Psychosocial modulators of angina response to myocardial ischemia

Sex Differences in Psychosocial Factors and Angina in Patients With Chronic Coronary Disease

BACKGROUND

Women with chronic coronary disease have more frequent angina and worse health status than men, despite having less coronary artery disease (CAD). We examined whether perceived stress and depressive symptoms mediate sex differences in angina, and whether this relationship differs in the setting of obstructive CAD or ischemia with no obstructive coronary artery disease (INOCA).

METHODS

We analyzed the association between sex, stress (Perceived Stress Scale-4) and depressive symptoms (Patient Health Questionnaire-8) on angina-related health status (Seattle Angina Questionnaire [SAQ]) at enrollment in the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial and CIAO-ISCHEMIA (Changes in Ischemia and Angina Over 1 Year Among ISCHEMIA Trial Screen Failures With No Obstructive CAD on Coronary CT [Computed Tomography] Angiography) ancillary study.

RESULTS

Scores for the SAQ, Perceived Stress Scale-4, and Patient Health Questionnaire-8 were available in 1626 participants (N=1439 CAD and N=187 INOCA). Women had lower (worse) SAQ-7 summary scores than men in both CAD and INOCA cohorts (CAD: median 76 [25th, 75th percentiles 60, 90] versus 83 [70, 96], P<0.001; INOCA: 80 [64,89] versus 85 [75, 93], P=0.012). Higher stress and depressive symptoms were associated with worse angina in both cohorts. Female sex, Perceived Stress Scale-4 score, and Patient Health Questionnaire-8 score were each independently associated with lower SAQ summary score, but CAD versus INOCA cohort was not. There was no interaction between sex and stress (-0.39 [95% CI, -1.01 to 0.23]) or sex and depression (-0.00 [95% CI, -0.53 to 0.53]) on SAQ summary score.

CONCLUSIONS

High stress and depressive symptoms were independently associated with worse angina and poorer health status, without interaction with sex with or without obstructive CAD. Factors other than stress or depression contribute to worse health status in women with obstructive CAD or INOCA.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02347215, NCT01471522.

Variation in Health Status With Invasive vs Conservative Management of Chronic Coronary Disease

BACKGROUND

The ISCHEMIA trial found that patients with chronic coronary disease randomized to invasive strategy had better health status than those randomized to conservative strategy. It is unclear how best to translate these population-level results to individual patients.

OBJECTIVES

The authors sought to identify patient characteristics associated with health status from invasive and conservative strategies, and develop a prediction algorithm for shared decision-making.

METHODS

One-year disease-specific health status was assessed in ISCHEMIA with the Seattle Angina Questionnaire (SAQ) Summary Score (SAQ SS) and Angina Frequency, Physical Limitations (PL), and Quality of Life (QL) domains (range 0-100, higher = less angina/better health status).

RESULTS

Among 4,617 patients from 320 sites in 37 countries, mean SAQ SS was 74.1 ± 18.9 at baseline and 85.7 ± 15.6 at 1 year. Lower baseline SAQ SS and younger age were associated with better 1-year health status with invasive strategy (P interaction = 0.009 and P interaction = 0.004, respectively). For the individual domains, there were significant treatment interactions for baseline SAQ score (Angina Frequency, PL), age (PL, QL), anterior ischemia (PL), and number of baseline antianginal medications (QL), with more benefit of invasive in patients with worse baseline health status, younger age, anterior ischemia, and on more antianginal medications. Parsimonious prediction models were developed for 1-year SAQ domains with invasive or conservative strategies to support shared decision-making.

CONCLUSIONS

In the management of chronic coronary disease, individual patient characteristics are associated with 1-year health status, with younger age and poorer angina-related health status showing greater benefit from invasive management. This prediction algorithm can support the translation of the ISCHEMIA trial results to individual patients. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Prevalence of depression and its association with quality of life in patients after pacemaker implantation during the COVID-19 pandemic: A network analysis

Background

This study was designed to investigate the prevalence and predictors of depression in patients after pacemaker implantation during the COVID-19 pandemic in addition to identifying specific depressive symptoms associated with quality of life (QOL) using network analysis (NA).

Methods

This cross-sectional, observational study was conducted in China between July 1, 2021, and May 17, 2022. Descriptive analysis was used to calculate depression prevalence. Univariate analyses were used to compare differences in demographic and clinical characteristics between depressed and non-depressed patients following pacemaker implantation. Binary logistic regression analysis was used to assess factors independently associated with depression. Network analysis “expected influence,” and flow function indexes were used to identify symptoms central to the depression network of the sample and depressive symptoms that were directly associated with QOL, respectively. Network stability was examined using a case-dropping bootstrap procedure.

Results

In total, 206 patients implanted with a pacemaker met the study entry criteria and completed the assessment. The overall prevalence of depression (PHQ-9 total score ≥ 5) was 39.92% [95% confidence interval (CI) = 29.37−42.47%]. A binary logistic regression analysis revealed that patients with depression were more likely to report a poor health status (p = 0.031), severe anxiety symptoms (p &lt; 0.001), and fatigue (p &lt; 0.001). In the network model for depression, “Sad mood,” “Poor Energy,” and “Guilt” were the most influential symptoms. “Fatigue” had the strongest negative association with QOL, followed by “Sad mood” and “Appetite”.

