Coronary disease severity and functional impairment: how strong is the relation?

Myocardial infarction and physical function: the REasons for Geographic And Racial Differences in Stroke prospective cohort study

Objective

To examine associations between myocardial infarction (MI) and multiple physical function metrics.

Methods

Among participants aged ≥45 years in the REasons for Geographic And Racial Differences in Stroke prospective cohort study, instrumental activities of daily living (IADL), activities of daily living (ADL), gait speed, chair stands, and Short Form-12 physical component summary (PCS) were assessed after approximately 10 years of follow-up. We examined associations between MI and physical function (no MI [n = 9,472], adjudicated MI during follow-up [n = 288, median 4.7 years prior to function assessment], history of MI at baseline [n = 745], history of MI at baseline and adjudicated MI during follow-up [n = 70, median of 6.7 years prior to function assessment]). Models were adjusted for sociodemographic characteristics, health behaviours, depressive symptoms, cognitive impairment, body mass index, diabetes, hypertension, and urinary albumin to creatinine ratio. We examined subgroups defined by age, gender, and race.

Results

The average age at baseline was 62 years old, 56% were women, and 35% Black. MI was significantly associated with worse IADL and ADL scores, IADL dependency, chair stands, and PCS, but not ADL dependency or gait speed. For example, compared to participants without MI, IADL scores (possible range 0-14, higher score represents worse function) were greater for participants with MI during follow-up (difference: 0.37 [95% CI 0.16, 0.59]), MI at baseline (0.26 [95% CI 0.12, 0.41]), and MI at baseline and follow-up (0.71 [95% CI 0.15, 1.26]), p < 0.001. Associations tended to be greater in magnitude among participants who were women and particularly Black women.

Conclusion

MI was associated with various measures of physical function. These decrements in function associated with MI may be preventable or treatable.

Depressive symptoms, cardiovascular disease severity, and functional status in older adults with coronary heart disease: the heart and soul study

OBJECTIVES

To compare the contributions of depressive symptoms and cardiovascular disease (CVD) severity to functional decline in individuals with coronary heart disease.

DESIGN

Longitudinal.

SETTING

Twelve outpatient clinics in the San Francisco Bay area.

PARTICIPANTS

Older adults (N = 960; mean age 67) with stable coronary heart disease recruited between September 2000 and December 2002.

MEASUREMENTS

At baseline, depressive symptoms and angina pectoris were assessed according to self-report, and left ventricular ejection fraction (LVEF) and exercise capacity were evaluated using echocardiography and exercise treadmill testing. Difficulty performing activities of daily living and instrumental activities of daily living was assessed at baseline and annually for the next 5 years. Covariates included demographic characteristics, comorbid conditions, cognitive function, social support, and health behaviors. Five years later, 658 participants returned for follow-up assessments.

RESULTS

Higher baseline depressive symptoms predicted greater risk of functional decline over 5 years, whereas higher baseline exercise capacity was associated with lower risk of functional decline. In 658 participants who returned for follow-up, 5-year changes in depressive symptoms and exercise capacity were associated with 5-year changes in functional status. Angina pectoris frequency and LVEF were not associated with functional decline or change in functional status, after adjusting for covariates and other predictors.

CONCLUSION

In older adults with coronary heart disease, depressive symptoms and lower exercise capacity predicted functional decline over 5 years. In contrast, other traditional measures of CVD severity (LVEF and angina pectoris) were not independently predictive of subsequent functional status. These findings suggest that efforts to ameliorate depressive symptoms may be as important as treating CVD severity to enhance functional status.

Clinical severity and epithelial endotypes in chronic rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous disease defined by epithelial inflammation. The link between measures of traditional disease severity and markers of epithelial inflammation is poorly understood as prior research has focused on presence of polyps or degree of eosinophilia. The expression of 3 epithelial derived cytokines implicated in initiation of T-helper 2 (Th2) inflammation and an eosinophil chemoattractant were compared with clinical measures used in CRS.

