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Aromatherapy is the use of highly concentrated aromatic plant oils administered in various ways for a wide range of therapeutic indications. The purpose of this review is to present an overview of the evidence on aromatherapy during the perinatal period. There is research on the prenatal use of aromatherapy to treat nausea and vomiting, reduce stress, and support immune function; the intrapartum use of aromatherapy for labor pain/anxiety and labor progress; and the postpartum use of aromatherapy for postcesarean symptoms, perineal trauma, sleep, and symptoms of depression and anxiety. Overall, the evidence suggests that aromatherapy can be administered safely and effectively in obstetrics.

This systematic review and meta-analysis aimed to evaluate the effects of cognitive behavioural therapy (CBT) on depression, quality of life, hospitalisations and mortality in heart failure patients. The search strategy was developed for Ovid MEDLINE and modified accordingly to search the following bibliographic databases: PubMed, EMBASE, PsycINFO, CENTRAL and CINAHL. Databases were searched from inception to 6 March 2016 for randomised controlled trials (RCTs) or observational studies that used CBT in heart failure patients with depression or depressive symptoms. Six studies were identified: 5 RCTs and 1 observational study, comprising 320 participants with predominantly NYHA classes II-III, who were mostly male, with mean age ranging from 55 to 66 years. Compared to usual care, CBT was associated with a greater improvement in depression scores both initially after CBT sessions (standardised mean difference −0.34, 95% CI −0.60 to −0.08, p = 0.01) and at 3 months follow-up (standardised mean difference −0.32, 95% CI −0.59 to −0.04, p = 0.03). Greater improvement in quality of life scores was evident for the CBT group initially after CBT sessions, but with no difference at 3 months. Hospital admissions and mortality were similar, regardless of treatment group. CBT may be more effective than usual care at improving depression scores and quality of life for heart failure patients initially following CBT and for depression at 3 months. Larger and more robust RCTs are needed to evaluate the long-term clinical effects of CBT in heart failure patients. Electronic supplementary material The online version of this article (doi:10.1007/s10741-017-9640-5) contains supplementary material, which is available to authorized users.

Problem and background Approximately one in four women in Australia have their labour induced, and prolonged pregnancy is likely the most common reason for induction. Clinical guidelines recommend offering induction at 41 weeks, because it is thought that induction lowers the risk of stillbirth without increasing the Caesarean rate. However, the evidence behind this recommendation warrants closer investigation. Questions What is the risk of stillbirth as women go past their due dates, and what are the benefits and risks of elective labour induction? Findings A large body of evidence shows that the relative risk of stillbirth increases starting after 37–38 weeks, but more recent data show the absolute risk does not rise substantially until 42 weeks, when it reaches 1 in 1000. As women get closer to 41 weeks, it is appropriate for midwives to discuss the benefits and risks of elective induction and expectant management. Meta-analyses that have studied the effects of elective induction were driven by the Hannah Post Term trial, which was limited by high rates of cross-over between groups. Conclusion Ultimately, after receiving accurate, evidence-based information and guidance from health care providers, women have the right to decide whether they prefer to induce labour, or wait for spontaneous labour with appropriate foetal monitoring, as both are reasonable options.

Health care disparities associated with African American race may influence event-free survival in patients with heart failure (HF). A secondary data analysis included 863 outpatients enrolled in a multicenter HF registry. Cox regression was used to determine whether African American race was associated with shorter HF event-free survival after controlling for covariates. The multivariable-adjusted hazard ratios (95% confidence intervals [CI]) of older age (1.03, 95% CI = [1.01, 1.04]), New York Heart Association (NYHA) functional class (1.73, 95% CI = [1.29, 2.31]), depressive symptoms (1.05, 95% CI = [1.02, 1.07]), and African American race (1.64, 95% CI = [1.01, 2.68]) were predictors of shorter event-free survival (all ps < .05). Comparisons showed that NYHA functional class was predictive of shorter event-free survival in Caucasians (1.81, 95% CI = [1.33, 2.46]) but not in African Americans (1.24, 95% CI = [.40, 3.81]). African Americans with HF experienced a disparate risk of shorter event-free survival not explained by a variety of risk factors.

Introduction Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM. Methods This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29 [6] years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience. Results The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from “new mom anxiety” to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again. Discussion Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.

