Deborah Manandi

Background: Depression is a known risk factor for cardiovascular disease (CVD), but the impact of long‐term depressive symptom burden remains unclear. We examined the association between cumulative depression burden and risks of CVD and all‐cause death among adults aged ≥50 years in China and Mexico. Methods: Data were obtained from 2 nationally representative cohorts: CHARLS (China Health and Retirement Longitudinal Study) and MHAS (Mexican Health and Aging Study). Cumulative depression burden was quantified using 2 approaches: (1) the area under the curve of repeated depression scores and (2) the number of waves with depression. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for incident CVD and all‐cause death. Results: The analysis included 5277 CVD‐free participants from CHARLS and 4779 from MHAS. Higher cumulative depression burden was significantly associated with elevated risk of CVD. Compared with the lowest‐quartile group, participants in the highest‐quartile group had significantly greater CVD risk (CHARLS: HR, 1.723 [95% CI, 1.420–2.090]; MHAS: HR, 1.739 [95% CI, 1.347–2.245]). Dose–response associations were observed in both cohorts. Persistent depression was also linked to higher CVD risk compared with isolated or less frequent episodes. Associations with all‐cause death differed by cohort, with significant associations observed in CHARLS but not in MHAS. Conclusions: Long‐term cumulative depression burden is strongly associated with increased CVD risk among adults aged ≥50 years. Routine screening and sustained management of depressive symptoms should be considered integral to CVD prevention strategies.

Background: Cardiac rehabilitation supports recovery after cardiac events, but it is unclear whether outcomes differ by socioeconomic characteristics in low‐resource settings. This study aimed to identify whether pre‐program socioeconomic characteristics (financial strain, age, education, employment) were associated with cardiac rehabilitation completion, and–among completers–to examine associations with changes in depressive symptoms and quality of life from pre‐ to post‐program. Methods: Individuals with pre‐program data (2021‐May 2024) in the ICRR (International Cardiac Rehab Registry), from 17 programs in low‐resource settings across 11 countries, were included. Outcomes were changes in Patient Health Questionnaire‐2 depressive symptoms and Cantril's Ladder quality of life scores. Among completers, associations were examined using robust linear mixed‐effects models, adjusting for characteristics, with a random intercept for site. Results: Among 3520 individuals (mean age 59 years [SD=12], 79% men), 2190 (62%) completed cardiac rehabilitation. Completion was more common among those without financial strain (20% versus 10%, P 12 years of education (57% versus 44%, P P P =0.021), while employment was associated with smaller improvement (β=0.297, 95% CI=0.104, 0.489, P =0.019). Age and education were not associated with change in depressive symptoms. No socioeconomic characteristics were associated with change in quality of life. Conclusions: These findings suggest socioeconomic pressures are associated with differences in recovery. Flexible cardiac rehabilitation models may support individuals in low‐resource settings.

BACKGROUND: This trial aimed to test the effectiveness of a data-driven quality improvement program in primary care on cardiovascular hospitalizations, major adverse cardiovascular events (MACE), risk factor profiles, and medication prescriptions at 24 months in people with coronary heart disease (CHD) compared with standard care. METHODS: A single-blind, cluster randomized controlled trial recruiting Australian primary care practices (2019–2022) was conducted. Practices using compliant data extraction software and having ≥200 adult patients annually with CHD were the units of randomization, and adults with CHD (who visited their general practitioner in the past 12 months) were the units of analysis. Practices were randomized to intervention (12-month data-driven quality improvement including benchmarking, monthly reporting, and improvement planning) or control (standard care). The primary outcome was the proportion of participants who had unplanned cardiovascular disease hospitalizations at 24 months. Secondary outcomes were MACE, medication prescriptions, risk factor targets, and management planning. Data were extracted from electronic records linked to administrative data. RESULTS: A total of 51 primary care practices participated, resulting in a patient cohort of 7864. The mean age of the patient cohort was 71.9 (±11.8) years, 68% were men, and 24% had a prior myocardial infarction. At 24 months, there was no significant difference between the groups for unplanned cardiovascular disease hospitalizations (relative risk, 0.91 [95% CI, 0.75–1.10]; MACE, 0.81 [95% CI, 0.61–1.07]; prescription of antiplatelet, 0.94 [95% CI, 0.79–1.13]), statin, 1.03 [95% CI, 0.97–1.09], angiotensin-converting enzyme or angiotensin receptor blocker, 1.00 [95% CI, 0.93–1.07]; risk factor targets for low-density lipoprotein cholesterol, 0.99 [95% CI, 0.86–1.13], systolic blood pressure, 0.97 [95% CI, 0.87–1.09], or smoking, 0.96 [95% CI, 0.57–1.59]; or management planning, 1.02 [95% CI, 0.64–1.63]). CONCLUSIONS: A primary care, data-driven quality improvement program did not improve unplanned hospitalizations, MACE, medication prescriptions, achievement of risk factor targets, or management planning for people with CHD. Robust evidence for the use of a data-driven, collaborative approach to improving care for people with CHD in primary care remains elusive. REGISTRATION: URL: https://www.anzctr.org.au ; Unique identifier: ACTRN12619001790134.

