Publications by authors named "Jamal Hajjari"

16 Publications

  • Page 1 of 1

Non-Invasive Imaging in the Evaluation of Cardiac Allograft Vasculopathy in Heart Transplantation: A Systematic Review.

Curr Probl Cardiol 2022 Jan 8:101103. Epub 2022 Jan 8.

Department of Medicine, University Hospitals, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals and School of Medicine, Case Western Reserve University, Cleveland, Ohio. Electronic address:

Cardiac allograft vasculopathy (CAV) is the leading cause of long-term graft dysfunction in patients with heart transplantation and is linked with significant morbidity and mortality. Currently, the gold standard for diagnosing CAV is coronary imaging with intravascular ultrasound (IVUS) during traditional invasive coronary angiography (ICA). Invasive imaging, however, carries increased procedural risk and expense to patients in addition to requiring an experienced interventionalist. With the improvements in non-invasive cardiac imaging modalities such as transthoracic echocardiography (TTE), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), an alternative non-invasive imaging approach for the early detection of CAV may be feasible. In this systematic review, we explored the literature to investigate the utility of non-invasive imaging in diagnosis of CAV in >3000 patients across 49 studies. We also discuss the strengths and weaknesses for each imaging modality. Overall, all four imaging modalities show good to excellent accuracy for identifying CAV with significant variations across studies. Majority of the studies compared non-invasive imaging with ICA without intravascular imaging. In summary, non-invasive imaging modalities offer an alternative approach to invasive coronary imaging for CAV. Future studies should investigate longitudinal non-invasive protocols in low-risk patients after heart transplantation.
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http://dx.doi.org/10.1016/j.cpcardiol.2022.101103DOI Listing
January 2022

Inflammatory Markers and Risk of Heart Failure With Reduced to Preserved Ejection Fraction.

Am J Cardiol 2022 Jan 2. Epub 2022 Jan 2.

Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio. Electronic address:

Chronic systemic inflammation is associated with an increased risk of heart failure (HF). We sought to determine the association between biomarkers of systemic inflammation interleukin (IL)-6, IL-2, tumor necrosis factor alpha (TNF-α), and C-reactive protein (CRP) with those of HF and its subtypes. We hypothesize that inflammatory biomarkers IL-6, IL-2, TNF-α, and CRP are associated with HF and its subtypes. We included participants from the Multi-Ethnic Study of Atherosclerosis (a prospective population-based cohort study [2000 to 2002]), without a history of HF, and with available baseline inflammatory biomarkers. We explored the association of IL-6, IL-2, TNF-α, and CRP with incident HF, HF with reduced ejection fraction (left ventricular ejection fraction [LVEF] <40%, HFrEF), HF with midrange EF (LVEF 40% to 50%, HFmrEF), and HF with preserved ejection fraction (LVEF >50%, HFpEF). Among 6,814 participants, 195 developed HF over 10.9 years (56 HFrEF, 30 HFmrEF, and 57 HFpEF). In the models adjusted for clinical risk factors of HF, IL-6 (hazard ratio [HR] 1.33 per doubling; 95% confidence interval [CI] 1.10 to 1.60), TNF-α (HR 2.49 per doubling; 95% CI 1.18 to 5.28), and CRP (HR 1.18 per doubling; 95% CI 1.06 to 1.30) were associated with all HF, and IL-6 (HR 1.51 per doubling; 95% CI 1.09 to 2.10) and CRP (HR 1.21 per doubling; 95% CI: 1.01 to 1.45) were associated with incident HFpEF, whereas none of the examined biomarkers were associated with HFmrEF or HFrEF. In conclusion, inflammatory biomarkers (IL-6, TNF-α, and CRP) are independently associated with incident HF. IL-6 and CRP are associated with incident HFpEF but not HFrEF or HFmrEF. These findings suggest that activation of the IL-6/CRP pathway (as cause, consequence, or epiphenomenon) may be unique to HFpEF.
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http://dx.doi.org/10.1016/j.amjcard.2021.11.045DOI Listing
January 2022

Myeloperoxidase is Independently Associated with Incident Heart Failure in Patients with Coronary Artery Disease and Kidney Disease.

Curr Probl Cardiol 2021 Dec 12:101080. Epub 2021 Dec 12.

Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center and School of Medicine, Case Western Reserve University, Cleveland, OH. Electronic address:

Chronic kidney disease (CKD) is associated with high cardiovascular risk and mortality. Myeloperoxidase (MPO) has been linked to adverse events in patients with mild-moderate CKD. We sought to investigate whether MPO levels are associated with adverse outcomes in patients with CKD. We studied participants with mild to moderate CKD in the prospective chronic renal insufficiency cohort (CRIC). We followed patients for incident heart failure (HF), death, and composite outcome (myocardial infarction, incident peripheral arterial disease, cerebrovascular accident and death). A total of 3872 patients were included (2702 without CVD, 1170 with CVD). After multiple adjustments, doubling of MPO in patients with prior CAD was associated with risk of HF (HR 1.15 [1.01-1.30], P = 0.032) and mortality (HR 1.16 [1.05-1.30], P = 0.005), and composite outcome of MI, PAD, CVA and death (HR 1.12 [1.01-1.25], P = 0.031). In this cohort of patients with mild to moderate CKD and CAD, MPO levels are independently associated with incident HF, all-cause mortality, and a composite outcome.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.101080DOI Listing
December 2021

Inflammation mediated Vitamin K and Vitamin D effects on vascular calcifications in people with HIV on active antiretroviral therapy.

AIDS 2021 Dec 13. Epub 2021 Dec 13.

Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH Clinical Research Center, University Hospital Cleveland Medical Center Department of Medicine and Pediatrics, University Hospital Cleveland Medical Center, Cleveland, Ohio Case Western Reserve University, Cleveland, Ohio.

Background: People with HIV (PWH) experience increased systemic inflammation and monocyte activation, leading to increased risk of cardiovascular (CV) events (death, stroke, and myocardial infarction) and higher coronary artery calcium scores (CACs). Vitamins D and K2 have significant anti-inflammatory effects; in addition, vitamin K2 is involved in preventing vascular calcifications in the general population. The roles of Vitamins D and K in increased coronary calcifications in successfully treated PWH is less understood.

Methods: We prospectively recruited 237 PWH on antiretroviral (ART) treatment and 67 healthy controls. CACs were derived from non-contrast chest CT and levels of 25-hydroxyvitamin D (vitamin D) and inactive vitamin K dependent dephosphorylated-uncarboxylated matrix Gla protein (dp-uc MGP, marker of vitamin K deficiency) were measured in plasma during a fasting state. The relationship between inflammation markers, dp-uc MGP, and vitamin D on CACs were estimated using zero-inflated negative binomial regression. Adjusted models included 25(OH)D, MGP, gender, race, age, and markers of inflammation or monocyte activation.

Results: Overall, controls had lower median age (45.8 vs. 48.8; p = 0.03), a larger proportion of females (55.2% vs. 23.6%; p < .0001), and non-white (33.8% vs. 70.0%; p < .0001). Among PWH, < 1% had detectable viral load and the median CD4 was 682.00 (IQR: 473.00, 899.00). 62.17% of the participants had zero CACs and 51.32% were vitamin D deficient (<20 ng/mL). There was no difference in detectable CACs (p = 0.19) or dp-uc MGP (p = 0.42) between PWH and controls. In adjusted models, PWH with non-zero CACs have three times greater expected CAC burden compared to controls. Every 1% increase in MGP (worse K status) decreases the probability of having CACs equal to zero by 21.33% (p = 0.01). Evidence suggests that the effects of 25(OH)D and MGP are inflammation mediated, specifically through sVCAM, TNF-αRI, and TNF-αRII.

Conclusion: Vitamin K deficiency is a modifiable preventive factor against coronary calcification in PWH. Further research should determine whether vitamin K supplementation would reduce systemic inflammation, vascular calcification and risk of CV events in PWH.
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http://dx.doi.org/10.1097/QAD.0000000000003149DOI Listing
December 2021

Clot in Transit and Pulmonary Artery Percutaneous Mechanical Thrombectomy.

Kans J Med 2021 5;14:287-289. Epub 2021 Nov 5.

Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH.

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http://dx.doi.org/10.17161/kjm.vol14.15601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8641437PMC
November 2021

Diaphragmatic pacemaker-induced ventricular tachycardia leading to cardiac arrest: a case report.

Eur Heart J Case Rep 2021 Sep 7;5(9):ytab352. Epub 2021 Sep 7.

Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, 11100 Euclid Ave Cleveland 44106, OH, USA.

Background: Diaphragmatic pacemakers are used to assist respiration in ventilator-dependent patients. Electromagnetic interference with intrinsic cardiac electrical activity is a theoretical risk but has never been reported in the literature. This case highlights a serious complication of cardiac arrest as a result of diaphragmatic pacing.

Case Summary: We report a quadriplegic patient with recent diaphragmatic pacemaker implantation who presented with ventricular tachycardia leading to cardiac arrest. Extensive workup was negative for other aetiologies for ventricular arrhythmias. Reduction of the left-sided diaphragmatic pacemaker voltage resulted in cessation of ventricular ectopy.