Background: Depressive symptoms are predictors of shorter cardiac event-free survival, whereas increased body mass index (BMI) is associated with longer cardiac event-free survival in patients with heart failure (HF). However, the impact of BMI on the link between depressive symptoms and cardiac event-free survival is unexplored. The purpose of this study was to determine whether the relationship between depressive symptoms and cardiac event-free survival differs among HF patients stratified by BMI tertiles. Methods: A total of 297 outpatients withHFcompletedthePatientHealthQuestionnaire-9toassess depressivesymptoms. Body massindexwas calculated as weight in kilograms divided by height in meters squared. Patients were followed for 1 year to determine cardiac event-free survival. Cox proportional hazard regression with survival curves was used to determine the relationships among depressive symptoms, BMI, and cardiac event-free survival. Results: Both depressive symptoms (P G .001) and lower BMI (P = .002) are independent predictors of shorter cardiac event-free survival after controlling for age, gender, etiology, total comorbidity scores, ejection fraction, New York Heart Association functional class, and prescribed medications. Patients with depressive symptoms had shorter cardiac event-free survival compared with patients without depressive symptoms in the lowest (P = .001) and middle (P = .036) BMI tertiles. There was no difference in cardiac event-free survival between patients with and without depressive symptoms in the highest tertile (P = .894). Conclusions: Higher BMI has a protective role in the adverse effect of depressive symptoms on health outcomes in patients with HF.

Background Patients with heart failure (HF) experience multiple psychologic symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown. Objective To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. Method A total of 1260 patients with HF participated in this study. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous-level variables, then as categorical variables using standard published cut points. Patients were then divided into 4 groups based on the presence of anxiety and depression symptoms. Results When entered as a continuous variable, the interaction between anxiety and depression (hazard ratio=1.02; 95% CI: 1.01–1.03; p = 0.002) was a significant predictor of all-cause mortality in patients with HF. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (vs no symptoms or symptoms of anxiety or depression alone) independently predicted all-cause mortality (hazard ratio=2.59; 95% CI: 1.49–4.49; p = 0.001). None of the psychologic variables was a predictor of cardiac rehospitalization in patients with HF whether using the continuous or categorical level of measurement. Conclusion To improve mortality outcomes in patients with HF, attention must be paid by health care providers to the assessment and management of co-morbid symptoms of depression and anxiety.

Objectives To describe self-reported stress level, cognitive appraisal and coping among patients with heart failure (HF), and to examine the association of cognitive appraisal and coping strategies with event-free survival. Methods This was a prospective, longitudinal, descriptive study of patients with chronic HF. Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale, Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event-free survival was defined as cardiac rehospitalization and all-cause death. Results A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated. Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidant emotional coping (β = -0.28; 95% CI: -0.21 – 0.02; p = 0.02) and event free survival (HR = 0.53; 95% CI: 0.28 – 1.02; p = 0.05). Conclusions The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event-free survival.

Depressive symptoms in patients with heart failure can affect the relationship between physical signs and symptoms and inflammation.To examine the relationship between soluble tumor necrosis factor receptor I and physical signs and symptoms and the effects of depressive symptoms on this relationship in patients with heart failure.Data on physical signs and symptoms (Symptom Status Questionnaire-Heart Failure), depressive symptoms (Beck Depression Inventory-II), and levels of the receptor (blood samples) were collected from 145 patients with heart failure. Data on the receptor were square root transformed to achieve normality. Patients were divided into 2 groups according to their scores for depressive symptoms (nondepressed14 and depressed ≥14). Hierarchical multiple regression was used to analyze the data.In the total sample, with controls for covariates, higher levels of the receptor were significantly related to more severe physical signs and symptoms (F = 7.915; P.001). In subgroup analyses, with controls for covariates, levels of the receptor were significantly related to physical signs and symptoms only in the patients without depression (F = 3.174; P = .005).Both depressive symptoms and inflammation should be considered along with physical signs and symptoms in patients with heart failure. Further studies are needed to determine the effects of improvement in inflammation on improvement in physical signs and symptoms, with consideration given to the effects of depressive symptoms.

Background Scientists have systematically established the prevalence and the consequences of depressive symptoms in patients with heart failure (HF). However, a comprehensive understanding of patient perspectives about depressive symptoms, in combination with HF, has not been published. A patient-centered approach may support the design of interventions that are effective and acceptable to patients with HF and depressive symptoms. Objective The aim of this study was to review qualitative findings about patient perspectives of contributing factors, associated symptoms, consequences, and self-care strategies used for depressive symptoms in HF. Methods Qualitative studies were included if they were published between 2000 and 2012, if they were in English, and if they described emotional components about living with HF. Three electronic databases were searched using the key words heart failure, qualitative, and depression or psychosocial or stress or emotional. Results Thirteen studies met the inclusion criteria. Patients with HF reported that financial stressors, overall poor health, past traumatic life experiences, and negative thinking contributed to depressive symptoms. The patients described cognitive-affective symptoms of depression and anxiety but not somatic symptoms of depression. Perceived consequences of depressive symptoms included hopelessness, despair, impaired social relationships, and a decreased ability to engage in HF self-care. Recommended management strategies consisted of enhanced social support and cognitive strategies. Conclusions Depressive symptoms in patients with HF were associated with a number of contributing factors, including those not specifically related to their disease, and serious consequences that reduced their self-care ability. Nonpharmacological management approaches to depressive symptoms that include improved social support or cognitive interventions may be effective and acceptable strategies.