METHODS

Sinus mucosal samples from CRS patients undergoing sinus surgery were analyzed for interleukin-25 (IL-25), IL-33, thymic stromal lymphopoietin (TSLP), and eotaxin-3 messenger RNA (mRNA) expression by quantitative polymerase chain reaction (PCR). Tumor patients undergoing surgery transnasally with normal sinus mucosa were controls. Gene expression was compared with symptom, radiology, and endoscopy scores, serological markers, presence of reactive airways disease (RAD), and atopy.

RESULTS

Thirty-seven patients (38% female, mean age 48 ± 15 years), 12 CRS with nasal polyps (CRSwNP), 18 CRS without nasal polyps (CRSsNP), and 7 controls were recruited. CRSwNP phenotype predicted elevated IL-25, IL-33, and eotaxin-3 levels. Increased eotaxin-3 correlated with poorer computed tomography (CT) (p = 0.004) and endoscopic scores (p = 0.049). Increased IL-25 correlated with poorer CT scores (p = 0.012) and raised serum eosinophils (p = 0.006). No associations with RAD, atopy, and symptom measures were found. No associations for IL-33 and TSLP were found.

CONCLUSION

Inflammatory mediators of the epithelium in CRS has some correlation with traditional measures of disease burden. Certain epithelial profiles may predict highly dysfunctional epithelial barriers and prospective evaluation of the clinical outcomes from interventions is required. Future endotyping of the epithelium in CRS may be able to provide prognostic information.

Associations between disease severity, coping and dimensions of health-related quality of life in patients admitted for elective coronary angiography - a cross sectional study

Background

In patients with suspected coronary artery disease (CAD), the overall aim was to analyse the relationships between disease severity and both mental and physical dimensions of health related quality of life (HRQOL) using a modified version of the Wilson and Cleary model.

Methods

Using a cross-sectional design, 753 patients (74% men), mean age 62 years, referred for elective cardiac catheterisation were included. The measures included 1) physiological factors 2) symptoms (disease severity, self-reported symptoms, anxiety and depression 3) self-reported functional status, 4) coping, 5) perceived disease burden, 6) general health perception and 7) overall quality of life. To analyse relationships, we performed linear and ordinal logistic regressions.

Results

CAD and left ventricular ejection fraction (LVEF) were significantly associated with symptoms of angina pectoris and dyspnea. CAD was not related to symptoms of anxiety and depression, but less depression was found in patients with low LVEF. Angina pectoris and dyspnea were both associated with impaired physical function, and dyspnea was also negatively related to social function. Overall, less perceived burden and better overall QOL were observed in patients using more confronting coping strategy.

Conclusion

The present study demonstrated that data from cardiac patients to a large extent support the suggested model by Wilson and Cleary.

Indicators of Functional Deficits After Coronary Artery Bypass Surgery

The purposes of this study were to determine if ratings of difficulty or pain were more likely to detect deficits in activities of daily living (ADL) than degree of dependency and to longitudinally examine ADL in patients recovering from coronary artery bypass (CAB) surgery. This study included 40 patients who had recently undergone CAB surgery. We evaluated ADL performance using 3 subcategories of the Functional Status Index: mobility, personal care, and hand activities. Subjects completed the Functional Index before, 2 weeks after, and 2 months after CAB surgery. The percent of participants reporting difficulty or pain on the FSI was greater than the percent needing assistance except for hand activities preoperatively. Up to 65% of study participants reported deficits in ADL performance. In conclusion, assessments of ADL abilities that rely only on need for assistance may underestimate the presence of functional deficits in patients recovering from CAB surgery. Understanding functional level will assist in determining patient's need for rehabilitation services after CAB surgery.

Functional status of patients during subacute recovery from coronary artery bypass surgery

BACKGROUND

Patients recovering from coronary artery bypass (CAB) surgery are particularly vulnerable to impaired functional status because in addition to the direct effects of heart disease on cardiac performance, many surgical factors may contribute to loss of function.

OBJECTIVES

The purposes of this study were to describe functional status across multiple domains using performance-based and self-report assessments and to determine the relationship among different domains of functional status in patients recovering subacutely (<6 months) from CAB surgery.

METHODS

The participants in this study (n = 25) had undergone CAB surgery in the past 6 months. This cross-sectional descriptive study measured functional status in several domains using self-report and performance-based assessments.