Discussion: Diaphragmatic pacing at high voltages can cause unwanted transmission of impulses to the cardiac myocytes as a rare complication. This should be noted as a possible complication of intramuscular diaphragmatic pacing, and efforts should be taken to circumvent this risk in the future.
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http://dx.doi.org/10.1093/ehjcr/ytab352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8440889PMC
September 2021

Anisocytosis Is Associated With Reduced Bone Marrow Activity Evaluated by Positron Emission Tomography.

Am J Cardiol 2021 08 11;152:179-180. Epub 2021 Jun 11.

Department of Medicine and Pediatrics, University Hospital Cleveland Medical Center, Cleveland, Ohio; School of Medicine, Case Western Reserve University, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.05.001DOI Listing
August 2021

Left Ventricular Gunshot Injury With Migration to the Aorta Causing Severe Aortic Insufficiency.

J Cardiothorac Vasc Anesth 2021 Apr 24. Epub 2021 Apr 24.

Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH.

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http://dx.doi.org/10.1053/j.jvca.2021.04.027DOI Listing
April 2021

Myocardial Injury and the Risk of Stroke in Patients With Chronic Kidney Disease (From the Chronic Renal Insufficiency Cohort Study).

Angiology 2021 Apr 7:33197211005595. Epub 2021 Apr 7.

Harrington Heart and Vascular Institute, 24575University Hospitals Cleveland Medical Center, OH, USA.

Patients with chronic kidney disease (CKD) are at increased risk for stroke. High-sensitivity troponin (hsTP), a marker of myocardial injury, has been associated with stroke risk in patients without CKD, but whether this applies to patients with CKD is not known. We assessed whether hsTP levels is associated with incident stroke in patients with mild-to-moderate CKD without a history of stroke enrolled in the Chronic Renal Insufficiency Cohort. Patients were followed for incident stroke, and the association with hsTP was assessed. A total of 3477 patients without prior stroke were included in this investigation. Over a median follow-up of 7.3 years, 101 (2.8%) patients had an incident stroke. Baseline hsTP was associated with a 9-year risk of stroke (quartile 1: 1.8%, quartile 2: 3.8%, quartile 3: 4.9%, quartile 4: 7.3%; < .001). After adjusting for traditional stroke risk factors, patients in the fourth quartile (hazard ratio: 2.52, 95% CI: 1.10-5.76, = .021) had higher risk of stroke when compared with the lowest quartile of hsTP. In conclusion, hsTP levels are associated with increased risk of incident stroke in patients with mild to moderate CKD, and this association remains significant despite the adjustment for traditional risk factors and CKD.
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http://dx.doi.org/10.1177/00033197211005595DOI Listing
April 2021

COVID19: a case report of thrombus in transit.

Eur Heart J Case Rep 2020 Oct 17;4(FI1):1-4. Epub 2020 Jun 17.

Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland OH, USA.

Background: The global pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused significant morbidity and mortality, not only through devastating lung injury, but also due to multiple malfunctions in the cardiovascular system. The primary aetiology is believed to be mediated through lung alveolar injury; however, a few published reports have linked SARS-CoV-2 to significant organ dysfunction, venous thrombo-embolism, and coagulopathy. In view of the fact that the utility of tissue plasminogen activator in this population is not well studied, we present this case of rapid improvement in oxygenation after successful lytic therapy for thrombus in transit in this patient with SARS-CoV-2.

Case Summary: We discuss a patient admitted with SARS-CoV-2 pneumonia. Due to the development of dramatic hypoxia, he underwent echocardiography which demonstrated extensive thrombus in transit. He received successful thrombolytic therapy with tissue plasminogen activator, with subsequent improvement in oxygenation. The patient was successfully discharged home on 2 L of oxygen via nasal cannula, and continues to improve at follow-up with his cardiologist and primary care physician.

Conclusion: This case not only highlights embolic causes of hypoxia in SARS-CoV-2, but demonstrates the important utility of an echocardiogram and tissue plasminogen activator in this population.
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http://dx.doi.org/10.1093/ehjcr/ytaa189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7337692PMC
October 2020

Prognostic Value of Left Ventricular Global Longitudinal Strain in COVID-19.

Am J Cardiol 2020 09 3;131:134-136. Epub 2020 Jul 3.

Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio; Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.amjcard.2020.06.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332458PMC
September 2020

Contrast-enhanced echocardiographic detection of severe aortic insufficiency in venoarterial extracorporeal membrane oxygenation.

