio = 1.11, 95% confidence interval = 1.03-1.20) and homocysteine level (hazard ratio = 1.10, 95% confidence interval = 1.01-1.21) were independent predictors of recurrent cardiac events after other risk factors were controlled for. Patients with high trait anger (score > or = 24) and high serum level of homocysteine (> or = 11.3 mumol/L) had the shortest time to recurrent cardiac events (P = .01)., Conclusion: Trait anger had a combined effect on the link between serum level of homocysteine and recurrent cardiac events. Interventions to reduce trait anger may improve health outcomes by influencing both trait anger and homocysteine level.

Background: Heart failure (HF) self-care is poor in developed countries like the United States, but little is known about self-care in developing countries., Methods and Results: A total of 2082 adults from 2 developed (United States and Australia) and 2 developing countries (Thailand and Mexico) were studied in a descriptive, comparative study. Self-care was measured using the Self-Care of HF Index, which provided scores on self-care maintenance, management, and confidence. Data were analyzed using regression analysis after demographic (age, gender, education), clinical (functional status, experience with the diagnosis, comorbid conditions), and setting of enrollment (hospital or clinic) differences were controlled. When adequate self-care was defined as a standardized score >or=70%, self-care was inadequate in most scales in most groups. Self-care maintenance was highest in the Australian sample and lowest in the Thai sample (P < .001). Self-care management was highest in the US sample and lowest in the Thai sample (P < .001). Self-care confidence was highest in the Mexican sample and lowest in the Thai sample (P < .001). Determinants differed for the three types of self-care (eg, experience with HF was associated only with self-care maintenance)., Conclusion: Interventions aimed at improving self-care are greatly needed in both the developed and the developing countries studied.

Background: Patients with heart failure often experience depressive symptoms that affect health-related quality of life, morbidity, and mortality. Researchers have not described the experience of patients with heart failure living with depressive symptoms. Understanding this experience will help in developing interventions to decrease depressive symptoms., Objective: To describe the experience of patients with heart failure living with depressive symptoms., Methods: This study was conducted by using a qualitative descriptive design. The sample consisted of 10 outpatients (50% female, mean age 63 [SD, 13] years, 70% New York Heart Association class III or IV) with heart failure who were able to describe depressive symptoms. Data were collected via taped, individual, 30- to 60-minute interviews. ATLAS ti (version 5) was used for content analysis., Results: Participants described emotional and somatic symptoms of depression. Negative thinking was present in all participants and reinforced their depressed mood. The participants experienced multiple stressors that worsened depressive symptoms. The overarching strategy for managing depressive symptoms was "taking my mind off of it." Patients managed depressive symptoms by engaging in activities such as exercise and reading, and by using positive thinking, spirituality, and social support., Conclusions: Patients with heart failure experience symptoms of depression that are similar to those experienced by the general population. Clinicians should assess patients with heart failure for stressors that worsen depressive symptoms. Strategies that researchers and clinicians can use to reduce depressive symptoms in patients with heart failure include engaging patients in activities, positive thinking, and spirituality. Helping patients find enhanced social support may also be important.

Background: Among patients with heart failure, women have worse functional status than do men, but little research has focused on determining factors that influence functional status in either sex., Objectives: To compare factors that influence functional status in men and women with heart failure and to test whether depressive symptoms mediate the relationship between physical symptoms and functional status., Methods: A cross-sectional, descriptive study design was used. A total of 231 patients, 133 men and 98 women, were recruited from an inpatient heart failure clinic in South Korea. Functional status (the Korean Activity Scale/Index), physical symptoms (the Symptom Status Questionnaire), depressive symptoms (the Beck Depression Inventory), and situational factors (living status, socioeconomic status) were measured. Hierarchical multiple regression and mediation analysis were used for data analysis., Results: Women (mean score, 24.5; SD, 17.3) had worse functional status than did men (mean score, 31.9; SD, 20.1; P = .004). Dyspnea on exertion (beta = -0.16), ankle swelling (beta = -0.19), fatigue (beta = -0.20), and depressive symptoms (beta = -0.19) were independently associated with functional status in women, whereas only dyspnea on exertion (beta = -0.30) influenced functional status of men in hierarchical multiple regression analysis. Mediation analysis indicated that depressive symptoms mediated the relationship between physical symptoms and functional status in women with heart failure, but not in men., Conclusions: Distinct physical and psychological symptoms influence functional status in women with heart failure. A systematic multidimensional intervention may be required to target depressive symptoms to improve functional status in women with heart failure.

