- Email: [email protected]
Prevalence of Substance-Related Disorders in Heart Transplantation Candidates
Prevalence of Substance-Related Disorders in Heart Transplantation Candidates L. Sirri, L. Potena, M. Masetti, E. Tossani, F. Grigioni, C. Magelli, A. Branzi, and S. Grandi ABSTRACT Substance abuse cessation is one of the leading factors in determining the eligibility for the heart transplantation waiting list, as noncompliance with this issue may seriously endanger posttransplantation outcomes. Yet, the prevalence of substance-related disorders among candidates for heart transplantation has not been evaluated enough. Eighty three heart transplantation candidates were assessed for prior or current substance-related disorders through the Structured Clinical Interview for mental disorders according to DSM-IV. A prior history of at least one substance-related disorder was found in 64% of patients, with nicotine dependence as the most prevalent diagnosis (61.4% of the sample). Ten subjects were currently smokers, despite heart failure. A prior history of alcohol abuse and caffeine intoxication was found in 9.6% and 2.4% of patients, respectively. Substance abuse or dependence behaviors should be monitored during all the phases of heart transplantation program. Early identification of current substance-related disorders may allow better allocation of organ resources and proper lifestyle modification programs provision. A prior history of substance-related disorders should alert physicians to assess patients for possible relapse, especially after transplantation. The inclusion of a specialist in the assessment and treatment of substance-related disorders in the heart transplantation unit may reduce the risk of unsuccessful outcomes due to noncompliance with an adequate lifestyle.
T
HE DANGERS OF SUBSTANCE ABUSE on the cardiovascular system have been largely documented.1,2 Cigarette smoking is one of the major causes of cardiovascular morbidity and mortality, it seems to explain about one fifth of all heart disease–related deaths.3,4 Nicotine dependence has been found to two- to fourfold increase the risk of coronary heart disease and to double that of heart failure. Smoking has been linked with sudden cardiac death and with decreased efficacy of beta-blocking drugs in patients with myocardial infarction, through persistent sympathomimetic actions.3– 6 Detrimental hemodynamic effects of cigarette smoking have been documented in heart failure patients.7,8 Smoking cessation results in a strong reduction in mortality risk from both coronary heart disease and stroke in the general population3 and in a better prognosis among patients with myocardial infarction, with a lower reinfarction risk and increased survival rates.9 Yet, only one third to one half of patients with myocardial infarction quit or reduce cigarette smoking.10 Some studies have documented the beneficial effects of smoking cessation programs for cardiac patients to decrease the risk of cardiac recurrences.11 Yet, smoking
cessation programs are not routinely included in the clinical management of patients with cardiovascular disorders.10 A relationship has been documented between life-threatening cardiovascular effects and massive intake of other substances, such as caffeine, cocaine, and methamphetamine.1,2 Excessive caffeine consumption has been related to increased systolic and diastolic blood pressure and it has been proposed to have a direct effect on cardiac mitochondria.12,13 Although a possible cardioprotective effect of mild to moderate alcohol consumption has been suggested, the abuse of alcohol may be conducive to cardiomyopathy, hypertension, and arrhythmia.2 Excessive alcohol intake was further associated with a greater risk of intracranial hemorrhage and ischemic stroke.14,15 A possible detrimental role of ethanol abuse on the progression of heart failure From the Department of Psychology (L.S., E.T., S.G.) and Cardiology Institute (L.P., M.M., F.G., C.M., A.B.), University of Bologna, Bologna, Italy. Address reprint requests to S. Grandi, MD, Dept of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. E-mail: [email protected]
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.05.020
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1970
Transplantation Proceedings, 39, 1970 –1972 (2007)
SUBSTANCE-RELATED DISORDERS
1971
and arrhythmias has been hypothesized.16 Patients who continue alcohol abuse after the onset of heart failure showed a sixfold 4-year mortality compared with those who become abstinent.17 A substantial reduction or the abstinence from drinking may reverse or stabilize alcoholrelated cardiovascular complications.2,16 Among patients with severe heart failure, substance abuse cessation is mandatory before being included in the waiting list for heart transplantation. Noncompliance with substance abuse discontinuation may seriously worsen the clinical outcome of heart transplantation, making costly, complex pharmacological treatments useless.18,19 For these reasons, substance abuse or dependence cessation deserves continuous monitoring in all the phases of the heart transplantation program starting from the early stages. Previous studies reporting the prevalence rates of substance-related disorders among heart transplantation candidates rarely differentiated between various types of substances.20 The aim of this study was to assess the prevalence of substance-related disorders among heart transplantation candidates.