RESULTS

The study results indicate that participants had deficits in health-related quality of life, activities of daily living performance, endurance/aerobic capacity, and cognitive/memory ability. Several correlations between the scores for outcome measures in different domains were found in this study.

CONCLUSIONS

Impaired functional status occurs in patients recovering subacutely from CAB surgery. Different aspects of functional status are related, and an understanding of these relationships may help to improve the medical management of patients after CAB surgery.

Quality of life following cardiac surgery: impact of the severity and course of depressive symptoms

OBJECTIVES

The purpose of this study was to examine the impact of the severity and course of depressive symptoms on change in quality of life (QOL) 6 months after cardiac surgery.

METHODS

Ninety patients were interviewed before heart surgery and 2 and 6 months after surgery. Depressive symptoms were assessed using the Beck Depression Inventory, and QOL was assessed using physical and psychosocial functioning indices derived from the Medical Outcomes Study instrument. Multiple regression examined the effects of the severity and course of depressive symptoms on QOL adjusting for demographic and biomedical predictors.

RESULTS

Higher levels of presurgical depressive symptoms predicted poorer physical functioning after cardiac surgery. A similar effect on psychosocial functioning fell short of significance. An increase in depressive symptoms 2 months after surgery was significantly predictive of poorer physical and psychosocial functioning at 6 months. The effect of increased depressive symptoms on psychosocial functioning was significantly stronger in patients with high presurgical Beck Depression Inventory scores.

CONCLUSIONS

Both preoperative depressive symptoms and postoperative increases in depressive symptoms seem associated with poorer QOL 6 months after cardiac surgery. Further examination of these associations and the mechanisms they reflect may provide a basis for guiding treatment decisions before and after coronary artery bypass graft surgery.

The role of premorbid psychological attributes in short- and long-term adjustment after cardiac disease. A prospective study in the elderly in The Netherlands

The role of mastery, self-efficacy expectancies and neuroticism in explaining individual differences in physical and psychological adjustment to cardiac disease was studied in 208 patients. Premorbid data were available from a community-based survey in the Netherlands. Hierarchical linear regression analyses showed that self-efficacy expectancies at baseline were significantly related to adjustment in terms of physical functioning in the short- and long-term and depressive symptoms in the short-term (six weeks after diagnosis). Mastery was significantly related to depressive symptoms and anxiety in the long-term (1 year after diagnosis). Neuroticism was a predictor for depressive symptoms and anxiety both in the short- and long-term. The results of this longitudinal study showed that premorbidly assessed psychological attributes do have a role in explaining individual differences in vulnerability to negative consequences of cardiac disease.

Disability predicted mortality in men but not women with coronary heart disease

OBJECTIVE

Disability increases mortality in patients with myocardial infarction in acute clinical settings, but the impact of disability on mortality in persons with coronary heart disease (CHD) at the population level is largely unknown.

STUDY DESIGN AND SETTING

We assessed disability as a predictor of mortality among 4,501 men and women aged 45 and over in a national sample of the Finnish population, examined in 1978-1980.

RESULTS

During follow-up until the end of 1994, 897 men and 846 women died. Disability was related to increased all-cause and CHD mortality after adjustment for cardiovascular risk factors in men regardless of baseline CHD status. In women with CHD at baseline, disability was not related to excess mortality, although disability predicted mortality in women without baseline CHD.

CONCLUSION

Disability predicts mortality in men with CHD, but not in women. This may reflect a gender difference in the nature of CHD, but these findings need to be verified in other large-scale population studies.

Barriers and facilitators of self-reported physical activity in cardiac patients

The purpose of this study was to examine the relationships of personal factors (age and gender), barriers (symptom distress and negative well-being), and facilitators (self-efficacy to exercise and positive well-being) with self-reported physical activity in cardiac patients. Sixty-four participants (50 men, 14 women) 6-12 months post-cardiac event participated in this study. We found that age and gender accounted for 14.7% of the variance, symptom distress and negative well-being accounted for an additional 21.6% of the variance, and self-efficacy accounted for the remaining 7.6% of the variance for a total of 44% of the variance in physical activity levels explained. These results suggest that personal factors and barriers are central variables, in addition to self-efficacy, in understanding the levels of physical activity achieved by patients after a cardiac event.