Purpose: Recommendation of a low-sodium diet is the most common nonpharmacologic intervention used in patients with heart failure (HF). However, nonadherence to this recommendation is extremely high. There are no instruments available for the specific measurement of patients' perceptions of their barriers to, and attitudes toward, following a low-sodium diet. The purpose of this study was to evaluate the psychometric properties of a new instrument, the Dietary Sodium Restriction Questionnaire (DSRQ). Based on the Theory of Planned Behavior (TPB), the DSRQ assesses adherence through the use of 3 subscales. Each subscale represents a construct of the TPB: attitude, subjective norm, and perceived behavioral control., Methods: The sample consisted of 174 patients with HF (age 62.4 +/- 13.5 years, 56.1% were male, 83.8% were white, and 86.9% had New York Heart Association class II/III). Factorial validity was tested using principal component analysis. Reliability was tested using Cronbach's alpha to assess the internal consistency of the 3 subscales. Reliability was further evaluated with item-total correlations and inter-item correlations., Results: Principal component analysis of the DSRQ resulted in the extraction of 3 factors, each factor corresponding to a construct of the TPB. The 3-factor solution explained a total of 54.2% of the variance, with Attitude contributing 23.4%, Perceived Behavioral Control contributing 18.1%, and Subjective Norm contributing 12.7%. The Cronbach's coefficient alpha for each subscale was Attitude .88, Subjective Norm .62, and Perceived Behavioral Control .76., Conclusions: The DSRQ is a valid and reliable tool for measuring patients' attitudes, beliefs, and barriers related to following a low-sodium diet in adult, white patients with New York Heart Association class II/III HF.

Background: Heart failure (HF) is a progressive clinical condition that results in substantial impairment of quality of life (QOL). Helping patients maintain optimal QOL is essential. QOL reflects patients' subjective perceptions about the impact of a clinical condition and its treatment on daily life; however, definitions in the literature vary widely and few reflect the patient's perspective., Purpose: The study explored how patients with HF define and perceive QOL., Methods: Qualitative data were obtained from 14 men and 6 women with HF (mean age 58 +/- 10 years) using semistructured open-ended interviews. The interviews were analyzed using content analysis., Results: Patients with HF defined QOL as their ability to 1) perform desired physical and social activities to meet their and their family's needs; 2) maintain happiness; and 3) engage in fulfilling relationships with others. Patients perceived a variety of factors as positively or negatively affecting QOL: physical (symptoms and good or poor physical status), psychologic (mood and positive or negative perspective), economic (financial status), social (social support and ability for social activities), spiritual, and behavioral (self-care). Patients perceived that HF had a serious impact on QOL, but most evaluated their QOL as good nonetheless., Conclusion: Patients' definition of QOL reflected not only the impact of HF on their daily life but also their active pursuit of happiness. Patients' self-evaluation of QOL reflected the negative impact of HF and patients' altered expectations of what constituted good QOL.

Background: Despite the importance of medication adherence in heart failure, clinically relevant cutpoints for distinguishing the level of adherence associated with outcomes are unknown., Objective: The purpose of this study is to determine the cutpoint above which there is a positive relationship between level of medication adherence and event-free survival., Methods: This was a longitudinal study of 135 patients with heart failure. Medication adherence was measured using a valid and objective measure, the Medication Event Monitoring System. Two indicators of adherence were assessed by the Medication Event Monitoring System (AARDEX, Union City, CA): (1) dose count, percentage of prescribed doses taken, and (2) dose days, percentage of days the correct number of doses was taken. Patients were followed up to 3.5 years to collect data on outcomes. A series of Kaplan-Meier plots with log-rank tests, Cox survival analyses, and receiver operating characteristic curves were assessed comparing event-free survival in patients divided at one-point incremental cutpoints., Results: Event-free survival was significantly better when the prescribed number of doses taken (dose count) or the correct dose (dose day) was > or =88%. This level was confirmed in a Cox regression model controlling for age, gender, ejection fraction, New York Heart Association, comorbidity, angiotensin-converting enzyme inhibitor use, and beta-blocker use. Receiver operating characteristic curves showed that adherence rates above 88% produced the optimal combination of sensitivity and specificity with respect to predicting better event-free survival. With 88% as the adherence cutpoint, the hazard ratio for time to first event for the nonadherent group was 2.2 by dose count (P = .021) and 3.2 by dose day (P = .002)., Conclusion: The results of this study provide clinicians and researchers with an evidence-based recommendation about the level of adherence needed to achieve optimal clinical outcomes.

