Background Acute allograft rejection appears to be associated with increases in QT/QTc intervals. Objectives To determine the relationship between acute allograft rejection and electrocardiogram changes in patients undergoing an orthotopic heart transplant. Methods The study population comprised 220 adult patients undergoing heart transplant and enrolled in the NEW HEART study. Electrocardiograms obtained within 72 hours of endomyocardial biopsy were analyzed; electrocardiograms obtained fewer than 10 days after transplant surgery were excluded. Repeated-measures analysis was performed with statistical models including effects for rejection severity (mild and moderate/severe) and time trends independent of rejection status. Results The 151 male and 69 female transplant recipients (mean age [SD], 54 [13] years) had 969 biopsy/electrocardiogram pairs: 677 with no rejection, 280 with mild rejection, and 12 with moderate/severe rejection. Moderate to severe organ rejection was associated with significant increases in QRS duration ( P < .001), QT ( P = .009), QTc ( P = .003), and PR interval ( P = .03), as well as increased odds of right bundle block branch ( P = .002) and fascicular block ( P = .009) occurring. Conclusions Moderate to severe acute allograft rejection was associated with electrocardiographic changes after transplant surgery. Studies are needed to assess the value of computerized electrocardiogram measurement algorithms for detecting acute allograft rejection.

Background Assessing depression in patients hospitalized with coronary heart disease is clinically challenging because depressive symptoms are often confounded by poor somatic health. Objective To identify symptom clusters associated with clinical depression in patients hospitalized with coronary heart disease. Method Secondary analyses of 3 similar data sets for hospitalized patients with coronary heart disease who had diagnostic screening for depression (99 depressed, 224 not depressed) were done. Depressive symptoms were assessed by using the Hamilton Depression Rating Scale or the Beck Depression Inventory. Hierarchical cluster analysis was performed on 11 symptom variables: anhedonia, dysphoria, loss of appetite, sleep disturbance, fatigue, guilt, suicidal symptoms, hypochondriasis, loss of libido, psychomotor impairment, and nervous irritability. Associations between symptom clusters and presence or absence of clinical depression were estimated by using logistic regression. Results Fatigue (69%) and sleep disturbance (55%) were the most prevalent symptoms. Guilt (25%) and suicidal symptoms (9%) were the least common. Three symptom clusters (cognitive/affective, somatic/affective, and somatic) were identified. Compared with patients without cognitive/affective symptoms, patients with the cognitive/affective symptom cluster (anhedonia, dysphoria, guilt, suicidal symptoms, nervous irritability) had an odds ratio of 1.41 ( P <.001; 95% CI, 1.223–1.631) for clinical depression. Conclusion Clinicians should be alert for clinical depression in hospitalized patients with coronary heart disease who have the cognitive/affective symptom cluster.

Background Depression screening in cardiac patients has been recommended by the American Heart Association, but the best approach remains unclear. Objectives To evaluate nurse-administered versions of the Patient Health Questionnaire for depression screening in patients hospitalized for acute coronary syndrome. Methods Staff nurses in an urban cardiac care unit administered versions 2, 9, and 10 of the questionnaire to 100 patients with acute coronary syndrome. The Depression Interview and Structured Hamilton was administered by advanced practice nurses blinded to the results of the Patient Health Questionnaire. With the results of the Depression Interview and Structured Hamilton as a criterion, receiver operating characteristic analyses were done for each version of the Patient Health Questionnaire. The Delong method was used for pairwise comparisons. Cutoff scores balancing false-negatives and false-positives were determined by using the Youden Index. Results Each version of the questionnaire had excellent area-under- the-curve statistics: 91.2%, 92.6%, and 93.4% for versions 2, 9, and 10, respectively. Differences among the 3 versions were not significant. Each version yielded higher symptom scores in depressed patients than in nondepressed patients: version 2 scores, 3.4 vs 0.6, P = .001; version 9 scores, 13 vs 3.4, P < .001; and version 10 scores, 14.5 vs 3.6, P < .001. Conclusions For depression screening in hospitalized patients with acute coronary syndrome, the Patient Health Questionnaire 2 is as accurate as longer versions when administered by nurses. Further study is needed to determine if screening with this tool changes clinical decision making or improves outcomes in these patients.