Inflammation may be a link between depressive symptoms and outcomes in patients with heart failure. It is not clear whether inflammatory markers are independently related to depressive symptoms in this population.To determine which inflammatory biomarkers are independently associated with depressive symptoms in heart failure.We analyzed data from 428 outpatients enrolled in a heart failure registry (32% female, 61 ± 12 years, 48% New York Heart Association Class III/IV). Depressive symptoms were measured with the Beck Depression Inventory-II. Serum C-reactive protein (CRP), cytokines (interleukin 1 receptor antagonist, 2, 4, 6, 8, 10), tumor necrosis alpha, and soluble receptors sTNFR1 and sTNFR2 were measured with enzyme immunoassay. Multiple regressions were used to determine which biomarkers were associated with depressive symptoms controlling for demographics, heart failure severity, and clinical variables. Twenty-seven percent (n = 119) had depressive symptoms. CRP was related to depressive symptoms after controlling for age and gender, but no inflammatory biomarkers were associated with depressive symptoms after controlling for all variables in the model.There was no relationship between inflammatory biomarkers and depressive symptoms. Our findings, in combination with prior researchers', suggest there is not a robust relationship between depressive symptoms and individual biomarkers of inflammation in heart failure.

The purpose of this secondary data analysis was to compare event-free survival among four groups of patients with heart failure (HF) that were stratified by presence of depressive symptoms and antidepressants.We analyzed data from 209 outpatients (30.6% female, 62 ± 12 years, 54% NYHA Class III/IV) enrolled in a multicenter HF registry who had data on depressive symptoms, antidepressant use, and cardiac rehospitalization and death outcomes during 1 year follow up. Depressive symptoms were assessed using the Patient Health Questionnaire-9.Depressive symptoms, not antidepressant therapy, predicted event-free survival (HR = 2.4, 95% CI = 1.2-4.6, p = .009). Depressed patients without antidepressants had 4.1 times higher risk of death and hospitalization than non-depressed patients on antidepressant (95% CI = 1.2-13.9, p = .022) after controlling for age, gender, NYHA class, body mass index, diabetes, medication of ACEI and beta-blockers.Antidepressant use was not a predictor of event-free survival outcomes when patients still reported depressive symptoms. Ongoing assessment of patients on antidepressants is needed to assure adequate treatment.

Psychological conditions such as depression can have a greater impact on morbidity and mortality outcomes than traditional risk factors for these outcomes. Despite their importance, it is rare for clinicians to assess patients for these conditions and rarer still for them to consistently and adequately manage them. Illumination of the phenomena of comorbid psychological conditions in heart failure may increase awareness of the problem, resulting in improved assessment and management.

Aims: To describe correlations and agreement between salivary and serum B-type natriuretic peptide (BNP), C-reactive protein (CRP), interleukin (IL)-6, and IL-10 and determine which biomarkers predict worse functional class in patients with heart failure (HF). Methods: Serum and saliva were collected from 75 hospitalized patients with HF (57 ± 12 years, 43% female, New York Heart Association [NYHA] Classes I [4%], II [43%], and III [53%]). Oral inflammation was rated as good, fair, or poor. Spearman’s ρ and Bland–Altman were used to determine correlations and agreement of the salivary and serum forms of each biomarker. Logistic regressions were used to determine which biomarkers predicted worse NYHA functional class, controlling for depression, body mass index, smoking, and oral inflammation. Results: Median biomarker concentrations were as follows: BNP (serum 361 pg/ml, saliva 9 pg/ml), CRP (serum 13 ng/ml, saliva 25.6 ng/ml), IL-6 (serum 19.3 pg/ml, saliva 10.5 pg/ml), and IL-10 (serum 64.1 pg/ml, saliva 4.7 pg/ml). There was a moderate-to-strong correlation for serum–salivary CRP, weak correlation for serum–salivary IL-6, and no correlations for serum–salivary BNP and IL-10. The Bland–Altman test showed good salivary–serum agreement for all biomarkers, but as serum concentrations rose, salivary measures underestimated serum levels. Visible oral inflammation was the only predictor of worse NYHA class.

The purpose of this study was to describe how people use social media to find and disseminate information about evidence-based maternity care. We used a cross-sectional Internet-based survey design in which 1,661 participants were recruited from childbirth-related blogs. Participants answered questions about how they find, use, and share evidence-based maternity information using social media. Overall, women in this study were highly engaged in using social media to find and share maternity information. Most respondents were very interested in reading evidence-based maternity care articles online. Most intend to use this information that they found, despite the fact that a substantial percentage had no intentions of discussing this information with their childbirth educators or physician.