Echocardiography 2020 06 8;37(6):905-907. Epub 2020 Jun 8.

Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH, USA.

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support is an increasingly used temporizing therapy for patients with refractory cardiogenic shock. Contrast-enhanced echocardiography plays a critical role in the diagnosis and management of diseases that precipitate severe cardiac failure. In this case report, we describe a previously healthy 60-year-old woman who presented with dyspnea on exertion, and whose hospital course was complicated by ventricular fibrillation, emergent coronary artery bypass surgery (CABG), and ECMO support. Her contrast-enhanced ECMO images demonstrated a unique pattern of opacification of three of the four cardiac chambers, which led to a diagnosis of severe aortic insufficiency.
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http://dx.doi.org/10.1111/echo.14752DOI Listing
June 2020

High Sensitivity Troponin and Risk of Incident Peripheral Arterial Disease in Chronic Kidney Disease (from the Chronic Renal Insufficiency Cohort [CRIC] Study).

Am J Cardiol 2020 02 21;125(4):630-635. Epub 2019 Nov 21.

Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio. Electronic address:

Patients with chronic kidney disease (CKD) are at increased risk for peripheral arterial disease (PAD). A novel biomarker to accurately and reliably predict new onset PAD in high risk patients is needed. High sensitivity troponin (HsTP) is a new assay which allows detection of very low troponin levels with high precision. We sought to explore the association between HsTP and risk of PAD in CKD. The Chronic Renal Insufficiency Cohort (CRIC) is a prospective cohort of 3,939 individuals with mild to moderate CKD using age related criteria for glomerular filtration rate. High sensitivity troponin T was measured at study enrollment. Patients with previous history of PAD or coronary artery disease were excluded. Patients were followed for new-onset adjudicated PAD, and the association between HsTP and incident PAD was examined. A total of 2,909 participants free of PAD and coronary artery disease at enrollment were included in this analysis. Over a mean follow up 7.4 years [interquartile ranges 5.8 to 8.5] years, 79 (2.7%) patients developed PAD. The 3-, 6-, and 9-year incidence of PAD was 1.00%, 2.03%, and 2.72%, respectively. At 9 years, the cumulative rates of PAD increased with HsTP (Quartile 1: 0.3%, Quartile 2: 2.4%, Quartile 3: 3.7%, Quartile 4: 10.7%; p <0.001). After adjusting for clinical risk factors of PAD, patients in the third quartile (Hazards ratio 5.89, 95% confidence interval: 1.31 to 26.47, p = 0.021) and fourth quartile of HsTP (Hazards ratio 10.24, 95% confidence interval 2.23 to 47.08, p = 0.003) had higher risk of PAD compared with lowest quartile of HsTP. HsTP had good discrimination of PAD at 3 years (area under the curve [AUC] 0.76), 6 years (AUC 0.79) and 9 years (AUC 0.80). Addition of HsTP to Framingham risk score improved model discrimination of PAD. In conclusion, in patients with mild-moderate CKD, HsTP levels are associated with and predictive of risk of incident PAD. This association remains significant despite adjustment for traditional PAD risk factors and chronic kidney disease.
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http://dx.doi.org/10.1016/j.amjcard.2019.11.019DOI Listing
February 2020

High-sensitivity troponin and the risk of atrial fibrillation in chronic kidney disease: Results from the Chronic Renal Insufficiency Cohort Study.

Heart Rhythm 2020 02 14;17(2):190-194. Epub 2019 Aug 14.

Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio. Electronic address:

Background: Patients with chronic kidney disease (CKD) are at an increased risk of atrial fibrillation (AF). There is a need for novel biomarkers to reliably and accurately predict AF in this population. High-sensitivity troponin (HsTP) allows the detection of low troponin concentrations. The utility of HsTP for evaluating the risk of AF in CKD has not been established.

Objective: We sought to explore the association between HsTP and the risk of incident AF in CKD.

Methods: The Chronic Renal Insufficiency Cohort is a prospective cohort of 3939 individuals with mild to moderate CKD. HsTP was measured at study enrollment. Patients with a history of AF were excluded. Patients were followed for new-onset AF, and the association between HsTP and incident AF was examined using the Cox regression model.

Results: A total of 3217 participants were included. Over a median follow-up period of 7.1 years (interquartile range 5.0-8.4 years), 252 patients developed new-onset AF (12 events per 1000 person-years of follow-up). The incidence of new-onset AF was 2.46%, 7.06%, and 11.5% at 3, 6, and 9 years, respectively. Compared with the lowest quartile of HsTP, patients in the third quartile of HsTP (hazard ratio 2.40; 95% confidence interval 1.58-3.65; P < .001) and the fourth quartile of HsTP (hazard ratio 4.43; 95% confidence interval 2.98-6.59; P < .001) had a higher incidence of AF.