They were 50 men (98%) and one woman, with a mean age of 56 years (SD ⫽ 9.2; range 18 to 66 years). Eighty two percent were married or living as married. Ten subjects (12%; 90% men, mean age ⫽ 54.7 ⫾ 12 years, range 26 to 68, 90% married) continued tobacco smoking at the time of evaluation: six reported a sporadic use, four met the DSM-IV criteria for nicotine dependence. Eight patients (9.6%) had suffered from alcohol abuse. They were men of mean age of 59 years (SD ⫽ 4.9; range 49 to 64) and 5 (62.5%) were married. Six patients also had a prior history of nicotine dependence. In two men (2.4%) a past diagnosis of caffeine intoxication was found. They were married or living as married and were 56 and 37 years old. They also reported a prior history of nicotine dependence. None of the patients received a current diagnosis of alcohol abuse or caffeine intoxication. No patient reported more than two substance-related disorders.
MATERIALS AND METHODS
This descriptive study documented a notable prevalence of prior substance-related disorders among patients evaluated for or awaiting heart transplantation. Nicotine dependence appeared to be the main cause, as it was found in the past of more than half of the patients. Although the majority of patients had recovered from cigarette smoking, 12% had not discontinued smoking at the time of evaluation. Previous studies have recognized substance abuse during the preoperative phase as a risk factor for posttransplantation problems.19 A past history of alcohol abuse was found in a nonnegligible number of subjects (9.6%) and seemed to confirm the relationship between excessive alcohol intake and cardiac risk.14 –17 To our knowledge, no studies were performed to evaluate the prevalence of caffeine intoxication among heart transplantation candidates, despite the documented cardiotoxicity of a massive use of this substance.12,13 In our sample, a past diagnosis of caffeine intoxication, as defined by DSM-IV criteria, was marginal, yet present. Future studies on patients awaiting heart transplantation should not omit to assess this disorder. The identification of current substance-related disorders is a crucial issue in the preoperative evaluation of heart transplantation candidates, as it plays a fundamental role in the decision-making process for listing on the heart transplantation waiting list. Patients who do not discontinue cigarette smoking or other substance abuse represent a subgroup at particular risk of clinical problems due to noncompliance with adequate lifestyle modification, especially after transplantation. The inclusion of a specialist in substance-related disorders in the heart transplantation unit may thus result in a reduced risk of unsuccessful outcomes related to patients’ unhealthy behaviors. A past diagnosis of substance-related disorders should alert physicians to thoroughly assess the stability of remission. After transplantation, when functional status im-
Eighty three consecutive outpatients with heart failure were recruited from outpatients between November 2002 and June 2005. There were 75 men (90.4%). The overall mean age was 55 years (SD ⫽ 9.9; range 18 to 68 years). Sixty-seven subjects (80.7%) were married or living as married. Fifty one patients (61.4%) were undergoing a thorough medical screening to evaluate eligibility for the heart transplant waiting list. Thirty two (38.6%) were already included on the heart transplantation waiting list. Written informed consent was obtained from all patients. The presence of both prior and current substance-related disorders was evaluated with the Italian version of the Structured Clinical Interview for DSM-IV.21 The interviews were conducted by the same clinical psychologist, who had extensive experience in psychosomatic research.