Clinical and health services relationships between major depression, depressive symptoms, and general medical illness

Patients with chronic medical illness have a high prevalence of major depressive illness. Major depression may decrease the ability to habituate to the aversive symptoms of chronic medical illness, such as pain. The progressive decrements in function associated with many chronic medical illnesses may cause depression, and depression is associated with additive functional impairment. Depression is also associated with an approximately 50% increase in medical costs of chronic medical illness, even after controlling for severity of physical illness. Increasing evidence suggests that both depressive symptoms and major depression may be associated with increased morbidity and mortality from such illnesses as diabetes and heart disease. The adverse effect of major depression on health habits, such as smoking, diet, over-eating, and sedentary lifestyle, its maladaptive effect on adherence to medical regimens, as well as direct adverse physiologic effects (i.e., decreased heart rate variability, increased adhesiveness of platelets) may explain this association with increased morbidity and mortality.

The new subjective medicine: taking the patient's point of view on health care and health

Calls to respect patient autonomy and produce patient-centered outcomes have recently brought the patient's point of view back into the center of clinical medicine. Bioethics has argued that patient values must be respected in health care decisions. But it has generally not questioned medicine's goals, including its definition of health. For bioethics, health has remained an objective biological fact. However, pressures to improve the cost-effectiveness of medical care have increased interest in the subjective health and quality of life of patients. Perceived health, health-related quality of life, and health-state utilities bring health assessment progressively closer to the patient's perspective. Now even death's harm to patients is qualified by the value patients place on their health state. Medicine's epidemiological transition from acute to chronic disease is thus prompting an epistemological transition from primarily objective to primarily subjective evidence of health and health care effectiveness. Now some of the most important patient outcomes, like patient choices before them, are valid because they are subjective. Pathophysiology is appropriately becoming a means to produce health as it is defined from the patient's point of view. The physicians' job description will be changed to focus on patients' lives rather than patients' bodies. Definitive evaluations of medical effectiveness will occur within patients' lives rather than within doctors' hospitals. This further incorporation of patient subjectivity should carry us well beyond informed consent and the other protections for patient autonomy bequeathed to us by bioethics.

The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community

OBJECTIVES

To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey.

DESIGN

Analysis of longitudinal survey data.

SETTING

A nationally representative community-based survey.

PARTICIPANTS

Six thousand two hundred five Medicare beneficiaries age 65 and older.

MEASUREMENTS

Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline.

RESULTS

A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of >or=3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of.78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system.

CONCLUSIONS

A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

Depression and self-reported physical health in patients with coronary disease: mediating and moderating factors

OBJECTIVES

The purpose of this study was to define how the relation between depression and self-reported physical health in patients with coronary disease is modified by other patient-centered factors.

METHODS

We conducted a prospective cohort study of 111 patients (members of a health maintenance organization) with angiographically documented coronary disease, examining factors (physical symptoms, psychological states and traits, and spousal support) modifying the relation between depression and patient-reported physical health 5 years later using multiple hierarchical regression models.

RESULTS

Five regression models (all including demographic and disease severity covariates) were constructed to predict physical health from depression only (R2 = 0.22); depression plus angina and fatigue (R2 = 0.53); depression plus positive affect and novelty seeking and their interaction (R2 = 0.48); depression plus spousal support (R2 = 0.27); and depression, angina, fatigue, positive affect, and novelty seeking (overall model) (R2 = 0.65). Depression remained significant in each model, but the proportion of variance it predicted was diminished in the presence of the other variables (bivariate r = 0.39, partial r = 0.37-0.13).

CONCLUSIONS

The effect of depression on self-reported physical health is significantly mediated by physical symptoms (angina and fatigue), personality states and traits (positive affect and novelty seeking), and spousal support. Positive affect and novelty seeking had more marked effects on physical health in the presence of more depression. Thus, a broad range of factors beyond the severity of coronary disease itself affect the perceived physical health of patients with coronary heart disease.