Conclusion

Depression is common among patients having undergone pacemaker implantation during the COVID-19 pandemic. Anxiety, central symptoms of depression (i.e., “Sad mood”, “Poor Energy”, and “Guilt”) and depressive symptoms linked to QOL (i.e., “Sad mood”, “Appetite”, and “Fatigue”) identified in this study are promising targets for interventions and preventive measures for depression in patients who have undergone pacemaker implants.

The Central Nervous System and Psychosocial Factors in Primary Microvascular Angina

Patients diagnosed with ischemia without obstructive coronary artery disease (INOCA) comprise the group of patients with primary microvascular angina (MVA). The pathophysiology underlying ischemia and angina is multifaceted. Differences in vascular tone, collateralization, environmental and psychosocial factors, pain thresholds, and cardiac innervation seem to contribute to clinical manifestations. There is evidence suggesting potential interactions between the clinical manifestations of MVA and non-cardiac conditions such as abnormal function of the central autonomic network (CAN) in the central nervous system (CNS), pain modulation pathways, and psychological, psychiatric, and social conditions. A few unconventional non-pharmacological and pharmacological techniques targeting these psychosocial conditions and modulating the CNS pathways have been proposed to improve symptoms and quality of life. Most of these unconventional approaches have shown encouraging results. However, these results are overall characterized by low levels of evidence both in observational studies and interventional trials. Awareness of the importance of microvascular dysfunction and MVA is gradually growing in the scientific community. Nonetheless, therapeutic success remains frustratingly low in clinical practice so far. This should promote basic and clinical research in this relevant cardiovascular field investigating, both pharmacological and non-pharmacological interventions. Standardization of definitions, clear pathophysiological-directed inclusion criteria, crossover design, adequate sample size, and mid-term follow-up through multicenter randomized trials are mandatory for future study in this field.

Ischemia and no obstructive coronary arteries in patients with stable ischemic heart disease

A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed.

Relationship Between Myocardial Perfusion Imaging Abnormalities on Positron Emission Tomography and Anginal Symptoms, Functional Status, and Quality of Life

BACKGROUND

Myocardial perfusion imaging (MPI) identifies abnormalities that occur early in the ischemic cascade leading to angina. Our aim was to study the association between ischemic measures on positron emission tomography MPI and patients' health status; their symptoms, function, and quality of life.

METHODS

Health status was collected using the Seattle Angina Questionnaire (SAQ-7, 0-100, higher=better) and Rose Dyspnea Score (RDS) on 1515 outpatients with known or suspected coronary artery disease presenting for clinically indicated pharmacological ⁸²Rb positron emission tomography MPI from July 2018 to July 2019. Adjusted multivariable ordinal regression models were used to assess the association between MPI findings of ischemia and the SAQ physical limitation, angina frequency, quality of life, summary score, and the RDS.

RESULTS

The mean SAQ and RDS scores of the cohort (mean age 71.7 years, 55% male, 37.6% prior myocardial infarction or revascularization) were 73.8±28.6 (physical limitation), 87.4±21.7 (angina frequency), 79.0±26.1 (quality of life), 81.3±19.0 (summary score), and 2±2 (RDS). No perfusion, flow or function abnormalities were significantly associated with SAQ angina frequency scores. Low left ventricular ejection fraction reserve (≤0%), low global and regional myocardial blood flow reserve (<2) were independently associated with worse SAQ Physical Limitation score, SAQ summary score, and RDS (30% to 57% greater odds; all P≤0.01), but reversible perfusion defects were not.

CONCLUSIONS

Impaired augmentation of left ventricular ejection fraction and myocardial blood flow with stress is associated with significant angina-associated functional limitation, health status, and dyspnea in patients who underwent positron emission tomography MPI, but not the frequency of their angina. Future studies should evaluate whether therapies that improve stress-induced abnormalities in systolic function and myocardial flow may improve patients' health status.

Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine

Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.

Facial Expressions of Emotions During Pharmacological and Exercise Stress Testing: the Role of Myocardial Ischemia and Cardiac Symptoms

Background

Negative emotions have been linked to ischemic heart disease, but existing research typically involves self-report methods and little is known about non-verbal facial emotion expression. The role of ischemia and anginal symptoms in emotion expression was examined.

Methods

Patients undergoing cardiac stress testing (CST) using bicycle exercise or adenosine with myocardial perfusion imaging were included (N = 256, mean age 66.8 ± 8.7 year., 43% women). Video images and emotion expression (sadness, anxiety, anger, and happiness) were analyzed at baseline, initial CST , maximal CST, recovery. Nuclear images were evaluated using SPECT.