The purposes of this study were to describe heart failure patient perceptions regarding instructions received for following a low-sodium diet and the benefits, barriers, and ease and frequency of following the diet. A total of 246 patients with heart failure referred from academic medical centers in the United States and Australia participated in the study. A subset of 145 patients provided 24-hour urine samples for sodium excretion assessment. While most (80%) patients reported receiving recommendations to follow a low-sodium diet, their recall of specific instructions was poor. Although the majority (75%) reported following a low-sodium diet most or all of the time, 24-hour urine sodium excretion indicated that only 25% of patients were adherent. Patients who reported being more adherent, however, had lower urine sodium excretion levels. Attitudes regarding difficulty in and perceived benefits of following the diet were not related to sodium excretion. Data on attitudes and barriers provided guidance for strategies to improve adherence.

Background: Although self-care may reduce exacerbations of heart failure, reported rates of effective self-care in patients with heart failure are low. Modifiable factors, including psychosocial status, knowledge, and physical factors, are thought to influence heart failure self-care, but little is known about their combined impact on self-care., Objectives: The objective of this study was to identify factors related to self-care behaviors in patients with heart failure., Design: A cross-sectional, correlational study design was used., Participants and Settings: One hundred twenty-two patients (77 men and 45 women, mean age 60+/-12 years old, 66% New York Heart Association functional class III/IV) were recruited from the outpatient clinics of an academic medical center and two community hospitals., Methods: Data on self-care behaviors (Self-Care of Heart Failure Index), depressive symptoms, perceived control, self-care confidence, knowledge, functional status, and social support were collected. Factors related to self-care were examined using hierarchical multiple regression., Results: Mean self-care behavior scores were less than 70 indicating the majority of men and women with HF did not consistently engage in self-care behaviors. Higher self-care confidence and perceived control and better heart failure management knowledge were associated with better self-care (r2=.25, p<.001). Higher perceived control and better knowledge were related to better self-care behaviors in men (r2=.18, p=.001), while higher self-care confidence and poorer functional status were related to better self-care behaviors in women (r2=.35, p<.001)., Conclusion: This study demonstrates the substantial impact of modifiable factors such as confidence in one's self-care abilities, perceived control, and knowledge on self-care behaviors. This study demonstrates that there are gender differences in factors affecting self-care, even though at baseline men and women have similar knowledge levels, physical, psychological, and behavioral status. Effective interventions focusing on modifiable factors and the unique characteristics of men and women should be provided to improve self-care behaviors in patients with heart failure.

Objective: Medication nonadherence is presumed to be related to poor clinical outcomes, yet this relationship rarely has been tested using objective adherence measures in patients with heart failure. Which objective indicators of medication adherence predict clinical outcomes are unknown. The study objective was to determine which indicators of medication adherence are predictors of event-free survival., Methods: Patients (N = 134) with heart failure (69% were male, aged 61 +/- 11 years, 61% with New York Heart Association class III/IV heart disease) were enrolled in this 6-month longitudinal study. Adherence was measured using two measures: 1) an objective measure, the Medication Event Monitoring System (MEMS); and 2) self-reported adherence (Medical Outcomes Studies Specific Adherence Scale). Three indicators of adherence were assessed by MEMS: 1) dose-count, percentage of prescribed doses taken; 2) dose-days, percentage of days correct number of doses taken; and 3) dose-time, percentage of doses taken on schedule. Events (emergency department visits, rehospitalization, and mortality) were obtained by patient/family interview and hospital databases., Results: In Cox regression, two of the three MEMS indicators, dose-count and dose-day, predicted event-free survival before and after controlling for age, gender, ejection fraction, New York Heart Association class, angiotensin-converting enzyme inhibitor use, and beta-blocker use (P = .004, P = .008, and P = .224, respectively). Self-report adherence did not predict outcomes (P = .402)., Conclusion: Dose-count and dose-day predicted event-free survival. Neither dose-time nor self-reported adherence predicted outcomes. Health care providers should assess specific behaviors related to medication taking rather than a global patient self-assessment of patient adherence.