Background Physical symptoms are common and distressing problems for patients with heart failure and may be the strongest predictor of health-related quality of life. Identification of variables predictive of physical symptom status is needed to develop effective interventions to improve health-related quality of life. Methods A total of 84 patients discharged after being hospitalized for exacerbation of heart failure were followed up for 3 months. The Minnesota Living With Heart Failure Questionnaire and the Dyspnea-Fatigue Index were used to assess health-related quality of life and physical symptom status, respectively. Relationships of health-related quality of life and physical symptom status to baseline demographic, behavioral, biophysiological, and psychological variables were examined with bivariate correlations and stepwise multiple regression analyses. Results Patients with better physical symptom status and those who worked, were older, and were less anxious at baseline reported better health-related quality of life ( F =12.4, P <.001); physical symptom status was the strongest predictor. Patients who had less depression, worked, had higher perceived control, and were younger at baseline reported better physical symptom status ( F =14.4, P <.001); depression was the strongest predictor. Conclusions Physical symptom status is the most important predictor of health-related quality of life, and baseline depression and perceived control are the best predictors of physical symptom status. Interventions targeted to improve psychological status may improve physical symptom status and thereby improve health-related quality of life.

Background Major depression is common after coronary artery bypass graft surgery and is associated with increased mortality and morbidity. Clinicians have few practical options for detecting depression, especially in women, who are at higher risk for depression than men. Objectives To evaluate the clinical utility of common self-report and observer-rated instruments for detection of major depression in women after coronary artery bypass graft surgery. Methods In 66 women being discharged after coronary artery bypass graft surgery, 4 instruments were completed: the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Depression Inventory Short Form, and Beck Depression Inventory for Primary Care. For each instrument, receiver-operating-characteristic curves were analyzed, and positive and negative predictive values were calculated for cutoff points determined from the curves. Results At hospital discharge, all 4 instruments yielded highly accurate curves. Compared with cutoffs suggested for patients without medical illness and hospitalized nonsurgical patients, identified cutoffs for screening were higher when all types of depressive symptoms (cognitive, affective, behavioral, somatic) were measured with the Hamilton Depression Rating Scale and the Beck Depression Inventory but lower when only cognitive and/or affective symptoms were measured with the 2 subscales of the Beck Depression Inventory. Conclusions The Hamilton Depression Rating Scale and both subscales of the Beck Depression Inventory may be useful for detecting major depression in women shortly after coronary artery bypass graft surgery. Further study is warranted to confirm cutoffs in these patients.

• Background Effects of postoperative depression on recovery from coronary artery bypass grafting have not been widely studied. • Objectives To evaluate emotional and physical recovery after bypass surgery and investigate associations between depressive symptoms and infections and impaired wound healing in patients with high and low levels of depressive symptoms. • Methods A nonrandomized, comparative, longitudinal design was used to study 72 bypass surgery patients without serious noncardiac comorbidities who were available for follow-up after discharge. Patients completed questionnaires to assess depressive symptoms, emotional recovery, and physical recovery within 48 hours after extubation, at discharge from the hospital, and 6 weeks later and performed 6-minute walk tests at the last 2 times. Infections and impaired wound healing (as indicated by positive cultures, antibiotic treatment, or extra treatments, such as debridements or incisions and drainage) were identified by chart audit. • Results At discharge, patients with higher depressive symptom scores (indicating more symptoms) reported poorer emotional recovery (P < .001) and poorer physical recovery (P = .007) and achieved shorter walking distances (P<.001) than did patients with lower scores (indicating fewer symptoms). Six weeks after discharge, emotional and physical recovery remained lower in patients with more depressive symptoms (P < .001). Infections and impaired wound healing were more common among patients with higher depressive symptom scores (46%) than among patients with lower scores (19%, P=.03). • Conclusions After bypass surgery, depressive symptoms are associated with infections, impaired wound healing, and poor emotional and physical recovery.

• Background Care of cardiac surgery patients has changed substantially in the past decade, with an emphasis on streamlined procedures and shortened hospital stays. The few qualitative reports of patients’ perspectives of this experience focus primarily on physical complications and discomforts during the immediate postoperative period. • Objective To examine patients’ perceptions of the quality of the nursing and medical care they received during their hospital stay after cardiac surgery. • Methods Data were collected from a consecutive sample of 89 cardiac surgical patients who consented to participate in 2 telephone interviews at 1 week and 6 weeks after hospitalization. Patients responded to a single open-ended question: “What do you want your nurses and doctors to know to help them do a better job?” Thematic extraction analysis of patients’ responses was conducted by using commercially available statistical software. Extracted themes were applied to the structure-process-outcome framework of quality of care. • Results Four major themes (and 12 subthemes) were identified: (1) being satisfied (having a positive experience, getting information), (2) not being cared for (feeling depersonalized, having expectations that did not match recovery experiences, not being listened to, experiencing unprofessional behavior by care providers, experiencing continued care needs after going home), (3) physical needs unmet (sleep, pain, complications, physical environment), and (4) informational needs unmet (needing more or different information). • Conclusions Patients want nurses and doctors to provide a smooth transition to home, recognize the patients as individuals, prepare them honestly for their experiences with specific information, and manage pain and sleep.