Results

Ischemia (N = 89; 35%) was associated with higher levels of sadness (p = .017, d = 0.34) and lower happiness (p = .015, d = 0.30). During recovery, patients with both ischemia and anginal symptoms had the highest sadness expression (F (3,254) = 3.67, p = .013, eta² = 0.042) and the lowest happiness expression (F (3, 254) = 4.19, p = .006, eta² = .048).

Conclusion

Sadness and reduced happiness were more common in patients with ischemia. Also, anginal symptoms were associated with more negative emotions.

Myocardial infarction with non-obstructive coronary arteries as compared with myocardial infarction and obstructive coronary disease: outcomes in a Medicare population

AIMS

The prognosis of patients with MINOCA (myocardial infarction with non-obstructive coronary arteries) is poorly understood. We examined major adverse cardiac events (MACE) defined as all-cause mortality, re-hospitalization for acute myocardial infarction (AMI), heart failure (HF), or stroke 12-months post-AMI in patients with MINOCA versus AMI patients with obstructive coronary artery disease (MICAD).

METHODS AND RESULTS

Multicentre, observational cohort study of patients with AMI (≥65 years) from the National Cardiovascular Data Registry CathPCI Registry (July 2009-December 2013) who underwent coronary angiography with linkage to the Centers for Medicare and Medicaid (CMS) claims data. Patients were classified as MICAD or MINOCA by the presence or absence of an epicardial vessel with ≥50% stenosis. The primary endpoint was MACE at 12 months, and secondary endpoints included the components of MACE over 12 months. Among 286 780 AMI admissions (276 522 unique patients), 16 849 (5.9%) had MINOCA. The 12-month rates of MACE (18.7% vs. 27.6%), mortality (12.3% vs. 16.7%), and re-hospitalization for AMI (1.3% vs. 6.1%) and HF (5.9% vs. 9.3%) were significantly lower for MINOCA vs. MICAD patients (P < 0.001), but was similar between MINOCA and MICAD patients for re-hospitalization for stroke (1.6% vs. 1.4%, P = 0.128). Following risk-adjustment, MINOCA patients had a 43% lower risk of MACE over 12 months (hazard ratio = 0.57, 95% confidence interval 0.55-0.59), in comparison to MICAD patients. This pattern was similar for adjusted risks of the MACE components.

CONCLUSION

This study confirms an unfavourable prognosis in elderly patients with MINOCA undergoing coronary angiography, with one in five patients with MINOCA suffering a major adverse event over 12 months.

Gender in cardiovascular medicine: chest pain and coronary artery disease

Ischaemic heart disease (IHD) remains the leading cause of morbidity and mortality among women and men yet women are more often underdiagnosed, have a delay in diagnosis, and/or receive suboptimal treatment. An implicit gender-bias with regard to lack of recognition of sex-related differences in presentation of IHD may, in part, explain these differences in women compared with men. Indeed, existing knowledge demonstrates that angina does not commonly relate to obstructive coronary artery disease (CAD). Emerging knowledge supports an inclusive approach to chest pain symptoms in women, as well as a more thoughtful consideration of percutaneous coronary intervention for angina in stable obstructive CAD, to avoid chasing our tails. Emerging knowledge regarding the cardiac autonomic nervous system and visceral pain pathways in patients with and without obstructive CAD offers explanatory mechanisms for angina. Interdisciplinary investigation approaches that involve cardiologists, biobehavioural specialists, and anaesthesia/pain specialists to improve angina treatment should be pursued.

The association between psychological distress and angina pectoris: A population-based study

BACKGROUND

Psychological distress is an undifferentiated combination of symptoms that may be related to the occurrence of angina pectoris (AP). However, few studies have investigated the relationship between psychological distress and AP, particularly in Asian populations. The purpose of this study was to examine the relationship between psychological distress and AP in Taiwanese adults.

METHODS

We adopted a cross-sectional design to explore the data of the 2005-2008 Nutrition and Health Survey in Taiwan. In total, 2080 subjects (aged ≥ 19 years) responded to questionnaire interviews and underwent physical examinations. Each of the five dimensions of psychological distress (sleep disturbance, anxiety, hostility, depression, and feelings of inferiority) were scored (from 0-20) according to the Five-Item Brief Symptom Rating Scale (BSRS-5). A score ≥ 6 points indicated psychological distress. AP was evaluated using a modified Rose questionnaire.

FINDINGS

In total, 102 subjects (3.6%) had AP, and 231 subjects (8.8%) had symptoms of psychological distress. After adjusting for the basic data, metabolism, and lifestyle covariates, the BSRS-5 total score was associated with AP (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.13-1.26, p < 0.001). Subjects with psychological distress had a higher risk of AP (OR = 2.97, 95% CI = 1.76-4.99, p < 0.001).

CONCLUSIONS

The presence of AP is associated with psychological distress. Health care providers should therefore be aware of the impact of psychological distress on AP. Our study findings can serve as a reference for AP assessments. Large scale longitudinal studies are needed to confirm a causal relationship between psychological distress and AP.