There are a number of factors related to heart failure pathophysiology and treatment that influence nutrient requirements for patients. These include catabolism, inflammation, oxidative stress, diuretic use, and presence of comorbidities. On the other hand, there is evidence that specific nutrients can alter heart failure pathophysiology. This article reviews the current evidence for nutritional recommendations regarding sodium and fluid restriction, macro- and micronutrient intake, and dietary changes required by the presence of common comorbidities.

Objective: Poor adherence to a low-sodium diet (LSD) and prescribed medications increases rehospitalization risk in patients with heart failure (HF). Clinicians have difficulty assessing adherence objectively, so they depend on patients' self-report. The degree to which self-reported adherence reflects actual adherence is unclear. We examined patients' ability to self-monitor adherence to an LSD and medications by comparing self-reported adherence with objective evidence of adherence., Methods: A total of 133 patients with HF (male 71%; ejection fraction 35% +/- 14%) completed the Medical Outcomes Study Specific Adherence Scale. Adherence to the LSD and medication were assessed objectively using 24-hour urinary sodium excretion and dose counting with an electronic monitoring device, respectively. On the basis of self-report, patients were divided into adherent and non-adherent groups and evaluated for differences according to objective adherence., Results: There were no differences in urinary sodium levels between the self-reported LSD adherent and non-adherent groups (4560 mg vs. 4333 mg; P = .59). Self-reported adherent and non-adherent medication groups took 92.4% and 80.4% of prescribed doses, respectively (P < .001)., Conclusion: Patients were able to accurately estimate adherence to medication, but they failed to estimate LSD adherence. This finding suggests that we need to improve our means of evaluating adherence to the LSD and of educating patients more thoroughly about following the LSD. We speculated that the inability to estimate LSD adherence may be the result of gaps in patients' knowledge that preclude accurate self-assessment.

Data indicate that nonadherence plays a major role in preventable rehospitalizations. The first step to improving adherence is determining the affecting factor. This article critically reviews the literature on factors affecting medication adherence in heart failure patients. Findings about effects of age, gender, race, and living status on adherence are quite inconsistent. Patients who believe taking medications is beneficial or who have no side effects are more adherent, as are those highly motivated to improve their well-being. Forgetfulness, social support, and patient-provider relationship are related to adherence. Providers seeking to increase adherence must consider patients' expectations for their health, their environment, their barriers to following prescribed regimen, and their understanding of their condition and how it relates to medication taking.

Background: Health-related quality of life (HRQOL) in older adults with heart failure may be affected by a variety of variables including aging. It is important to determine the unique impact of heart failure to more effectively improve HRQOL in this population., Objective: The purpose of this study was to compare HRQOL and physical, psychologic, clinical, and sociodemographic status in older adults with and without heart failure., Methods: The HRQOL of 90 older adults with heart failure and 116 healthy older adults was compared. The factors best associated with HRQOL in each group were determined using multiple regression model., Results: HRQOL was substantially worse among older adults with heart failure than among healthy older adults. Older adults with heart failure had more severe physical and emotional symptoms, poorer functional status, and worse health perceptions. Physical symptom status was the strongest predictor of HRQOL in both groups. In addition, in older adults with heart failure, physical symptom status, age, and anxiety were related to HRQOL., Conclusion: The poor HRQOL seen in patients with heart failure is not just a reflection of aging. Comprehensive interventions targeted toward the factors that specifically negatively impact HRQOL are essential in older adults with heart failure.

Background: Despite the importance of the sodium-restricted diet (SRD) to heart failure (HF) management, patient adherence is poor. Little is known about gender differences in adherence or factors that affect patients' ability to follow SRD recommendations. The purposes of this study were to determine whether there were gender differences in (1) adherence to the SRD; (2) knowledge about SRD and HF self-care; and (3) perceived barriers to following the SRD., Methods and Results: Forty-one men and 27 women completed the Heart Failure Attitudes and Barriers questionnaire that measured HF self-care, knowledge, and perceived barriers to follow an SRD. Diet adherence was measured by 24-hour urinary sodium excretion (UNa). Women were more adherent to the SRD than men as reflected by 24-hour urine excretion (2713 versus 3859 mg UNa, P = .01). Women recognized signs of excess sodium intake such as fluid buildup (P = .001) and edema (P = .01) more often than men and had better understanding of appropriate actions to take related to following an SRD. There were no gender differences in perceived barriers to follow an SRD., Conclusions: Although men and women perceived similar barriers, women were more adherent to the SRD and had greater knowledge about following an SRD. Further investigation of this phenomenon is warranted to determine if better adherence contributes to improved outcomes in women.