RESULTS
Fifty three (64%) patients had a prior history of at least one substance-related disorder. Of these, 52 were men (98%). The overall mean age was 56.5 years (SD ⫽ 9.1; range 18 to 66 years). Forty three (81%) were married or living as married. Table 1 shows the percentages of DSM-IV disorders. The most prevalent diagnosis was nicotine dependence: 51 patients (61.4%) had a positive history for this disorder. Table 1. Prevalence of DSM-IV Substance-Related Disorders DSM-IV Substance-Related Disorders
n
Percent of Patients (n ⫽ 83)
Any prior substance-related disorder Any current substance-related disorder Prior nicotine dependence Current nicotine dependence Prior alcohol abuse Current alcohol abuse Prior caffeine intoxication Current caffeine intoxication
53 10 51 10 8 0 2 0
64 12 61.4 12 9.6 0 2.4 0
DISCUSSION
1972
proves, it should be ascertained that these patients do not restart substance abuse. A proper evaluation of both prior and current substancerelated disorders during the preoperative phase should be followed by patients with multifaceted lifestyle modification programs or relapse prevention strategies.10,11,22 REFERENCES 1. Frishman WH, Del Vecchio A, Sanal S, et al: Cardiovascular manifestations of substance abuse part 1: cocaine. Heart Dis 5:187, 2003 2. Frishman WH, Del Vecchio A, Sanal S, et al: Cardiovascular manifestations of substance abuse part 2: alcohol, amphetamines, heroin, cannabis, and caffeine. Heart Dis 5:253, 2003 3. Lakier JB: Smoking and cardiovascular disease. Am J Med 93:8S, 1992 4. Manley AF: Cardiovascular implications of smoking: the surgeon general’s point of view. J Health Care Poor Underserved 8:303, 1997 5. Rempher KJ: Cardiovascular sequelae of tobacco smoking. Crit Care Nurs Clin North Am 18:13, 2006 6. Peters RW, Benowitz NL, Valenti S, et al: Electrophysiologic effects of cigarette smoking in patients with and without chronic beta-blocker therapy. Am J Cardiol 60:1078, 1987 7. Nicolozakes AW, Binkley PF, Leier CV: Hemodynamic effects of smoking in congestive heart failure. Am J Med Sci 296:377, 1988 8. Robertson D, Tseng CJ, Appalsamy M: Smoking and mechanisms of cardiovascular control. Am Heart J 115:258, 1988 9. Sparrow D, Dawber T, Colton T: The influence of cigarette smoking on prognosis after first myocardial infarction. J Chronic Dis 31:425, 1978 10. Dornelas EA, Sampson RA, Gray JF, et al: A randomized controlled trial of smoking cessation counseling after myocardial infarction. Prev Med 30:261, 2000
SIRRI, POTENA, MASETTI ET AL 11. Ludvig J, Miner B, Eisenberg MJ: Smoking cessation in patient with coronary artery disease. Am Heart J 149:565, 2005 12. Umemura T, Ueda K, Nishioka K, et al: Effects of acute administration of caffeine on vascular function. Am J Cardiol 98:1538, 2006 13. Sardao VA, Oliveira PJ, Moreno AJ: Caffeine enhances the calcium-dependent cardiac mitochondrial permeability transition: relevance for caffeine toxicity. Toxicol Appl Pharmacol 179:50, 2002 14. O’Connor AD, Rusyniak DE, Bruno A: Cerebrovascular and cardiovascular complications of alcohol and sympathomimetic drug abuse. Med Clin North Am 89:1343, 2005 15. Mukamal KJ, Ascherio A, Mittleman MA, et al: Alcohol and risk for ischemic stroke in men: the role of drinking patterns and usual beverage. Ann Intern Med 142:11, 2005 16. Regan TJ, Haider B: Ethanol abuse and heart disease. Circulation 64:14, 1981 17. Fabrizio L, Regan TJ: Alcoholic cardiomyopathy. Cardiovasc Drugs Ther 8:89, 1994 18. Stowe J, Kotz M: Addiction medicine in organ transplantation. Prog Transplant 11:50, 2001 19. Rivard AL, Hellmich C, Sampson B, et al: Preoperative predictors for postoperative problems in heart transplantation: psychiatric and psychosocial considerations. Prog Transplant 15: 276, 2005 20. Bernazzali S, Basile A, Balistreri A, et al: Standardized psychological evaluation pre- and posttransplantation: a new option. Transplant Proc 37:669, 2005 21. First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-I CV). Italian version by Mazzi F, Morosini P, De Girolamo G, et al. Florence, Italy: Organizzazioni Speciali; 2000 22. Kotz MM, Stowe JA: Addiction relapse prevention in solidorgan transplantation. Transplant Proc 31:48S, 1999
