Underutilization of Evidence-Based Smoking Cessation Support Strategies Despite High Smoking Addiction Burden in Peripheral Artery Disease Specialty Care: Insights from the International PORTRAIT Registry

Background

Smoking is the most important risk factor for peripheral artery disease (PAD). Smoking cessation is key in PAD management. We aimed to examine smoking rates and smoking cessation interventions offered to patients with PAD consulting a vascular specialty clinic; and assess changes in smoking behavior over the year following initial visit.

Methods and Results

A total of 1272 patients with PAD and new or worsening claudication were enrolled at 16 vascular specialty clinics (2011–2015, PORTRAIT (Patient‐Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry). Interviews collected smoking status and cessation interventions at baseline, 3, 6, and 12 months. Among smokers, transition state models analyzed smoking transitions at each time point and identified factors associated with quitting and relapse. On presentation, 474 (37.3%) patients were active, 660 (51.9%) former, and 138 (10.8%) never smokers. Among active smokers, only 16% were referred to cessation counseling and 11% were prescribed pharmacologic treatment. At 3 months, the probability of quitting smoking was 21%; among those continuing to smoke at 3 months, the probability of quitting during the next 9 months varied between 11% and 12% (P<0.001). The probability of relapse among initial quitters was 36%. At 12 months, 72% of all smokers continued to smoke.

Conclusions

More than one third of patients with claudication consulting a PAD provider are active smokers and few received evidence‐based cessation interventions. Patients appear to be most likely to quit early in their treatment course, but many quickly relapse and 72% of all patients smoking at baseline are still smoking at 12 months. Better strategies are needed to provide continuous cessation support.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01419080.

Centralized Communication of Blood Culture Results Leveraging Antimicrobial Stewardship and Rapid Diagnostics

Objective

This study aimed to determine if integrating antimicrobial stewardship program (ASP) personnel with rapid diagnostic testing resulted in improved outcomes for patients with positive blood cultures.

Method

Beginning in 2016, Saint Luke’s Health System (SLHS) implemented a new process where all positive blood cultures were communicated to ASP personnel or SLHS pharmacy staff. Pharmacists then became responsible for interpreting results, assessing patient specific information, and subsequently relaying culture and treatment information to providers. This was a multisite, pre-post, quasi-experimental study (Pre: August to December 2014; Post: August to December 2016). Patients 18 years of age and older with a positive blood culture during admission were included (2014, n = 218; 2016, n = 286). Coprimary outcomes of time to optimal and appropriate therapy were determined from time of culture positivity via gram stain. Secondary outcomes focused on clinical, process, and fiscal endpoints. A pre-post intervention physician survey was conducted to assess the impact on antimicrobial decision making and perceived effect on patient outcomes.

Results

There was no difference in time to appropriate therapy groups (P = .079). Time to optimal therapy was 9.2 hours shorter in 2016 (P = .004). Provider surveys indicated the process improved communication among clinicians and facilitated a shared decision-making process with a perceived improvement in patient care.

Conclusions

An ASP-led blood culture communication process for patients with positive blood cultures was shown to improve time to optimal therapy, support physicians in their decision making on critical lab data, and improve the care for hospitalized patients.

Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking?

Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20-1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization.

Validation of the Seattle angina questionnaire in women with ischemic heart disease

BACKGROUND

Although the Seattle Angina Questionnaire (SAQ) has been widely used to assess disease-specific health status in patients with ischemic heart disease, it was originally developed in a predominantly male population and its validity in women has been questioned.

METHODS

Using data from 8892 men and 4013 women across 2 multicenter trials and 5 registries, we assessed the construct validity, test-retest reliability, responsiveness to clinical change, and predictive validity of the SAQ Summary Score (SS) and its 5 subdomains (Physical Limitation (PL), Anginal Stability (AS), Angina Frequency (AF), Treatment Satisfaction (TS), and Quality of Life (QoL)) separately in men and women.

RESULTS

Comparable correlations of the SAQ SS with Canadian Cardiovascular Society class was demonstrated in both men and women (-0.48 for men, -0.46 for women). Similar correlations between the SAQ PL scale with treadmill exercise duration and Short Form-12 (SF-12) Physical Component Summary were observed in women and men (0.34-0.63 and 0.40-0.63, respectively). SAQ AS scores were significantly lower for both men and women with acute syndromes compared with 1 month later. The SAQ AF scale was strongly correlated with daily angina diaries (0.62 for men and 0.66 for women). The SAQ QoL scores were moderately correlated with the EQ5D visual analog scale and SF-12 general health question in men (0.43-0.50) and women (0.33-0.39). All SAQ scales demonstrated excellent reliability (intraclass correlation ≥0.78) in both men and women with stable CAD and were very sensitive to change after percutaneous coronary intervention (≥15-point difference in scores, standardized response mean ≥ 0.67). The SAQ SS was similarly predictive of 1-year mortality and cardiac re-hospitalizations for both men and women.