Promoting optimal nutritional intake may play an important role in the management of patients with heart failure. Unfortunately, no nutritional guidelines are currently available to assist clinicians in assuring adequate nutritional intake of these patients. The purposes of this article are to review currently available information on nutrition in heart failure and outline initial recommendations for micronutrient, protein, and omega-3 fatty intake. In addition, implications regarding the recent data showing improved health outcomes in obese patients are also addressed.

Background: Dietary fat intake affects proinflammatory cytokine levels of healthy adults. Whether dietary fats have similar effects in patients with heart failure (HF) is unknown. The purposes of this study were to determine (1) effect of dietary fat on interleukin (IL)-6, tumor necrosis factor (TNF)-alpha, and soluble receptors sTNF-R1 and sTNF-R2 levels in patients with HF and (2) subsequent impact of these levels on event-free survival., Methods and Results: Forty-two patients provided 4-day food diaries and blood for cytokines. Event-free survival curves were calculated by Kaplan-Meier method and groups compared using log-rank test. IL-6 was not related to fat intake. TNF-alpha levels were elevated in patients with diets higher versus lower in saturated (6.9 +/- 5 versus 4.2 +/- 2 pg/mL) and trans fats (6.8 +/- 4.5 versus 4.5 +/- 2.8 pg/mL). Patients consuming diets higher in polyunsaturated fats had lower sTNF-R1 (2391 +/- 1010 versus 3373 +/- 2098 pg/mL) and sTNF-R2 (3803 +/- 1187 versus 5974 +/- 3275 pg/mL) levels. Higher omega-3 intake produced similar results: sTNF-R1 (2323 +/- 1304 versus 3307 +/- 1973) and sTNF-R2 (4117 +/- 2646 versus 5409 +/- 2801). Event-free survival was decreased in patients with higher TNF-alpha and sTNF-R1 levels., Conclusion: Dietary fat intake may affect proinflammatory cytokine levels in patients with HF. Research to determine whether changing composition of dietary fat can alter proinflammatory cytokine activity of HF patients is warranted.

Food intake and body weight changes in response to induction of acute inflammation were examined in intact cycling females, ovariectomized females, and sham-operated male rats. In intact females, body weight and feeding responses were compared between rats in which inflammation was induced on day of estrus with rats in which inflammation was induced on day of diestrus. Anorexia and weight loss were more severe in the female rats with inflammation induced on estrus day, which coincides with peak serum estrogen levels. In ovariectomized females, inflammation was induced the day after rats received injections of estrogen, progesterone, or sesame oil (vehicle). Males received vehicle injections. Among female rats, the group that received estradiol injections the previous day displayed the most severe anorexia. The least severe anorexia was observed in female rats that received progesterone the previous day. Food intake of female rats that received vehicle injections prior to induction of inflammation was greater than the rats receiving estrogen but less than the rats receiving progesterone. Male rats displayed the most severe anorexia and greatest weight loss. These data suggest that, although females exposed to estradiol prior to induction of acute inflammation display more severe anorexia than those exposed to progesterone, it may be that progesterone attenuates severity of anorexia rather than estrogen solely potentiating severity. Male rats, however, appear to experience the most severe anorexia in response to this form of inflammation.

Background: Despite significant progress in the treatment of coronary artery disease, myocardial infarction is still the leading cause of death in the United States. As suggested by Leventhal's Self-Regulation Model of Illness, the continued high morbidity and mortality may be due to a failure to address the role of psychosocial factors such as illness representation, depression, and anxiety in recovery., Objective: To determine the relationship between illness representation of myocardial infarction and the occurrence of in-hospital complications and if anxiety and depression mediate this relationship., Method: A prospective correlational design was used to measure illness representation, depression, and anxiety 24 to 48 hours after admission for myocardial infarction in 49 patients and the frequency of complications during the acute event. Logistic regression was used to determine the likelihood of experiencing a complication., Results: When demographic and clinical variables were controlled for, the more negative the representation of illness, the greater were the odds of experiencing a complication (chi2 = 16.9, df = 6, P =.01). The odds of experiencing a complication increased 5.1% for each 1 unit increase in the score on the Illness Preparation Questionnaire (B = 0.05, Wald = 4.442, Exp(B) = 1.051, 95% CI = 1.003-1.1010). Neither anxiety (chi2 = 3.0, df = 1, P =. 09) nor depression (chi2 = 2.5, df = 1, P = .11) were significant predictors of the occurrence of complications., Conclusion: In these patients, illness representation was predictive of the likelihood of experiencing a complication. Thus, illness representation appears to be an important psychosocial factor in acute recovery from myocardial infarction.