Functional decline after congestive heart failure and acute myocardial infarction and the impact of psychological attributes. A prospective study

This article examines the influence of three pre-morbidly assessed psychological attributes (i.e. neuroticism, mastery and self-efficacy expectancies) on functional decline after congestive heart failure (CHF; n = 134) and acute myocardial infarction (AMI; n = 79) in late middle-aged and older persons. Due to the prospective design of the study initial baseline levels of functional disability and number of chronic medical conditions could be adjusted, next to age, gender and the severity of either CHF or AMI. Functional disability was re-assessed 8 weeks after the diagnosis of either CHF or AMI. Significant unique contributions of self-efficacy expectancies were found for functional decline after CHF, while mastery significantly contributes to functional decline after AMI: those patients with higher levels of mastery or self-efficacy expectancies showed less decline. In conclusion, pre-morbidly assessed psychological attributes substantially influence functional decline after cardiac disease in late middle-aged and older persons, but the impact of specific attributes is somewhat different for CHF and AMI.

Five-year prospective study of the effects of anxiety and depression in patients with coronary artery disease

Anxiety and depression have significant and widespread effects on daily function and symptoms of patients with coronary artery disease over a 5-year period. This may partially explain why results of treadmill stress testing and angiography poorly predict the daily functioning of patients with coronary artery disease.

Self-efficacy and self-reported functional status in coronary heart disease: a six-month prospective study

OBJECTIVE

We examine prospectively the role of specific forms of self-efficacy in the physical and role function for patients with coronary heart disease after controlling for the effects of anxiety and depression.

METHODS

A 6-month prospective cohort study was conducted after cardiac catheterization of 198 HMO members, demonstrating clinically significant coronary disease. Coronary disease severity was assessed through cardiac catheterization; physical function, role function, anxiety, depression, and self-efficacy were assessed through questionnaires.

RESULTS

The Cardiac Self-Efficacy Scale had two factors (maintain function and control symptoms) with high internal consistency and good convergent and discriminant validity. In multiple regression models, the self-efficacy scales significantly predicted physical function, social function, and family function after controlling for baseline function, baseline anxiety, and other significant correlates.

CONCLUSIONS

Self-efficacy to maintain function and to control symptoms helps predict the physical function and role function, after accounting for coronary disease severity, anxiety, and depression in patients with clinically significant coronary disease. Interventions to improve self-efficacy may have a broader applicability in the heart disease population than previously appreciated.

Functional status in coronary artery disease: a one-year prospective study of the role of anxiety and depression

PURPOSE

Although coronary disease is the second most common cause of work and functional disability, little is known about the relative contributions of biomedical and psychosocial factors to this disability. This study was conducted to determine the associations of depression and anxiety with self-reported physical function and activity interference in patients with coronary artery disease.

METHODS

This was a 1-year prospective cohort study of 198 HMO members who had elective cardiac catheterization for coronary artery disease in 1992. Measures included: severity of coronary artery stenosis from cardiac catheterization reports; anxiety and depression severity using interviewer-administered Hamilton Anxiety and Depression Rating Scales; and self-reported physical function and activity interference.

RESULTS

At the time of catheterization, patients' self-reported physical function differed significantly by number of main coronary vessels stenosed >70% (P <0.03), by anxiety quartiles (P = 0.001), and by depression quartiles (P = 0.001). At 1 year, physical function was no longer associated with the number of main coronary vessels stenosed at baseline, but still was significantly associated with baseline anxiety (P <0.001) and depression quartiles (P = 0.01). Moreover, change in physical function scores from baseline to 12 months was associated with baseline anxiety (P <0.001) or depression (P <0.001) quartiles, but not with baseline number of occluded coronaries. Results for activity interference were similar to those for physical function. These associations were largely unchanged when corrected for age, sex, education, social class, medical versus surgical management of CAD, and degree of medical comorbidity.

CONCLUSION

Anxiety and depression have a significant and persistent effect on physical function in patients with coronary artery disease. Although current treatment methods appear to neutralize the influence of coronary stenosis on physical function during the year following catheterization, this is not true for anxiety and depression.