Depressive symptoms and poor health perceptions are predictors of higher hospitalization and mortality rates (heart failure [HF]). However, the association between depressive symptoms and health perceptions as they affect event-free survival outcomes in patients with HF has not been studied. The purpose of this secondary analysis was to determine whether depressive symptoms mediate the relationship between health perceptions and event-free survival in patients with HF. A total of 458 HF patients (61.6 ± 12 years, 55% New York Heart Association Class III/IV) responded to one-item health perception question and completed the Patient Health Questionnaire–9. Event-free survival data were collected for up to 4 years. Multiple regression and Cox proportional hazards regression analysis showed that depressive symptoms mediated the relationship between health perceptions and event-free survival. Decreasing depressive symptoms is essential to improve event-free survival in patients with HF.

Preeclampsia is a major cause of maternal and fetal morbidity and mortality affecting 5–10% of pregnancies. Mental health issues are often exhibited in this vulnerable population partly due to the rigid management of this condition including prolonged bed rest. The purpose of this qualitative study is to describe women's experience with preeclampsia and being placed on bed rest. Six themes emerged including: negative feelings and thoughts, lack of guidelines about their diagnosis, family stressors, lack of social support, not being heard, loss of normal pregnancy, and physical symptoms. The identified categories provide insight into improving care for these women.

Background Patients with heart failure (HF) experience depressive symptoms that contribute to poorer outcomes. We tested the effects of a brief cognitive therapy intervention on depressive symptoms, negative thinking, health-related quality of life, and cardiac event-free survival. Methods and Results Hospitalized patients with depressive symptoms (n = 41, 66 ± 11 years, 45% female, 81% New York Heart Association Class III/IV) were randomly assigned to control group or a brief, nurse-delivered cognitive therapy intervention, delivered during hospitalization and followed by a 1-week booster phone call. Depressive symptoms, negative thinking, and health-related quality of life were measured at 1 week and 3 months. Cardiac event-free survival was assessed at 3 months. Mixed models repeated measures analysis of variance, Kaplan-Meier, and Cox regression were used for data analysis. There were significant improvements in depressive symptoms and health-related quality of life in both groups but no interactions between group and time. The control group had shorter 3-month cardiac event-free survival (40% versus 80%, P P = .04) than the intervention group. Conclusion Nurses can deliver a brief intervention to hospitalized patients with heart failure that may improve short-term, event-free survival. Future research is needed to verify these results with a larger sample size.

Depression is a significant problem in patients with heart failure. Cognitive behavioral therapy (CBT) has been proposed as a potential non-pharmacological treatment for depression in patients with heart failure. The purpose of this review is to examine the evidence for the use of CBT in treating depression and depressive symptoms in patients with cardiovascular illness. In six of the ten studied reviewed, researchers found that CBT reduced depressive symptoms; however, the limitations of the studies prevent wide generalization of the results. There is insufficient evidence to support the use of CBT for the treatment of depressive symptoms in patients with cardiovascular illness at this time. Large randomized, controlled trials that demonstrate the efficacy of CBT are needed before nurses routinely refer patients with heart failure to CBT for the purpose of improving depression or depressive symptoms.

Background Depression is a significant clinical problem among patients with heart failure (HF). Cognitive therapy is a potential treatment for symptoms of depression in patients with HF. Cognitive therapy focuses on the reduction of negative thinking, a modifiable risk factor for depressive symptoms; however, researchers have not identified the best instrument for measuring negative thinking in patients with HF. Objective The purpose of this paper is to review the state of the science in the measurement of negative thinking in order to provide direction for the measurement of negative thinking in patients with HF. Findings Three of the most widely used instruments for negative thinking were selected for review. The Crandell Cognitions Inventory, Automatic Thoughts Questionnaire, and Cognitive Checklist- Depression all have strong evidence for validity and reliability. The Crandell Cognitions Inventory (CCI) has the best potential for measuring negative thinking in patients with HF. The CCI has the advantages of being developed with a clinical population and captures a wide range of negative thinking content. However, the CCI is lengthy (45 items) and needs to undergo rigorous psychometric testing among patients with HF before it can be recommended for use. Conclusions Future studies are needed to develop a shortened version of the CCI for use in clinical research and to test the CCI's reliability and validity for measuring negative thinking in patients with HF.