Depression, anxiety, and stress in patients with coronary heart disease

The analytical paper summarized the results of recent studies of an association of depression, anxiety, and stress with coronary heart disease (CHD). Mental disorders are shown to be associated with increased risk of CHD and to worsen the course of coronary disease. Antidepressants and psychotherapy improve the control of mental disorders, quality of life, and, in some cases, have a positive impact on the course of coronary disease.

Race and Sex Differences in Post-Myocardial Infarction Angina Frequency and Risk of 1-Year Unplanned Rehospitalization

BACKGROUND

Race and sex disparities in in-hospital treatment and outcomes of patients with acute myocardial infarction (MI) have been described, but little is known about race and sex differences in post-MI angina and long-term risk of unplanned rehospitalization. We examined race and sex differences in post-MI angina frequency and 1-year unplanned rehospitalization to identify factors associated with unplanned rehospitalization, testing for whether race and sex modify these relationships.

METHODS

Using TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome) data, we examined 6-week and 1-year angina frequency and 1-year unplanned rehospitalization stratified by race and sex among MI patients treated with percutaneous coronary intervention. We used multivariable logistic regression to assess factors associated with unplanned rehospitalization and tested for interactions among angina frequency, race, and sex.

RESULTS

A total of 11 595 MI patients survived to 1 year postdischarge; there were 66.6% white male patients, 24.3% white female patients, 5.3% black male patients, and 3.8% black female patients. Overall, 29.7% had angina at 6 weeks, and 20.6% had angina at 1 year postdischarge. Relative to white patients, black patients were more likely to have angina at 6 weeks (female: 44.2% versus 31.8%; male: 33.5% versus 27.1%; both P<0.0001) and 1 year (female: 49.4% versus 38.9%; male: 46.3% versus 31.1%; both P<0.0001). Rates of 1-year unplanned rehospitalization were highest among black female patients (44.1%), followed by white female patients (38.4%), black male patients (36.4%), and white male patients (30.2%, P<0.0001). In the multivariable model, 6-week angina was most strongly associated with unplanned rehospitalization (hazard ratio, 1.49; 95% confidence interval, 1.36-1.62; P<0.0001); this relationship was not modified by race or sex (adjusted 3-way P_interaction=0.41).

CONCLUSIONS

One-fifth of MI patients treated with percutaneous coronary intervention report 1-year postdischarge angina, with black and female patients more likely to have angina and to be rehospitalized. Better treatment of post-MI angina may improve patient quality of life and quality of care and help to lower rates of rehospitalization overall and particularly among black and female patients, given their high prevalence of post-MI angina.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.

There is No Association Between the Omega-3 Index and Depressive Symptoms in Patients With Heart Disease Who Are Low Fish Consumers

BACKGROUND

Long chain Omega-3 polyunsaturated fatty acids (LCn3PUFAs) may improve cardiovascular health and depression. This study investigated the relationships between erythrocyte membrane LCn3PUFA status, depression and angina symptoms in patients with heart disease.

METHODS

We recruited 91 patients (65 males and 26 females, mean age 59.2±10.3 years) with heart disease and depressive symptoms (Center for Epidemiological Studies Depression Scale, CES-D ≥ 16) and low fish/fish oil intakes. The Omega-3 Index (EPA+DHA) of erythrocyte membranes (as a percentage of total fatty acids) was assessed by gas chromatography. Depression status was measured by both self-report and clinician-report scales; CES-D and the Hamilton depression scale (HAM-D). Angina symptoms were measured using the Seattle Angina Questionnaire and the Canadian Cardiovascular Society Classification for Angina Pectoris.

RESULTS

The mean Omega-3 Index was 4.8±1.0% (±SD). Depression scores measured by CES-D and HAM-D were 29.2±8.8 (moderate to severe) and 11.0±5.7 (mild) (arbitrary units) respectively reflecting a different perception of depressive symptoms between patients and clinicians. Angina status was inversely associated with depression scores (r>-0.26, P<0.03). There were no significant relationships between individual LCn3PUFA or the Omega-3 Index and either the depression scores or the angina symptoms.

CONCLUSION

Worse angina status was associated with worse depression, but the Omega-3 Index was not associated with symptoms of depression or angina in patients with heart disease.

Impact of incomplete revascularization of coronary artery disease on long-term cardiac outcomes. Retrospective comparison of angiographic and myocardial perfusion imaging criteria for completeness

BACKGROUND

Coronary revascularization in patients with coronary artery disease may be guided by coronary angiography (CA) or alternatively by ischemia on stress myocardial perfusion imaging (MPI). Which strategy leads to optimal cardiac outcomes is uncertain.

METHODS

We performed a retrospective analysis of 170 patients with MPI ischemia and percutaneous coronary intervention. The primary endpoint was all-cause mortality at a mean follow-up of 47 ± 21 months; the secondary end point was the composite of deaths, nonfatal myocardial infarction, and repeat coronary revascularization (MACE). The coronary revascularization was defined as complete (CCR) or incomplete (ICR) as judged by CA criteria and by MPI ischemia matched with CA criteria.