CONCLUSION

The SAQ demonstrates similar psychometric properties in men and women with CAD. These findings provide evidence for validity of the SAQ in assessing women with IHD.

Preinfarct Health Status and the Use of Early Invasive Versus Ischemia-Guided Management in Non-ST-Elevation Acute Coronary Syndrome

Early invasive management improves outcomes in non-ST-elevation myocardial infarction (NSTEMI). The association between preinfarct health status and the selecting patients for early invasive management is unknown. The Prospective Registry Evaluating outcomes after Myocardial Infarctions: Events and Recovery and Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status are consecutive US multicenter registries, in which the associations between preinfarct angina frequency and quality of life (both assessed by the Seattle Angina Questionnaire on admission) and the Global Registry of Acute Coronary Events (GRACE) risk score and referral to early invasive management (coronary angiography within 48 hours) were evaluated using Poisson regression, after adjusting for site, demographics, and clinical and psychosocial variables. Of 3,768 patients with NSTEMI, 2,182 (57.9%) patients were referred for early invasive treatment. Patients with excellent, good, or very good baseline angina-specific quality of life, respectively, were more likely to receive early angiography, even after adjustment, as compared with patients reporting poor baseline quality of life because of angina (62.1.0%, 60.9%, 59.6%, vs 51.2%; adjusted relative risk [RR] = 1.09, 95% confidence interval [CI] 1.04 to 1.16; RR = 1.13, 95% CI 1.01 to 1.27; RR 1.14, 95% CI 0.99 to 1.31, respectively). Finally, patients with a GRACE score in the highest risk decile (199.5 to <321.4) had significantly lower rates of early invasive treatment (42.7%) than patients in the lowest decile of risk (67.6%; adjusted RR for continuous GRACE score per SD [1 SD = 40 points], 0.96, 95% CI 0.92 to 0.99, p = 0.019). In conclusion, in this real-world NSTEMI cohort, patients with the highest mortality risk and worst health status were less likely to be referred for early invasive management. Further work is needed to understand the role of preinfarct health status and in-hospital treatment strategy.

Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study

BACKGROUND

Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI.

METHODS

We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction.

RESULTS

One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women.

CONCLUSIONS

Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Noncardiac chest pain after acute myocardial infarction: Frequency and association with health status outcomes

BACKGROUND

The frequency of noncardiac chest pain (CP) hospitalization after acute myocardial infarction (AMI) is unknown, and its significance from patients' perspectives is not studied.

OBJECTIVES

To assess the frequency of noncardiac CP admissions after AMI and its association with patients' self-reported health status.

METHODS

We identified cardiac and noncardiac CP hospitalizations in the year after AMI from the 24-center TRIUMPH registry. Hierarchical repeated-measures regression was used to identify the association of these hospitalizations with patients' self-reported health status using the Seattle Angina Questionnaire Quality of Life domain (SAQ QoL) and Short Form 12 (SF-12) physical (PCS) and mental (MCS) component summary scores.

RESULTS

Of 3,099 patients, 318 (10.3%) were hospitalized with CP, of whom 92 (28.9%) were hospitalized for noncardiac CP. Compared with patients not hospitalized with CP, noncardiac CP hospitalization was associated with poorer health status (SAQ QoL-adjusted differences: -8.9 points [95% CI -12.1 to -5.6]; SF-12 PCS: -2.5 points [95% CI -4.2 to -0.8] and SF-12 MCS: -3.5 points [95% CI -5.1 to -1.9]). The SAQ QoL for patients hospitalized with noncardiac CP was similar to patients hospitalized with cardiac CP (adjusted difference: 0.6 points [95% CI -3.2 to 4.5]; SF-12 PCS (0.9 points [95% CI -1.1 to 2.9]), but was worse with regard to SF-12 MCS (adjusted difference: -2.0 points [95% CI -3.9 to -0.2]).

CONCLUSIONS

Noncardiac CP accounted for a third of CP hospitalizations within 1 year of AMI and was associated with similar disease-specific QoL as well as general physical and mental health status impairment compared with cardiac CP hospitalization.

Depression Treatment and 1-Year Mortality After Acute Myocardial Infarction: Insights From the TRIUMPH Registry (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status)

BACKGROUND

Depression among patients with acute myocardial infarction (AMI) is prevalent and associated with an adverse quality of life and prognosis. Despite recommendations from some national organizations to screen for depression, it is unclear whether treatment of depression in patients with AMI is associated with better outcomes. We aimed to determine whether the prognosis of patients with treated versus untreated depression differs.