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—Patients with heart failure often experience depressive symptoms that affect healthrelated 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. Heart failure is a chronic syndrome that affects 5 million people in the United States 1 and is the most common cause of hospitalization in elderly adults. 2 Major depressive disorder is common in hospitalized patients with heart failure. One-third of hospitalized patients with heart failure have major depression, and 40% of these persons are still depressed 1 year later. 3

Depression is a significant problem in patients with heart failure. Cognitive behavioral therapy (CBT) has been proposed as a potential non-pharmacological treatment for depression in patients with heart failure. The purpose of this review is to examine the evidence for the use of CBT in treating depression and depressive symptoms in patients with cardiovascular illness. In six of the ten studied reviewed, researchers found that CBT reduced depressive symptoms; however, the limitations of the studies prevent wide generalization of the results. There is insufficient evidence to support the use of CBT for the treatment of depressive symptoms in patients with cardiovascular illness at this time. Large randomized, controlled trials that demonstrate the efficacy of CBT are needed before nurses routinely refer patients with heart failure to CBT for the purpose of improving depression or depressive symptoms.

The purpose of this article is to discuss the problem of cervical cancer, examine policy solutions, and analyze factors that contributed to the failure of human papillomavirus (HPV) vaccine requirement legislation in Kentucky. During 2007, a Kentucky representative introduced legislation that would require HPV vaccination for all middle-school girls but allow parents to opt out for any reason. Evidence suggests that an HPV school requirement law would result in more Kentucky children being vaccinated than if there were no requirement law. However, this policy solution faced multiple factors that inhibited its ability to survive. Future proponents of HPV vaccine school requirement legislation can draw implications from Kentucky's experience. By building public support, undergoing a softening up period, and presenting a united, vocal front, proponents may be more likely to pass HPV vaccine legislation in the future.

Poor self-care is common among adults with heart failure and leads to poor health outcomes. Low self-efficacy, depression, and low social support are associated with poor self-care, but knowledge about these relationships in heart failure is limited. Secondary data analysis of cross-sectional data from 346 adults with heart failure measuring self-efficacy, depressive symptoms, social support, and self-care adherence was conducted. Tests of mediation using multiple linear regressions indicate that self-efficacy fully mediates the relationships between depression and adherence, and social support and adherence. Bolstering self-efficacy may have a greater impact on self-care adherence than targeting either depression or social support alone.

Introduction: A growing body of evidence links complications of pregnancy (gestational diabetes, preeclampsia, and pregnancy-induced hypertension) with double the risk of future cardiovascular disease (CVD) related death in affected women. However, little is known about which CVD risk factors are more prominent among women who have experienced pregnancy complications. Purpose: Compare the presence of modifiable CVD risk factors among women with and without a self-reported history of pregnancy complications living in Appalachian Kentucky- an area with the highest rate of CVD mortality in the U.S. Methods: Rural Kentucky Appalachian women (n = 122, 97% Caucasian, 42 ± 12 years) engaged in a comprehensive measurement of CVD risk factors including body mass index (BMI), waist circumference, blood pressure, A1C, lipid profile (total cholesterol, triglycerides, HDL, and LDL), tobacco smoke exposure (objectively measured with urine cotinine), depression (Patient Health Questionnaire-9), and anxiety (Brief Symptom Inventory). We used independent t-tests and chi-square analysis to compare risk factors between women with and without a history of pregnancy complications. Results: One-fourth of the sample had one or more pregnancy complications: gestational diabetes (8.2%), preeclampsia (6.6%) and pregnancy-induced hypertension (15.6%). Women with at least one pregnancy complication had a higher average BMI (33.4 vs. 30.4, p = .014), larger waist circumference (42.8 vs. 39.1 cm, p = .006), and a higher proportion with moderate to severe symptoms of depression (27.6% vs. 15.9%, p = .02) compared to women without a history of pregnancy complications. There were no differences between groups in systolic or diastolic blood pressure, A1C levels, lipid profiles, tobacco smoke exposure, or anxiety. Conclusions: Women with a history of pregnancy complications have several modifiable risk factors- higher BMI, higher waist circumference, and higher levels of depression- that could constitute a link between past pregnancy complications and their risk of future CVD death. Pinpointing which modifiable risk factors are elevated in these women will help us develop self-management interventions to prevent the development of CVD in this high-risk population.

Introduction: Health outcomes such as event-free survival (cumulative end-point in time to first health event) in heart failure (HF) patients is worse in African American than Caucasians. While the direct impact of traditional risk factors on outcomes are recognized, it is unknown how sociodemographic and psychosocial variables, disease, and treatment factors may alter the relationship between race and event-free survival. Hypothesis: Sociodemographics (age, gender, economic status), psychosocial factors (anxiety, depression), disease factors (smoking, functional status, diabetes) and treatments (beta blockers, ACE inhibitors) moderate the relationship between race and shorter event-free survival among patients with HF. Methods: Data were analyzed from 993 outpatients in a multicenter HF registry who were followed for a median of 1.9 years (37% female, 11.3% African American, 64±13 years, 44% NYHA Class III/IV). Data were collected via chart review and interview. Potential proposed moderators were analyzed with race as the predictor and the outcome event-free survival. Regressions were conducted on event-free survival using race and each proposed moderator, and the product of race and each moderator. Results: A primary analysis showed that African American patients are 1.54 times more likely to experience a cardiac event within this data set (p=.003). Further regression analyses indicate event-free survival in African American patients with HF is not moderated by the proposed moderators (all p>.05). Although an incomplete moderation, interactions with medication and race demonstrated better outcomes in African Americans than Caucasians not on ACE inhibitors, but Caucasians on prescribed ACE inhibitors have better comparative outcomes. Conclusions: Although many modifiable and non-modifiable risk factors may be associated with event free survival in African American HF patients, sociodemographic, psychosocial, disease, and treatment factors do not moderate the relationship between race and event-free survival. Future research is needed to better understand what factors contribute to and moderate evident disparities in the event-free survival of African American patients with HF.