Purpose: To investigate (1) the relationship between socioeconomic status of patients with acute coronary syndrome and participation in cardiac rehabilitation and (2) the relationship between patient participation stratified by socioeconomic status and their outcomes at 12 months. Methods: Analyzed data were from the CONCORDANCE registry. Patients were stratified (quintiles) according to the National Index of Relative Socio-Economic Disadvantage. The odds of a major adverse cardiovascular event (MACE; defined as heart failure, myocardial infarction, stroke, or cardiac-cause death) and separately all-cause death between hospital discharge and 12 months were analyzed using multilevel logistic regression models, adjusting for clinical history and hospital clustering. Results: Of 3787 patients referred to cardiac rehabilitation, followed up at 6 and 12 months, 1834 (48%) participated in cardiac rehabilitation. Participation rate was higher among patients in least socioeconomically disadvantaged quintiles (Q5 [least disadvantaged]: 61%, Q4: 53%, Q3: 42%, Q2: 47%, Q1 [most disadvantaged]: 42%). The odds of MACE were not different between participants and non-participants (6% vs 8%, OR = 0.87: 95% CI, 0.66-1.15). However, the odds of death were lower among participants than non-participants (0.4% vs 2%, OR = 0.35: 95% CI, 0.16-0.78). The association between participation and MACE and death did not differ by socioeconomic status ( P _interaction = .6943 and P _interaction = .6339, respectively). Conclusions: Although patient socioeconomic status may influence their participation rates in cardiac rehabilitation, no significant differences were observed in the relationships between participation and MACE or mortality at 12 months across socioeconomic groups. Targeted strategies are needed to improve participation rates across all socioeconomic groups.

Hypertension frequently co-exists with depression, leading to adverse health outcomes. This study aimed to examine the individual and joint effects of hypertension and depression on the risks of new-onset cardiovascular disease (CVD) and all-cause mortality among the middle-aged and older Chinese individuals. Data from the China Health and Retirement Longitudinal Study (CHARLS) during 2011–2020 were used. Participants were divided into four groups for comparison: hypertension alone, depression alone, both conditions, neither condition. Multivariate logistic regression models were established to compare the risks of all-cause mortality and CVD among the four groups. A total of 9178 participants without pre-existing CVD were included and followed for nine years. Compared with individuals with neither condition, the risk of all-cause mortality increased among individuals with hypertension alone (adjusted odds ratio [aOR]: 1.414, 95% confidence interval [CI]: 1.133–1.764), depression alone (aOR: 1.023, 95% CI: 0.795–1.317) and comorbid hypertension and depression (aOR: 1.524, 95% CI: 1.180–1.968). The aORs for CVD events in individuals with both conditions, hypertension alone, and depression only were 2.207 (95% CI: 1.885–2.584), 1.945 (95% CI: 1.702–2.222) and 1.572 (95% CI: 1.365–1.809), respectively. Furthermore, those with severe depressive symptoms were at higher risks of all-cause mortality and CVD, regardless of having hypertension. Hypertension with comorbid depression leads to higher risks of CVD and all-cause mortality than either condition alone. Screening and management of depression among individuals with hypertension are essential for the primary prevention of CVD and premature death.