RESULTS

Nighty-two patients (54%) had ICR by CA criteria (ICR-CA) and 84 (49%) had ICR by MPI criteria (ICR-MPI). Mortality and MACE were lower in patients with CCR-MPI than with ICR-MPI (P = .048, and P = .025). Survival of patients with CCR-CA and ICR-CA was not different (P = .081). Patients with both ICR-MPI and ICR-CA had the worst survival, whereas patients with CCR-MPI and CCR-CA had the best survival (P = .047). By multivariate analysis, ICR-MPI + ICR-CA was an independent predictor of death (P = .025).

CONCLUSION

Patients with ICR by MPI were at higher risk than those with CCR. Patients with both ICR by MPI and CA were at the highest risk, while patients with CCR by both MPI and CA had the best long-term event-free survival.

Angina Frequency After Acute Myocardial Infarction In Patients Without Obstructive Coronary Artery Disease

BACKGROUND

Myocardial infarction (MI) patients without obstructive coronary artery disease (CAD) are at increased risk for recurrent ischemic events, but angina frequency post-MI has not been described.

METHODS AND RESULTS

Among MI patients who underwent angiography, we assessed angina at baseline, 1, 6, and 12 months using the Seattle Angina Questionnaire (SAQ). A hierarchical repeated measures modified Poisson model assessed the association between the absence of obstructive CAD (defined as epicardial stenoses >70% or left main >50%) and angina. Among 5539 MI patients from 31 US hospitals (mean age 60, 68% male), 6.9% had no angiographic obstructive CAD. More patients without obstructive CAD (vs. obstructive CAD) were female (57% vs 30%), non-white (51% vs 24%) and had NSTEMI (87% vs 51%). In unadjusted analyses, patients without obstructive CAD had less angina prior to MI but more angina and worse health status post-discharge. After adjustment for socio-demographic and clinical factors, the risk of post-MI angina was similar in patients without vs. with obstructive CAD (IRR=0.89, 95% CI 0.77-1.02). Among patients without obstructive CAD, depression and self-reported avoidance of care due to cost were independently associated with angina (IRR=1.28 per 5 points on PHQ, 95% CI 1.17-1.41; IRR=1.34, 95% 1.02-1.1.74).

CONCLUSIONS

Following MI, patients without obstructive CAD experience an angina burden at least as high as those with obstructive CAD, affecting 1 in 4 patients at 12 months. As these patients are not candidates for revascularization, other anti-anginal strategies are needed to improve their health status and quality of life.

Angina and mental stress-induced myocardial ischemia

OBJECTIVE

Mental stress-induced myocardial ischemia is a common phenomenon in patients with coronary artery disease (CAD) and an emerging prognostic factor. Mental stress ischemia is correlated with ambulatory ischemia. However, whether it is related to angina symptoms during daily life has not been examined.

METHODS

We assessed angina frequency (past month) in 98 post-myocardial infarction (MI) subjects (age 18-60 years) using the Seattle Angina Questionnaire. Patients underwent [(99m)Tc]sestamibi SPECT perfusion imaging at rest, after mental stress, and after exercise/pharmacological stress. Summed scores of perfusion abnormalities were obtained by observer-independent software. A summed difference score (SDS), the difference between stress and rest scores, was used to quantify myocardial ischemia under both stress conditions.

RESULTS

The mean age was 50 years, 50% were female and 60% were non-white. After adjustment for age, sex, smoking, CAD severity, depressive, anger, and anxiety symptoms, each 1-point increase in mental stress-SDS was associated with 1.73-unit increase in the angina frequency score (95% CI: 0.09-3.37) and 17% higher odds of being in a higher angina frequency category (OR: 1.17, 95% CI: 1.00-1.38). Depressive symptoms were associated with 12% higher odds of being in a higher angina frequency category (OR: 1.12, 95% CI: 1.03-1.21). In contrast, exercise/pharmacological stress-induced SDS was not associated with angina frequency.

CONCLUSION

Among young and middle-aged post-MI patients, myocardial ischemia induced by mental stress in the lab, but not by exercise/pharmacological stress, is associated with higher frequency of retrospectively reported angina during the day. Psychosocial stressors related to mental stress ischemia may be important contributory factor to daily angina.

Angina self-management plan and quality of life, anxiety and depression in post coronary angioplasty patients

Background:

Coronary artery diseases are the most frequent cause of mortality in industrialized countries as well as Iran. Coronary artery disease affects patient’s quality of life (QoL) and produces some degrees of anxiety and depression. Although self-management programs have shown significant impact on chronic diseases, there is limited evidence in Iran regarding the effectiveness of these interventions, particularly in patients with coronary artery disease.

Objectives:

This study aimed to evaluate the effects of angina plan on QoL, anxiety, and depression in post coronary angioplasty patients referred to selected hospitals in Shiraz.