T
HE DANGERS OF SUBSTANCE ABUSE on the cardiovascular system have been largely documented.1,2 Cigarette smoking is one of the major causes of cardiovascular morbidity and mortality, it seems to explain about one fifth of all heart disease–related deaths.3,4 Nicotine dependence has been found to two- to fourfold increase the risk of coronary heart disease and to double that of heart failure. Smoking has been linked with sudden cardiac death and with decreased efficacy of beta-blocking drugs in patients with myocardial infarction, through persistent sympathomimetic actions.3– 6 Detrimental hemodynamic effects of cigarette smoking have been documented in heart failure patients.7,8 Smoking cessation results in a strong reduction in mortality risk from both coronary heart disease and stroke in the general population3 and in a better prognosis among patients with myocardial infarction, with a lower reinfarction risk and increased survival rates.9 Yet, only one third to one half of patients with myocardial infarction quit or reduce cigarette smoking.10 Some studies have documented the beneficial effects of smoking cessation programs for cardiac patients to decrease the risk of cardiac recurrences.11 Yet, smoking
cessation programs are not routinely included in the clinical management of patients with cardiovascular disorders.10 A relationship has been documented between life-threatening cardiovascular effects and massive intake of other substances, such as caffeine, cocaine, and methamphetamine.1,2 Excessive caffeine consumption has been related to increased systolic and diastolic blood pressure and it has been proposed to have a direct effect on cardiac mitochondria.12,13 Although a possible cardioprotective effect of mild to moderate alcohol consumption has been suggested, the abuse of alcohol may be conducive to cardiomyopathy, hypertension, and arrhythmia.2 Excessive alcohol intake was further associated with a greater risk of intracranial hemorrhage and ischemic stroke.14,15 A possible detrimental role of ethanol abuse on the progression of heart failure From the Department of Psychology (L.S., E.T., S.G.) and Cardiology Institute (L.P., M.M., F.G., C.M., A.B.), University of Bologna, Bologna, Italy. Address reprint requests to S. Grandi, MD, Dept of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. E-mail: [email protected]
0041-1345/07/$–see front matter doi:10.1016/j.transproceed.2007.05.020
© 2007 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
1970
Transplantation Proceedings, 39, 1970 –1972 (2007)
SUBSTANCE-RELATED DISORDERS
1971
and arrhythmias has been hypothesized.16 Patients who continue alcohol abuse after the onset of heart failure showed a sixfold 4-year mortality compared with those who become abstinent.17 A substantial reduction or the abstinence from drinking may reverse or stabilize alcoholrelated cardiovascular complications.2,16 Among patients with severe heart failure, substance abuse cessation is mandatory before being included in the waiting list for heart transplantation. Noncompliance with substance abuse discontinuation may seriously worsen the clinical outcome of heart transplantation, making costly, complex pharmacological treatments useless.18,19 For these reasons, substance abuse or dependence cessation deserves continuous monitoring in all the phases of the heart transplantation program starting from the early stages. Previous studies reporting the prevalence rates of substance-related disorders among heart transplantation candidates rarely differentiated between various types of substances.20 The aim of this study was to assess the prevalence of substance-related disorders among heart transplantation candidates.