Objectives: The high mortality and morbidity rates associated with heart failure are still not well explained. A few psychosocial factors have been studied and explain some of this risk, but other factors, like stress, remain largely unexplored in heart failure. This study aimed to (1) examine the association of stress with 6-month cardiac event-free survival, (2) examine the relationship of stress with salivary cortisol, and (3) examine the association of salivary cortisol level with 6-month cardiac event-free survival. Method: A total of 81 heart failure patients participated. Stress was measured using the brief Perceived Stress Scale. Cortisol was measured from unstimulated whole expectorated saliva. Cox regression analyses were used to determine whether stress predicted event-free survival, and if salivary cortisol predicted event-free survival. Linear and multiple regressions were used to determine the association of stress with salivary cortisol. Results: Stress was not a significant predictor of event-free survival in heart failure (heart rate = 1.06; 95% confidence interval = 0.95–1.81; p = 0.32). Salivary cortisol was a significant predictor of event-free survival in the unadjusted model (heart rate = 2.30; 95% confidence interval = 0.99–5.927; p = 0.05), but not in the adjusted model. Stress (β 1.06; 95% confidence interval = 0.95–1.18; p = 0.32) was not a significant predictor of salivary cortisol level. Conclusion: Stress is a complex phenomenon, and our measure of stress may not have captured it well. Alternatively, the physical stressors acting in heart failure produce levels of neurohormonal activation that mask the effects of psychosocial stressors or an indirect association of stress with outcomes that is mediated through another construct. Future studies are needed to investigate stress in patients with heart failure to provide definitive answers.

Background: Among patients with heart failure (HF), anxiety symptoms may co-exist with depressive symptoms. However, the extent of overlap and risk factors for anxiety symptoms have not been thoroughly described. Purpose: The aim of this study was to describe the coexistence of anxiety and depressive symptoms, and to determine the predictors of anxiety symptoms in patients with HF. Methods: The sample consisted of 556 outpatients with HF (34% female, 6212 years, 54% New York Heart Association (NYHA) class III/IV) enrolled in a multicenter HF quality of life registry. Anxiety symptoms were assessed with the Brief Symptom Inventory-anxiety subscale. Depressive symptoms were measured with the Beck Depression Inventory- II (BDI). We used a cut-point of 0.35 to categorize patients as having anxiety symptoms or no anxiety symptoms. Logistic regression was used to determine whether age, gender, minority status, educational level, functional status, comorbidities, depressive symptoms, and antidepressant use were predictors of anxiety symptoms. Results: One-third of patients had both depressive and anxiety symptoms. There was a dose-response relationship between depressive symptoms and anxiety symptoms; higher levels of depressive symptoms were associated with a higher level of anxiety symptoms. Younger age (odds ratio (OR)= 0.97, p=0.004, 95% confidence interval (CI) 0.950.99) and depressive symptoms (OR =1.25, p0.001, 95% CI 1.191.31) were independent predictors of anxiety symptoms. Conclusions: Patients with HF and depressive symptoms are at high risk for experiencing anxiety symptoms. Clinicians should assess these patients for comorbid anxiety symptoms. Research is needed to test interventions for both depressive and anxiety symptoms. © The European Society of Cardiology 2014.

Objective Although most patients with implantable cardioverter defibrillators (ICDs) adjust well, some have considerable psychological distress. Factors associated with psychological adjustment in ICD-recipients are still not well understood. Our purpose was to describe quality-of-life (QoL) and prevalence of self-reported symptoms of anxiety and depression in a large national cohort of ICD-recipients, and to determine socio-demographic, clinical, and ICD-related factors associated with these variables. Methods A cross-sectional, correlational design was used. All eligible adult ICD-recipients in the Swedish ICD- and Pacemaker Registry were invited to participate. Symptoms of anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS), and QoL with the EuroQol-5D. Results A total of 3067 ICD-recipients (66 ± 11 years, 80% male) were included. The mean HADS score was 3.84 ± 3.70 for anxiety symptoms and 2.99 ± 3.01 for symptoms of depression. The mean EQ-5D index score was 0.82 ± 0.21. The probability of symptoms of anxiety and depression was associated with younger age, living alone, and a previous history of myocardial infarction or heart failure. Additionally, female ICD-recipients had a higher probability of symptoms of anxiety. A higher level of ICD-related concerns was most prominently related to symptoms of anxiety, depressive symptoms and poorer QoL, while number of shocks, ICD-indication and time since implantation were not independently related. Conclusions In this large cohort of ICD-recipients, the association of ICD-related concerns with symptoms of anxiety, depressive symptoms, and poor QoL suggests that ICD specific factors should be addressed in order to improve outcomes.