Patients and Methods:

This parallel randomized, controlled trial was conducted in selected hospitals in Shiraz, Iran. We enrolled 80 post coronary angioplasty eligible patients in the study. After acquisition of the informed consent, eligible patients were randomly divided into two groups: control and experimental. Pretest data were obtained by using a demographic data form and two valid and reliable questionnaires for QoL, anxiety, and depression. Blood pressure, weight, and height (to calculate body mass index) were measured too. Patient’s history of smoking, diabetes, hypercholesterolemia, hypertension, and coronary vascular involvement (with grade and severity) were obtained from their medical records. A 12-week angina plan intervention consisted of a 30 to 40 minutes of counseling interview and telephone follow up at the end of 1, 4, 8, and 12 weeks were performed for experimental group. Post-test data were obtained three months after the pretest using the same questionnaires as pretest. QoL data were analyzed by analysis of co-variance (ANCOVA). The results (before and after intervention) regarding anxiety and depression were analyzed by independent t-tests or their equivalent nonparametric Mann-Whitney test using SPSS v. 11.5.

Results:

There was no statistically significant difference in demographic variables between two groups. Baseline mean scores for QoL, anxiety, and depression did not differ between the two groups. There was a significant difference between the experimental and control groups in terms of changes in perception of QoL before and after the intervention. Adjusted mean ± SD of perception of QoL for the control group was 38.48 ± 13.38 and for the experimental one was 56.30 ± 13.38, with a P value of less than 0.001. The mean difference of anxiety scores (before and after intervention) in experimental and control groups were 1.15 ± 1.99 and­.0.07 ± 2.22, respectively with a P value of less than 0.01. The mean difference of depression scores (before and after intervention) in experimental and control groups were 0.4 ± 2.89 and 0.13 ± 2.76, respectively (P > 0.05).

Conclusions:

Our results show that the self-management angina plan was effective in improving perception of QoL and reducing anxiety. Further studies with a larger sample size and a longer follow-up period are recommended to better understand the effectiveness of this plan.

Frequency of angina pectoris and secondary events in patients with stable coronary heart disease (from the Heart and Soul Study)

The extent to which angina pectoris (AP) predicts secondary cardiovascular events beyond independent of measures of disease severity is unknown. We evaluated the association between AP frequency and secondary events in patients with stable coronary heart disease (CHD). We administered the Seattle Angina Questionnaire to 1,023 participants with stable CHD enrolled from September 2000 to December 2002 and followed for a median of 8.9 years. We used Cox proportional hazards to evaluate the association of AP frequency with death and subsequent hospitalization for AP, revascularization, myocardial infarction (MI), or heart failure. At enrollment, 633 (62%) participants reported no AP, 279 (27%) reported monthly AP, and 111 (11%) reported daily or weekly AP. During follow-up, 396 participants died, 204 were hospitalized for AP, 194 for revascularization, 140 for MI, and 188 for heart failure. Compared with participants without AP, participants with daily or weekly AP were more likely to be hospitalized for AP (hazard ratio [HR] 3.3; 95% confidence interval [CI] 2.3 to 4.7; p<0.001), revascularization (HR 2.0; 95% CI 1.3 to 2.9; p=0.001), or heart failure (HR 1.6; 95% CI 1.0 to 2.5; p=0.03) and more likely to die (HR 1.5; 95% CI 1.1 to 2.0; p=0.01). AP was not independently associated with MI (HR 1.3; 95% CI 0.8 to 2.3; p=0.29). After adjusting for demographics, co-morbidities, treadmill exercise capacity, ejection fraction, and inducible ischemia, frequency of AP remained independently associated with hospitalization for AP (HR 2.4; 95% CI 1.6 to 3.6; p<0.001), revascularization (HR 1.7; 95% CI 1.1 to 2.7; p=0.02), and death (HR 1.4; 95% CI 1.0 to 2.0; p=0.045). In conclusion, in outpatients with stable CHD, AP frequency predicts higher rates of secondary cardiovascular events and death, independent of objective measures of disease severity.

Illness perceptions, mood and quality of life: a systematic review of coronary heart disease patients

OBJECTIVE

To examine published literature investigating the relationship between illness perceptions, mood and quality of life (QoL) in coronary heart disease (CHD) populations.

METHODS

Key databases were systematically searched (CINAHL, Medline, PsycINFO, Scopus and Web of Science) for studies matching the inclusion criteria between November 2011 and February 2012. References of included studies were examined and key authors contacted. Studies were subject to a quality control check.

RESULTS

21 studies met the inclusion criteria. A synthesis of the results found that illness perceptions were correlated to and predicted QoL and mood across CHD diagnoses. Specific illness perceptions (control, coherence and timeline) were found to be important for patients that had experienced an unexpected medical event, such as myocardial infarction.

CONCLUSION

The results of this study provide support that illness perceptions are related to outcomes across CHD populations and disease progression, however the results do not selectively support one particular model. Recommendations are consistent with cardiac rehabilitation guidelines. Further research should focus on the systemic impact of illness perceptions.

A social-cognitive sexual counseling intervention post-MI-development and pilot testing

PURPOSE

Individuals experiencing myocardial infarction (MI) report anxiety, depression, diminished quality of life (QOL), and reduced sexual activity.

