title: A genotype-specific, randomized controlled behavioral intervention to improve the neuroemotional outcome of cardiac surgery: study protocol for a randomized controlled trial.
abstract: BACKGROUND
  Cardiac surgery is one of the most commonly performed surgical procedures worldwide with >700,000 surgeries in 2006 in the US alone. Cardiac surgery results in a considerable exposure to physical and emotional stress; stress-related disorders such as depression or post-traumatic stress disorder are the most common adverse outcomes of cardiac surgery, seen in up to 20% of patients. Using information from a genome-wide association study to characterize genetic effects on emotional memory, we recently identified a single nucleotide polymorphism of the glucocorticoid receptor gene (the Bcll single nucleotide polymorphism) as a significant genetic risk factor for traumatic memories from cardiac surgery and symptoms of post-traumaticstress disorder. The Bcll high-risk genotype (Bcll GG) has a prevalence of 16.6% in patients undergoing cardiac surgery and is associated with increased glucocorticoid receptor signaling under stress. Concomitant animal experiments have confirmed an essential role of glucocorticoid receptor activation for traumatic memory formation during stressful experiences. Early cognitive behavioral intervention has been shown to prevent stress-related disorders after heart surgery.
  
  
  METHODS
  The proposed study protocol is based on the above mentioned earlier findings from animal experiments and preclinical studies in volunteers. Patients (n = 872) will be genotyped for the Bcll single nucleotide polymorphism before surgery, which should result in 120 homozygous high-risk carriers of the Bcll GG allele and 240 randomly selected low-risk heterozygous or non-carriers of the single nucleotide polymorphism. All patients will then undergo randomization to either cognitive behavioral intervention or a control intervention consisting of non-specific general information about the role of stress in heart disease. The primary efficacy endpoint will be post-traumatic stress levels at one year after surgery as determined by a standardized questionnaire that has been specifically validated in patients after critical illness.
  
  
  CONCLUSIONS
  The proposed randomized controlled trial intends to demonstrate that a preoperatively administered minimal cognitive behavioral intervention targeted to homozygous carriers of the Bcll *G high-risk allele reduces traumatic memories and post-traumatic stress disorder symptoms after heart surgery to a level seen in non-carriers of the mutation, and thus improves the neuroemotional outcome of cardiac surgery.
  
  
  BACKGROUND
  The trial will be registered at http://www.clinicaltrials.gov/ before commencing with the study.
authors.affiliation: Department of Anaesthesiology, Ludwig-Maximilians University, Munich 81377, Germany. daniela.hauer@med.uni-muenchen.de
authors.forename: Daniela
authors.initials: D
authors.lastname: Hauer
authors.forename: Iris-Tatjana
authors.initials: IT
authors.lastname: Kolassa
authors.forename: Rüdiger Paul
authors.initials: RP
authors.lastname: Laubender
authors.forename: Ulrich
authors.initials: U
authors.lastname: Mansmann
authors.forename: Christian
authors.initials: C
authors.lastname: Hagl
authors.forename: Benno
authors.initials: B
authors.lastname: Roozendaal
authors.forename: Dominique J-F
authors.initials: DJ
authors.lastname: de Quervain
authors.forename: Gustav
authors.initials: G
authors.lastname: Schelling
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000523:psychology*; D002985:Clinical Protocols; D015928:Cognitive Behavioral Therapy; D004644:Emotions; D005260:Female; D020022:Genetic Predisposition to Disease; D005858:Germany; D006579:Heterozygote; D006720:Homozygote; D006801:Humans; D008297:Male; D008568:Memory; D010641:Phenotype; D020641:Polymorphism, Single Nucleotide; D011569:Psychiatric Status Rating Scales; D011965:Receptors, Glucocorticoid / Q000235:genetics*; D012107:Research Design; D012307:Risk Factors; D012737:Sex Factors; D013313:Stress Disorders, Post-Traumatic / Q000175:diagnosis / Q000235:genetics / Q000517:prevention & control* / Q000523:psychology; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D011965:Receptors, Glucocorticoid
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