BACKGROUND Patients with heart failure (HF) commonly have unintentional weight loss, depressive symptoms, and elevated levels of high-sensitivity C-reactive protein (hsCRP). Each of these variables has been independently associated with shorter cardiac event-free survival. However, little data exist on the relationships of unintentional weight loss, hsCRP level, and depressive symptoms to cardiac event-free survival. OBJECTIVE The aims of this study were to determine (1) whether depressive symptoms and elevated hsCRP level predicted unintentional weight loss and (2) whether unintentional weight loss predicted shorter cardiac event-free survival. METHODS This was a prospective study of 243 consecutive HF patients (61% men, 61 ± 14 years old) enrolled during an index hospitalization for HF exacerbation. Patients provided blood samples to measure hsCRP level and completed the Beck Depression Inventory to assess depressive symptoms at discharge. Body weight was measured at discharge and 6 months later. Unintentional weight loss was defined as weight loss of greater than 6% of body weight since discharge. Cardiac event-free survival was followed for 1 year after the second measurement of body weight through monthly telephone interviews. Hierarchical logistic regression was used to determine whether depressive symptoms and elevated hsCRP level predicted unintentional weight loss. Cox hazard regression was used to determine whether unintentional weight loss predicted cardiac event-free survival. RESULTS Thirty-five patients (14.4%) experienced unintentional weight loss at 6 months after discharge. Hierarchical Cox hazard regression revealed that patients with unintentional weight loss had a 3.2 times higher risk for cardiac events, adjusting for other clinical factors (P < .001). In hierarchical logistic regression, elevated hsCRP level (odds ratio, 1.49; 95% confidence interval, 1.15-1.92) and depressive symptoms (odds ratio, 1.07, 95% confidence interval, 1.02-1.12) independently predicted unintentional weight loss. CONCLUSIONS Unintentional weight loss was an independent predictor of poor outcomes. Heart failure patients with depressive symptoms and elevated hsCRP levels are at a higher risk for unintentional weight loss.

Background Medication nonadherence and depressive symptoms predict hospitalization and death in patients with heart failure (HF). Depressed patients have lower medication adherence than nondepressed patients. However, the predictive power of the combination of medication adherence and depressive symptoms for hospitalization and death has not been investigated in patients with HF. Objective The aim of this study was to explore the combined influence of medication adherence and depressive symptoms for prediction of cardiac event–free survival in patients with HF. Methods and Results We monitored medication adherence in 216 HF patients who completed the Patient Health Questionnaire–9 (PHQ-9) at baseline. Medication adherence was measured objectively with the use of the Medication Event Monitoring System (MEMS). Patients were followed for up to 3.5 years to collect data on cardiac events. Survival analyses were used to compare cardiac event–free survival among groups. The risk of experiencing a cardiac event for patients with medication nonadherence and depressive symptoms was 5 times higher than those who were medication adherent without depressive symptoms. The risk of experiencing a cardiac event for patients with only 1 risk factor was 1.2–1.3 times that of those with neither risk factor. Conclusions Medication nonadherence and depressive symptoms had a negative synergistic effect on cardiac event–free survival in patients with HF.

Objective Prognosis is worse in unmarried patients compared with married patients with heart failure (HF). The reasons for differences in outcomes are unclear, but variations in medication adherence may play a role, because medication adherence is essential to achieving better outcomes. The study objective was to determine whether medication adherence mediated the relationship between marital status and cardiac event-free survival in patients with HF. Methods Demographic, clinical, and psychosocial data were collected by questionnaires and medical record review for 136 patients with HF (aged 61 ± 11 years, 70% were male, 60% were in New York Heart Association class III/IV). Medication adherence was monitored objectively for 3 months using the Medication Event Monitoring System. Cardiac event-free survival data were obtained by patient/family interview, hospital database, and death certificate review. A series of regression and Cox survival analyses were performed to determine whether medication adherence mediated the relationship between marital status and event-free survival. Results Cardiac event-free survival was worse in unmarried patients than in married patients. Unmarried patients were more likely to be nonadherent and 2 times more likely to experience an event than married patients (P = .017). Marital status was not a significant predictor of event-free survival after entering medication adherence in the model, demonstrating a mediation effect of adherence on the relationship of marital status to survival. Conclusion Medication adherence mediated the relationship between marital status and event-free survival. It is important to design interventions to increase medication adherence that take into account subgroups, such as unmarried patients, who are at higher risk for nonadherence.