DESIGN AND METHODS

We examined return to sexual activity post-MI, and pilot tested a comprehensive sexual counseling intervention based on social-cognitive theory. The intervention in this pretest/posttest preexperimental study used an informational video, newsletters, and telephone counseling, with cardiac patients (N = 10) and partners (N = 3). Measures included QOL; knowledge; sexual anxiety, depression, self-efficacy, and satisfaction.

FINDINGS

At 8 weeks, only 60% had returned to sexual activity, with low QOL and sexual satisfaction for patients and partners.

PRACTICE IMPLICATIONS

Supportive interventions by nurses are needed to assist MI patients and partners return to sexual activity.

Psychological and physiological predictors of angina during exercise-induced ischemia in patients with coronary artery disease

OBJECTIVE

This study compares sensory-biological, cognitive-emotional, and cognitive-interpretational factors in predicting angina on an exercise treadmill test (ETT).

METHODS

A total of 163 patients with ETT-induced ischemia and coronary artery disease in the National Heart, Lung, and Blood Institute Psychophysiological Investigations of Myocardial Ischemia study were given an ETT, during which 79 patients reported angina. We assessed the following as potential predictors of self-reported anginal pain: sensory-biological factors (β-endorphin reactivity, hot pain threshold, and maximal ST-segment depression), cognitive-emotional factors (negative affect and symptom perception), and cognitive-interpretational factors (self-reported history of exercise-induced angina). Models were covariate adjusted with predictors examined individually and as part of component blocks.

RESULTS

Logistic regression revealed that history of angina (odds ratio [OR] = 17.41, 95% confidence interval = 7.16-42.34) and negative affect (OR = 1.65, 95% confidence interval = 1.17-2.34), but not maximal ST-segment depression, hot pain threshold, β-endorphin reactivity, or symptom perception, were significant predictors of angina on the ETT. The sensory-biological block was not significantly predictive of anginal pain (χ(2)block = 5.15, p = .741). However, the cognitive-emotional block (χ(2)block = 11.19, p = .004) and history of angina (cognitive-interpretation; χ(2)block = 54.87, p < .001) were predictive of ETT angina. A model including all variables revealed that only history of angina was predictive of ETT pain (OR = 16.39, p < .001), although negative affect approached significance (OR = 1.45, p = .07).

CONCLUSIONS

In patients with ischemia, cognitive-emotional and cognitive-interpretational factors are important predictors of exercise angina.

Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery

The present study examined the association between patient-reported anxiety and postcardiac surgery mortality and major morbidity. Frailty Assessment Before Cardiac Surgery was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals from 2008 to 2009. The patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale, a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was a high level of anxiety, defined by a Hospital Anxiety and Depression Scale score of ≥ 11. The main outcome measure was all-cause mortality or major morbidity (e.g., stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression analysis examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for the Society of Thoracic Surgeons predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the Hospital Anxiety and Depression Scale. High levels of preoperative anxiety were present in 7% of patients. No differences were found in the type of surgery and Society of Thoracic Surgeons predicted risk across the preoperative levels of anxiety. After adjusting for potential confounders, high preoperative anxiety was remained independently predictive of postoperative mortality or major morbidity (odds ratio 5.1, 95% confidence interval 1.3 to 20.2; p = 0.02). In conclusion, although high levels of anxiety were present in few patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.

Perceived stress in myocardial infarction: long-term mortality and health status outcomes

OBJECTIVES

This study sought to determine the association of chronic stress with long-term adverse outcomes after acute myocardial infarction (AMI).

BACKGROUND

Chronic stress has been shown to be associated with the development of cardiovascular disease and, in the case of particular types of stress such as job and marital strain, with recurrent adverse events after AMI. Little is known, however, about the association of chronic stress with mortality and adverse health status outcomes in a general AMI population.

METHODS

In a cohort of 4,204 AMI patients from 24 U.S. hospitals completing the Perceived Stress Scale-4 (sum scores ranging from 0 to 16) during hospitalization, moderate/high stress over the previous month was defined as scores in the top 2 quintiles (scores of 6 to 16). Detailed data on sociodemographics, psychosocial status, and clinical characteristics were collected at baseline. Outcomes included patients' 1-year health status, assessed with the Seattle Angina Questionnaire, Short Form-12, and EuroQol Visual Analog Scale, and 2-year mortality.

RESULTS

AMI patients with moderate/high stress had increased 2-year mortality compared with those having low levels of stress (12.9% vs. 8.6%; p < 0.001). This association persisted after adjusting for sociodemographics, clinical factors (including depressive symptoms), revascularization status, and GRACE (Global Registry of Acute Coronary Events) discharge risk scores (hazard ratio: 1.42: 95% confidence interval: 1.15 to 1.76). Furthermore, moderate/high stress was independently associated with poor 1-year health status, including a greater likelihood of angina, worse disease-specific and generic health status, and worse perceived health (p < 0.01 for all).