The administration of psychologically provocative research instruments could serve as a transient source of stress and spuriously affect results. To determine whether the administration of selected psychosocial instruments activates the stress response, we examined the physiological stress response of stable patients post-myocardial infarction (MI) to completing the Beck Depression Inventory, the Illness Perception Questionnaire, and the Spielberger State Anxiety Inventory 24 to 48 hours post-acute event. Salivary cortisol, heart rate variability (HRV), heart rate, and mean arterial pressure (MAP) were measured prior to instrument administration and 30 minutes after as indicators of the stress response. Twenty-four subjects (16 men) completed the study. Mean baseline measures of salivary cortisol (0.558 mcg/dL), heart rate (86 bpm), and MAP (86 mm Hg) were within normal ranges. A repeated-measures analysis of variance demonstrated no significant difference in salivary cortisol, F(1, 23) = 2.59, NS; HRV, F(1, 18) = 0.27, NS; heart rate, F(1, 23) = 4.29, NS; or MAP, F(1, 22) = 0.859, NS, from preinterview to postinterview. These results suggest that completing these selected psychological instruments in thefirst 24 to 48 hoursfollowing MI was not a stressful event, at least for those who were stable post-percutaneous transluminal coronary angioplasty.

Previous research has shown that reductions in body weight prior to induction of acute inflammation can attenuate inflammation-induced anorexia in male rats. In the current study, potential mechanisms responsible for this observation were examined. Specifically, the effect of a 12% prior reduction in body weight on serum leptin, insulin, and corticosterone; levels of interleukin-1 (IL-1), interleukin-6 (IL-6) in the serum, liver, and spleen; neuropeptide Y (NPY) and POMC mRNA levels in the arcuate nucleus (ARC) of the hypothalamus were examined 8 h after induction of acute inflammation. Rats with prior weight reduction had significantly lower serum leptin levels and gene expression of POMC in the ARC than normal-weight rats. In contrast, prior weight reduction altered neither NPY mRNA in the ARC, nor IL-1alpha, IL-1beta, and IL-6 levels in the serum, liver, and spleen. These results suggest that the attenuation of inflammation-induced anorexia by prior weight reduction is not due to altered cytokine activity, but rather to changes in energy regulatory systems that moderate the anorexic actions of IL-1beta and IL-6. One potential change may be reduced activity of the CNS melanocortin system induced by decreased circulating leptin.

Assessments of hunger and/or appetite are common methods of screening for development of illness-related anorexia. There are limited data to determine whether these methods predict actual food intake in persons with HIV disease. Therefore, the authors examined the relationship between self-reported food intake and subjective ratings of hunger and appetite in 31 adults with HIV infection. Participants also indicated presence of additional factors that can decrease amount of food eaten. Subjective ratings of appetite and hunger correlated with each other but not with food intake. Twenty-four additional factors that can affect food intake were reported to be present. The most common were illness-related and factors such as eating with friends or family. These results indicate that measures of hunger and appetite are not sufficient to screen for decreased food intake. Additional factors that can affect food intake should also be included in a comprehensive assessment of adults with HIV infection.

In this pilot work, the authors compared the circadian rhythm responses of 3-month-old female fatty Zucker rats with those of lean Zucker rats and Sprague-Dawley rats to reversal of the light/dark (LD) cycle. Core temperature and spontaneous cage activity were continuously monitored by implanted microtelemetry devices prior to and for 5 days following complete LD cycle reversal. By the 5th day after LD reversal, temperature rhythm nadir had phase-advanced 10.5 hours in the lean Zucker rats, 10.8 hours in the Sprague-Dawley rats, and only 3.8 hours in the fatty Zucker rats. Similarly, total activity increased in lean Zucker rats and Sprague-Dawley rats after LD reversal but declined in the fatty Zucker rat during the same time. Results of this study show that obese Zucker rats displayed an impaired ability to reentrain circadian rhythms for temperature and activity when compared to lean Zucker rats and Sprague-Dawley rats. These findings suggest that dysfunction in the circadian pacemaker previously shown to manifest itself by 43 weeks of age in fatty Zucker rats may already be present at 3 months of age and suggest that altered thermoregulation may play a role in the development of obesity in this animal model of genetic obesity.