They were 50 men (98%) and one woman, with a mean age of 56 years (SD ⫽ 9.2; range 18 to 66 years). Eighty two percent were married or living as married. Ten subjects (12%; 90% men, mean age ⫽ 54.7 ⫾ 12 years, range 26 to 68, 90% married) continued tobacco smoking at the time of evaluation: six reported a sporadic use, four met the DSM-IV criteria for nicotine dependence. Eight patients (9.6%) had suffered from alcohol abuse. They were men of mean age of 59 years (SD ⫽ 4.9; range 49 to 64) and 5 (62.5%) were married. Six patients also had a prior history of nicotine dependence. In two men (2.4%) a past diagnosis of caffeine intoxication was found. They were married or living as married and were 56 and 37 years old. They also reported a prior history of nicotine dependence. None of the patients received a current diagnosis of alcohol abuse or caffeine intoxication. No patient reported more than two substance-related disorders.
MATERIALS AND METHODS
This descriptive study documented a notable prevalence of prior substance-related disorders among patients evaluated for or awaiting heart transplantation. Nicotine dependence appeared to be the main cause, as it was found in the past of more than half of the patients. Although the majority of patients had recovered from cigarette smoking, 12% had not discontinued smoking at the time of evaluation. Previous studies have recognized substance abuse during the preoperative phase as a risk factor for posttransplantation problems.19 A past history of alcohol abuse was found in a nonnegligible number of subjects (9.6%) and seemed to confirm the relationship between excessive alcohol intake and cardiac risk.14 –17 To our knowledge, no studies were performed to evaluate the prevalence of caffeine intoxication among heart transplantation candidates, despite the documented cardiotoxicity of a massive use of this substance.12,13 In our sample, a past diagnosis of caffeine intoxication, as defined by DSM-IV criteria, was marginal, yet present. Future studies on patients awaiting heart transplantation should not omit to assess this disorder. The identification of current substance-related disorders is a crucial issue in the preoperative evaluation of heart transplantation candidates, as it plays a fundamental role in the decision-making process for listing on the heart transplantation waiting list. Patients who do not discontinue cigarette smoking or other substance abuse represent a subgroup at particular risk of clinical problems due to noncompliance with adequate lifestyle modification, especially after transplantation. The inclusion of a specialist in substance-related disorders in the heart transplantation unit may thus result in a reduced risk of unsuccessful outcomes related to patients’ unhealthy behaviors. A past diagnosis of substance-related disorders should alert physicians to thoroughly assess the stability of remission. After transplantation, when functional status im-
Eighty three consecutive outpatients with heart failure were recruited from outpatients between November 2002 and June 2005. There were 75 men (90.4%). The overall mean age was 55 years (SD ⫽ 9.9; range 18 to 68 years). Sixty-seven subjects (80.7%) were married or living as married. Fifty one patients (61.4%) were undergoing a thorough medical screening to evaluate eligibility for the heart transplant waiting list. Thirty two (38.6%) were already included on the heart transplantation waiting list. Written informed consent was obtained from all patients. The presence of both prior and current substance-related disorders was evaluated with the Italian version of the Structured Clinical Interview for DSM-IV.21 The interviews were conducted by the same clinical psychologist, who had extensive experience in psychosomatic research.