One-third of patients with heart failure (HF) experience depressive symptoms that adversely affect health-related quality of life (HRQOL). We aimed to describe depressive symptom trajectory and determine whether a change in depressive symptoms predicts subsequent HRQOL.The sample consisted of 256 inpatients and outpatients with HF. Depressive symptoms were measured at baseline and 3 or 6 months with the Patient Health Questionnaire (PHQ-9). The Minnesota Living with HF Questionnaire was used to assess HRQOL at baseline, 3 to 6 months, and 1 year. Based on baseline and 3- to 6-month PHQ-9 scores, patients were categorized as depressive symptom-free (64%), depressive symptoms improved (15%), depressive symptoms developed (6%), or persistent depressive symptoms (15%). The groups differed in 1-year HRQOL levels (F = 36, P.001); patients who were depressive symptom-free or whose depressive symptoms improved had better 1-year HRQOL than patients with persistent depressive symptoms (Tukey honestly significant difference, P.01). Change in depressive symptoms was the strongest predictor of 1-year HRQOL (standardized β = .42, P.001), after controlling for functional status, demographics, and clinical variables.We found the trajectory of depressive symptoms predicts future HRQOL. Research is needed to determine whether interventions targeting depressive symptoms improve HRQOL in patients with HF.

Objective Negative thinking is a target for treatment of depressive symptoms in patients with heart failure (HF). A brief instrument is needed to measure negative thinking in these patients. The study objective was to shorten the Crandell Cognitions Inventory (CCI) for use in patients with HF. Methods Baseline data from outpatients with HF (N = 179, 30% were female, age 60 ± 13 years) were used to evaluate psychometrics of the CCI. Internal consistency reliability was measured with Cronbach’s alpha construct validity with hypothesis testing. Principal components analysis was used in shortening. A separate sample of hospitalized patients with HF (N = 77, 49% were female, age 66 ± 11years) was used to validate the shortened CCI (CCI-SF). Results The CCI showed evidence of reliability and validity, but there was item redundancy in outpatients with HF. The 12-item CCI-SF showed good evidence of reliability and validity in inpatients with HF. Conclusion The results support the reliability and validity of the CCI-SF to measure negative thinking in hospitalized patients with HF.

Background Depressive symptoms and poor social support are predictors of increased morbidity and mortality in patients with heart failure (HF). However, the combined contribution of depressive symptoms and social support event-free survival of patients with HF has not been examined. Objective To compare event-free survival in 4 groups of patients with HF stratified by depressive symptoms and perceived social support (PSS). Method A total of 220 patients completed the Beck Depression Inventory-II and the Multidimensional Perceived Social Support Scale and were followed for up to 4 years to collect data on death and hospitalizations. Results Depressive symptoms (hazard ratio = 1.73, P = .008) and PSS (hazard ratio = 1.51, P = .048) were independent predictors of event-free survival. Depressed patients with low PSS had 2.1 times higher risk of events than non-depressed patients with high PSS ( P = .003). Conclusion Depressive symptoms and poor social support had a negative additive effect on event-free survival in patients with HF.

Introduction: Cardiovascular disease has been identified as the leading cause of maternal mortality in the United States, with cardiomyopathy, including peripartum cardiomyopathy (PPCM), accounting for 12% to 16% of all pregnancy-related deaths. The purpose of this study was to describe women's experiences being diagnosed with PPCM. Methods: This investigation was conducted using a qualitative design. We collected publicly available narratives posted by 92 women with PPCM (mean [SD] age 29 [6] years, mean [SD] ejection fraction 25.5 [10.8]%) in 3 online support groups. Data were coded and thematically organized so as to produce a richly detailed account of this experience. Results: The experience of diagnosis was marked by the women's distinct memories of their initial symptoms and whether they were dismissed or taken seriously. The most commonly reported symptoms were extreme shortness of breath, orthopnea, tachycardia, palpitations, chest pain, cough, and edema. Nearly 40% of women experienced symptom dismissal by health care providers. One-fourth of women were initially given inaccurate diagnoses ranging from “new mom anxiety” to asthma. Women described their initial reaction to diagnosis as feeling terrified, devastated, and feeling a sense of doom. Women had difficulty caring for their newborns during the postpartum period, and they struggled with the medical advice they received to not get pregnant again. Discussion: Despite experiencing severe subjective and objective symptoms, nearly 40% of women with PPCM experienced symptom dismissal by health care providers, in part due to the overlap between normal symptoms of pregnancy or the postpartum period and symptoms of heart failure.