Anorexia associated with acute illness remains one of the most common, challenging, and difficult symptoms to treat. Surprisingly, little attention has been devoted to development of interventions to reverse this form of anorexia. Although incomplete, current understanding of the mechanisms responsible for illness-induced anorexia is sufficient to suggest therapeutic approaches. In this article, the major physiologic mechanisms underlying illness-induced anorexia are described. In addition, potential moderating effects of social, psychologic, and environmental factors are discussed. This information was used to develop recommendations for the treatment of anorexia. A majority of these interventions, however, are not research based. Further advances in the treatment of illness-induced anorexia will require greater understanding of the complex, interactive effects of psychologic, environmental, and biologic factors on eating behavior during illness. Therefore, areas requiring continued investigation are also outlined.

The response to acute inflammation of rats at two levels of prior weight reduction were compared with normal-weight rats to examine how prior alterations in body energy status influence inflammation-induced anorexia and weight loss. Specifically, body weights were either reduced by 6%, the level of weight loss expected in normal-weight rats following induction of acute inflammation, or by 12%, a level 6% below that expected of the normal-weight rats. Rats were either allowed to eat ad lib. on postinflammation Day 1 or were kept on food restriction until Day 5, when anorexia was no longer expected to be present. As predicted, normal-weight rats allowed to eat ad lib. beginning Day 1 displayed the most severe anorexia. Total food intake of this group over the first 5 days following inflammation induction was 33% less than the control (CON) group. Rats with 6% prior weight reduction displayed a milder anorexia, eating only 15% less than the CON group over the first 5 days. In contrast, rats with 12% prior weight reduction ate the same amount of food as the CON group. Interestingly, similar feeding patterns were observed in rats that resumed ad lib. feeding on Day 5. The outcome of these various feeding patterns was to bring body weights of all the inflammation groups to the same level, approximately 6% below CON group weights. These results provide further evidence that proinflammatory mediators induce a temporary reduction in the amount of body tissue (weight) spontaneously maintained that is directly proportionate to the magnitude of insult.

Tissue injury creates a paradoxical state in which nutritional intake is decreased at a time when the need for these nutrients is greatest. Examining the biological mechanisms underlying the metabolic response to injury provides insight into why this paradoxical state exists. The nurse can use this information to develop interventions that promote utilization of exogenous nutrition, thereby limiting net loss of body tissue.

An animal model of acute inflammation was used to examine how body energy status influences the syndrome of anorexia, negative nitrogen balance, and body weight loss typically seen in response to injury. Specifically, the metabolic response to acute inflammation was studied in rats of normal, elevated, or reduced body weights. Rats induced to overeat and gain weight prior to inflammation displayed protracted anorexia, greater subsequent weight loss, higher metabolic rates, and greater negative energy balance than rats of normal weight. Conversely, rats with reduced body weights displayed elevated food intakes, body weight gain, attenuated nitrogen loss, and normal rates of energy expenditure. Prior weight reduction did not affect postinflammation fever or levels of fibrinogen, iron, and interleukin-6-like activity, suggesting that the ability to mount an acute phase response was not impaired in weight-reduced rats. These results suggest that the usual postinflammation adjustments in body energy flux and body nitrogen are regulated components of a metabolic response to acute inflammation which renders normally protected sources of endogenous energy and substrate available for repair and recovery.

Three studies investigated the role of fever in the acute elevation of heat production induced by lateral hypothalamic (LH) lesions and the mechanisms by which this thermogenic response can be attenuated by reductions in body weight. In Study 1, reducing the weights of rats prior to lesioning the LH attenuated both the usual postlesion fever and elevation in thermogenesis. In Study 2, blocking prostaglandin synthesis with indomethacin likewise blunted both the lesion-induced fever and thermogenesis. In Study 3, treating already weight-reduced rats with indomethacin attenuated, but still failed to eliminate, the lesion-induced fever. Together, these results suggest that both the fever and increased thermogenesis induced by LH lesions are mediated, at least in part, by prostaglandin mechanisms which themselves are influenced by body energy status.