Conclusion: HsTP levels are associated with an increased risk of AF in patients with mild to moderate CKD. This association remains significant despite adjustment for traditional AF risk factors and chronic renal disease.
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http://dx.doi.org/10.1016/j.hrthm.2019.08.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268542PMC
February 2020

Circulating soluble urokinase plasminogen activator receptor levels and peripheral arterial disease outcomes.

Atherosclerosis 2017 Sep 8;264:108-114. Epub 2017 Jun 8.

Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States. Electronic address:

Background And Aims: Circulating soluble urokinase plasminogen activator receptor (suPAR) is a marker of immune activation associated with atherosclerosis. Whether suPAR levels are associated with prevalent peripheral arterial disease (PAD) and its adverse outcomes remains unknown and is the aim of the study.

Methods: SuPAR levels were measured in 5810 patients (mean age 63 years, 63% male, 77% with obstructive coronary artery disease [CAD]) undergoing cardiac catheterization. The presence of PAD (n = 967, 17%) was classified as carotid (36%), lower/upper extremities (30%), aortic (15%) and multisite disease (19%). Multivariable logistic and Cox regression models were used to determine independent predictors of prevalent PAD and outcomes including all-cause death, cardiovascular death and PAD-related events after adjustment for age, gender, race, body mass index, smoking, diabetes, hypertension, hyperlipidemia, renal function, heart failure history, and obstructive CAD.

Results: Plasma suPAR levels were 22.5% (p < 0.001) higher in patients with PAD compared to those without PAD. Plasma suPAR was higher in patients with more extensive PAD (≥2 compared to single site) p < 0.001. After multivariable adjustment, suPAR was associated with prevalent PAD; odds ratio (OR) for highest compared to lowest tertile of 2.0, 95% CI (1.6-2.5) p < 0.001. In Cox survival analyses adjusted for clinical characteristics and medication regimen, suPAR (in the highest vs. lowest tertile) remained an independent predictor of all-cause death [HR 3.1, 95% CI (1.9-5.3)], cardiovascular death [HR 3.5, 95% CI (1.8-7.0)] and PAD-related events [HR = 1.8, 95% CI (1.3-2.6) p < 0.001 for all].

Conclusions: Plasma suPAR level is predictive of prevalent PAD and of incident cardiovascular and PAD-related events. Whether SuPAR measurement can help screen, risk stratify, or monitor therapeutic responses in PAD requires further investigation.
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http://dx.doi.org/10.1016/j.atherosclerosis.2017.06.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5808930PMC
September 2017

Depression and chest pain in patients with coronary artery disease.

Int J Cardiol 2017 Mar 23;230:420-426. Epub 2016 Dec 23.

Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States. Electronic address:

Background: Depression is common in patients with coronary artery disease (CAD) and is associated with more frequent chest pain. It is however unclear whether this is due to differences in underlying CAD severity. We sought to determine [1] whether depressive symptoms are associated with chest pain independently of CAD severity, [2] whether improvement in depressive symptoms over time is associated with improvement in chest pain and [3] whether the impact of revascularization on chest pain differs between patients with and without depression.

Methods And Results: 5158 patients (mean age 63±12years, 65% male, 20% African American) undergoing cardiac catheterization completed the Seattle Angina Questionnaire (SAQ) and Patient Health Questionnaire-8 (PHQ-8) to assess angina severity and screen for depression, respectively, both at baseline and between 6 and 24months of follow-up. We found significant correlations between PHQ-8 scores and angina frequency (SAQ-AF, r=-0.28), physical limitation (SAQ-PL, r=-0.32) and disease perception (SAQ-DS r=-0.37, all P<0.001), which remained significant after adjustment for clinical characteristics, CAD severity, and anti-depressant use. Improvement in depressive symptoms at follow-up was associated with improvement in angina subscales (SAQ-AF β 1.34, P<0.001), SAQ-PL β 1.85, P<0.001), and SAQ-DS (β 2.12, P<0.001), independently of CAD severity or revascularization. Patients with depression who underwent revascularization had less improvement in chest pain frequency than those without depressive symptoms.

Conclusions: Depression is associated with angina, independently of CAD severity. Patients with depression may not derive as adequate symptomatic benefit from revascularization as those without. Whether treatment of underlying depression improves chest pain needs to be further studied.
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http://dx.doi.org/10.1016/j.ijcard.2016.12.091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5881400PMC
March 2017
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