RESULTS
Fifty three (64%) patients had a prior history of at least one substance-related disorder. Of these, 52 were men (98%). The overall mean age was 56.5 years (SD ⫽ 9.1; range 18 to 66 years). Forty three (81%) were married or living as married. Table 1 shows the percentages of DSM-IV disorders. The most prevalent diagnosis was nicotine dependence: 51 patients (61.4%) had a positive history for this disorder. Table 1. Prevalence of DSM-IV Substance-Related Disorders DSM-IV Substance-Related Disorders
n
Percent of Patients (n ⫽ 83)
Any prior substance-related disorder Any current substance-related disorder Prior nicotine dependence Current nicotine dependence Prior alcohol abuse Current alcohol abuse Prior caffeine intoxication Current caffeine intoxication
53 10 51 10 8 0 2 0
64 12 61.4 12 9.6 0 2.4 0
DISCUSSION
1972
proves, it should be ascertained that these patients do not restart substance abuse. A proper evaluation of both prior and current substancerelated disorders during the preoperative phase should be followed by patients with multifaceted lifestyle modification programs or relapse prevention strategies.10,11,22 REFERENCES 1. Frishman WH, Del Vecchio A, Sanal S, et al: Cardiovascular manifestations of substance abuse part 1: cocaine. Heart Dis 5:187, 2003 2. Frishman WH, Del Vecchio A, Sanal S, et al: Cardiovascular manifestations of substance abuse part 2: alcohol, amphetamines, heroin, cannabis, and caffeine. Heart Dis 5:253, 2003 3. Lakier JB: Smoking and cardiovascular disease. Am J Med 93:8S, 1992 4. Manley AF: Cardiovascular implications of smoking: the surgeon general’s point of view. J Health Care Poor Underserved 8:303, 1997 5. Rempher KJ: Cardiovascular sequelae of tobacco smoking. Crit Care Nurs Clin North Am 18:13, 2006 6. Peters RW, Benowitz NL, Valenti S, et al: Electrophysiologic effects of cigarette smoking in patients with and without chronic beta-blocker therapy. Am J Cardiol 60:1078, 1987 7. Nicolozakes AW, Binkley PF, Leier CV: Hemodynamic effects of smoking in congestive heart failure. Am J Med Sci 296:377, 1988 8. Robertson D, Tseng CJ, Appalsamy M: Smoking and mechanisms of cardiovascular control. Am Heart J 115:258, 1988 9. Sparrow D, Dawber T, Colton T: The influence of cigarette smoking on prognosis after first myocardial infarction. J Chronic Dis 31:425, 1978 10. Dornelas EA, Sampson RA, Gray JF, et al: A randomized controlled trial of smoking cessation counseling after myocardial infarction. Prev Med 30:261, 2000
SIRRI, POTENA, MASETTI ET AL 11. Ludvig J, Miner B, Eisenberg MJ: Smoking cessation in patient with coronary artery disease. Am Heart J 149:565, 2005 12. Umemura T, Ueda K, Nishioka K, et al: Effects of acute administration of caffeine on vascular function. Am J Cardiol 98:1538, 2006 13. Sardao VA, Oliveira PJ, Moreno AJ: Caffeine enhances the calcium-dependent cardiac mitochondrial permeability transition: relevance for caffeine toxicity. Toxicol Appl Pharmacol 179:50, 2002 14. O’Connor AD, Rusyniak DE, Bruno A: Cerebrovascular and cardiovascular complications of alcohol and sympathomimetic drug abuse. Med Clin North Am 89:1343, 2005 15. Mukamal KJ, Ascherio A, Mittleman MA, et al: Alcohol and risk for ischemic stroke in men: the role of drinking patterns and usual beverage. Ann Intern Med 142:11, 2005 16. Regan TJ, Haider B: Ethanol abuse and heart disease. Circulation 64:14, 1981 17. Fabrizio L, Regan TJ: Alcoholic cardiomyopathy. Cardiovasc Drugs Ther 8:89, 1994 18. Stowe J, Kotz M: Addiction medicine in organ transplantation. Prog Transplant 11:50, 2001 19. Rivard AL, Hellmich C, Sampson B, et al: Preoperative predictors for postoperative problems in heart transplantation: psychiatric and psychosocial considerations. Prog Transplant 15: 276, 2005 20. Bernazzali S, Basile A, Balistreri A, et al: Standardized psychological evaluation pre- and posttransplantation: a new option. Transplant Proc 37:669, 2005 21. First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-I CV). Italian version by Mazzi F, Morosini P, De Girolamo G, et al. Florence, Italy: Organizzazioni Speciali; 2000 22. Kotz MM, Stowe JA: Addiction relapse prevention in solidorgan transplantation. Transplant Proc 31:48S, 1999