CONCLUSIONS

Moderate/high perceived stress at the time of an AMI is associated with adverse long-term outcomes, even after adjustment for important confounding factors. Future studies need to examine whether stress mediates observed racial and socioeconomic disparities and whether novel interventions targeting chronic stress and coping skills can improve post-AMI outcomes.

Spiritual activation in very elderly individuals assessed as heart rate variability and plasma IL/10/IL-6 ratios

Proinflammatory cytokine responses might occur in elderly individuals with cardiovascular (CV) disease, cerebro-vascular (CVA) disease, and/or pulmonary disease (PD). Spiritual activation is an important coping mechanism, since psychiatric depression is an important risk factor for these individuals. Thirty-three very elderly individuals (87 ± 8 years) with previous CVD, CVA and/or PD participated in weekly 30 minute sermons by chaplains for over 20 months of chaplain liturgy (CL group). All underwent Holter ECG during the procedures and cardiac autonomic activities were assessed by maximum entropy analysis. Plasma IL-10 and IL-6 levels were compared with 26 age-matched (85 ± 10 years) individuals who did not participate in these activities (non-CL group). Both high frequency (HF) and pNN50 of heart rate variability (HRV) were higher in the CL group than in the non-CL group (HF, 190 ± 55 versus 92 ± 43 nu, P < 0.05; pNN50, 10.5 ± 16% versus 3.6 ± 3.8%, P < 0.05), whereas LF/HF was lower (1.4 ± 1.5 versus 2.2 ± 2.8, P < 0.05). Levels of IL-10/IL-6 were higher in the CL group (3.96 ± 5.0 versus 1.79 ± 1.6, P < 0.05). Hospitalization rates due to CVD and/or PD were lower in the CL group than in the non-CL group (4/33 versus 11/26, P < 0.05). We conclude that spiritual activation can modify proinflammatory cytokines and suppress CVD, CVA and/or PD via vagal modifications. Spiritual activation might be helpful for health in these very elderly individuals.

Symptom clusters and health-related quality of life in people with chronic stable angina

AIM

This paper reports findings of a study to examine the independent contribution of chest pain, fatigue and dyspnoea to health-related quality of life in people with chronic stable angina.

BACKGROUND

People with chronic stable angina experience poorer quality of life in multiple areas including physical and emotional health. Emerging evidence suggests the presence of concomitant symptoms yet there are no systematic studies examining the impact of symptom clusters on quality of life in people with chronic angina.

METHOD

Outpatients (n = 134), recruited over a 16-month period in 2000 and 2001, with confirmed coronary heart disease and chronic angina completed reliable and valid questionnaires measuring chest pain frequency, fatigue, dyspnoea and quality of life. The data have contemporary relevance because despite changes in treatment of coronary heart disease, chronic angina remains prevalent worldwide. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue and dyspnoea in predicting quality of life.

RESULTS

The sample was predominantly white (74·6%), men (59·7%) with a mean age of 63·4 (sd 12·12) years. Controlling for age, gender, social status and co-morbidities, the symptom cluster of chest pain frequency, dyspnoea and fatigue accounted for a statistically significant increase in unadjusted R² (F of Δ, P < 0·05) for the models predicting physical limitation (R² Δ 24·1%), disease perception (R² Δ 24·6%), Short Form-36 Physical Component Score (R² Δ 24·3%) and Mental Component Score (R² Δ 07·0%).

CONCLUSION

Symptom assessment and management of people with chronic stable angina should involve multiple symptoms. Greater fatigue predicted poorer quality of life in multiple areas. As a possible indicator of depression, it warrants further assessment and follow-up.

Impact and clinical management of depression in patients with coronary artery disease

The rates of major adverse coronary events, including recurrent ischemic events and death, in patients with coronary artery disease (CAD) have been shown to be significantly increased in patients with depression. In addition, health care costs are higher and health-related quality of life is lower in depressed patients with CAD. Several pathophysiologic mechanisms have been proposed for the association of increased events seen in this population. Studies have focused on antidepressants (specifically, selective serotonin reuptake inhibitors and mirtazapine), psychotherapy (cognitive behavioral therapy and interpersonal psychotherapy), and a wide range of other nonpharmacologic interventions. Pharmacologic and nonpharmacologic treatments are known to improve depressive symptoms in patients with CAD, but their effects on outcomes such as mortality and hospital admissions remain controversial. If treatment of depression is warranted, strategies should include sertraline or citalopram, with or without cognitive behavioral therapy, based on the known efficacy and safety of the drugs in this population. Nonpharmacologic therapy such as aerobic exercise has been shown to improve not only depression but also cardiovascular health. When selecting an appropriate antidepressant, clinicians should consider their patients' comorbid conditions and the potential for drug interactions, and treatment should be frequently monitored. Screening for depression in patients with cardiac disease should be instituted on a routine basis by using either case-finding or symptom-triggered approaches. Based on the high prevalence of depression and its known adverse effects in patients with CAD, future research is needed to help determine the role of antidepressants and nonpharmacologic strategies in improving outcomes in patients with both comorbidities.