Aim: To systematically evaluate whether relationships between cardiac rehabilitation participation and clinical outcomes, return to work, or knowledge about cardiovascular disease vary across socioeconomic indicators. Methods: A systematic review was conducted using CENTRAL, CINAHL, Embase and Medline up to 1 November 2024. Studies were included if they compared outcomes between participants who received cardiac rehabilitation and those who did not or received an exercise programme. Outcomes included all-cause death, all-cause and cardiovascular-related rehospitalisation, return to work and cardiovascular knowledge, stratified by socioeconomic indicators. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies—of Interventions-I tool. Results: Six studies involving 555 731 participants were included. Compared with non-participants, cardiac rehabilitation participants had lower rates of all-cause death (12.3%–16.9%) and all-cause rehospitalisation (15.2%–16.1%), with incidence rate differences in cardiovascular-related rehospitalisation reaching up to 27.8 fewer events/100 person-years. Some of the greatest differences were among participants residing in more disadvantaged areas, although this was not consistent across studies. No significant differences were observed in the combined outcome of all-cause death and cardiovascular-related rehospitalisation when stratified by educational attainment levels. Return to work and knowledge outcomes showed greater variation across education and income subgroups, with higher values consistently observed among cardiac rehabilitation participants from less disadvantaged backgrounds. All studies were observational and had moderate risk of bias. Conclusions: Cardiac rehabilitation improves clinical and functional outcomes across socioeconomic subgroups, although disparities in participation and outcomes persist. Tailoring programme delivery to be more flexible and responsive to literacy needs may help ensure its benefits are equitably achieved across patient subgroups. PROSPERO registration number: CRD42022332355

Research into cardiac rehabilitation (CR), a key model for secondary prevention of cardiovascular disease, has evolved since first described in 1927. This review aimed to explore this evolution by identifying CR-related publications from the Web of Science Core Collection and summarizing CR research publication history, trends in publication keywords, and citations over time. A total of 8729 CR publications appeared across 1441 journals (median impact factor: 2.6) and were cited 315,819 times, with over 85% (7455/8729) published in the past two decades. These publications involved contributions from 26,909 authors across 120 countries, despite disproportionate domination by high-income countries. Publication keywords have consistently focused on exercise but have evolved from evaluating clinical events, quality-of-life, and return-to-work outcomes to improving accessibility using digital interventions. However, a broader focus on other cardiovascular risk factors, comorbidities, and various research designs may be needed to modernize CR, particularly in lower-income countries.

Background: The study aimed to understand the acceptability, satisfaction, uptake, utility and feasibility of a quality improvement (QI) intervention to improve care for coronary heart disease (CHD) patients in Australian primary care practices and identify barriers and enablers, including the impact of COVID-19. Methods: Within the QUality improvement for Effectiveness of care for people Living with heart disease (QUEL) study, 26 Australian primary care practices, supported by five Primary Health Networks (PHN) participated in a 1-year QI intervention (November 2019 – November 2020). Data were collected from practices and PHNs staff via surveys and semi-structured interviews. Quantitative and qualitative data were analysed with descriptive statistics and thematic analysis, respectively. Results: Feedback was received from 64 participants, including practice team members and PHN staff. Surveys were completed after each of six workshops and at the end of the study. Interviews were conducted with a subgroup of participants (n = 9). Participants reported positive satisfaction with individual QI features such as learning workshops and monthly feedback reports. Overall, the intervention was well-received, with most participants expressing interest in participating in similar programs in the future. COVID-19 and lack of time were identified as common barriers, whereas team collaboration and effective leadership enabled practices’ participation in the QI program. Additionally, 90% of the practices reported COVID-19 effected their participation due to vaccination rollout, telehealth set-up, and continuous operational review shifting their focus from QI. Conclusion: Data-driven QI programs in primary care can boost practice staff confidence and foster increased implementation. Barriers and enablers identified can also support other practices in prioritising effective strategies for future implementation.