METHODS

The TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) is an observational multicenter cohort study that enrolled 4062 patients aged ≥18 years with AMI between April 11, 2005, and December 31, 2008, from 24 US hospitals. Research coordinators administered the Patient Health Questionnaire-9 (PHQ-9) during the index AMI admission. Depression was defined by a PHQ-9 score of ≥10. Depression was categorized as treated if there was documentation of a discharge diagnosis, medication prescribed for depression, or referral for counseling, and as untreated if none of these 3 criteria was documented in the medical records despite a PHQ score ≥10. One-year mortality was compared between patients with AMI having: (1) no depression (PHQ-9<10; reference); (2) treated depression; and (3) untreated depression adjusting for demographics, AMI severity, and clinical factors.

RESULTS

Overall, 759 (18.7%) patients met PHQ-9 criteria for depression and 231 (30.4%) were treated. In comparison with 3303 patients without depression, the 231 patients with treated depression had 1-year mortality rates that were not different (6.1% versus 6.7%; adjusted hazard ratio, 1.12; 95% confidence interval, 0.63-1.99). In contrast, the 528 patients with untreated depression had higher 1-year mortality in comparison with patients without depression (10.8% versus 6.1%; adjusted hazard ratio, 1.91; 95% confidence interval, 1.39-2.62).

CONCLUSIONS

Although depression in patients with AMI is associated with increased long-term mortality, this association may be confined to patients with untreated depression.

Beyond restenosis: Patients' preference for drug eluting or bare metal stents

OBJECTIVES

To assess patients' perspective about factors associated with stent choice.

BACKGROUND

Drug eluting stents (DES) markedly reduce the risk of repeat percutaneous coronary intervention (PCI), but necessitate a longer duration of dual anti-platelet therapy (DAPT) as compared with bare metal stents (BMS). Thus, understanding patients' perspective about factors associated with stent choice is paramount.

METHODS

Patients undergoing angiography rated, on a 10-point scale, the importance (1 = not important, 10 = most important) of avoiding repeat revascularization and avoiding the following potential DAPT drawbacks: bleeding/bruising, more pills/day, medication costs and delaying elective surgery. The factor, or group of factors, that was rated highest by each patient was identified.

RESULTS

Among 311 patients, repeat revascularization was the single most important consideration to 14.4% of patients, while 20.6% considered avoiding one of the DAPT drawbacks as most important. Most patients (65%) considered avoiding at least one DAPT drawback as important as avoiding repeat revascularization. In no subgroup of patients did more than a quarter of patients prefer avoiding repeat revascularization above all other concerns. Among patients undergoing PCI, more than three quarters received a DES, regardless of their stated preferences (DES use among those most valuing DES benefits, avoiding DAPT drawbacks, or both equally were 78.7%, 86.2%, and 85.6%, respectively, P = 0.56).

CONCLUSION

Most patients reported that avoiding DAPT drawbacks was as important as avoiding repeat revascularization. Eliciting patient preferences regarding stent type can enhance shared decision-making and allow physicians to better tailor stent choice to patients' goals and values.

TRIAL REGISTRATION

Developing and Testing a Personalized Evidence-based Shared Decision-making Tool for Stent Selection (DECIDE-PCI). ClinicalTrials.gov Identifier: NCT02046902. URL: https://clinicaltrials.gov/ct2/show/NCT02046902 © 2017 Wiley Periodicals, Inc.

Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction

Importance

Cardiac rehabilitation (CR) improves survival after acute myocardial infarction (AMI), and referral to CR has been introduced as a performance measure of high-quality care. The association of participation in CR with patients' health status (eg, quality of life, symptoms, and functional status) is poorly defined.

Objective

To examine the association of participation in CR with health status outcomes after AMI.

Design, Setting, and Participants

A retrospective cohort study was conducted of patients enrolled in 2 AMI registries: PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008. The analytic cohort was restricted to 4929 patients with data available on baseline health status, 6- or 12- month follow-up health status, and participation in CR. Data analysis was performed from 2014 to 2015.

Exposures

Participation in at least 1 CR session within 6 months of hospital discharge.

Main Outcomes and Measures

Patient health status was quantified using the Seattle Angina Questionnaire (SAQ) and the 12-Item Short-Form Health Survey (SF-12). The primary outcomes of interest were the mean differences in SAQ domain scores during the 12 months after AMI between patients who did and did not participate in CR. Secondary outcomes were the mean differences in the SF-12 summary scores and all-cause mortality.

Results

After successfully matching the cohorts of the 4929 patients (3328 men and 1601 women; mean [SD] age, 60.0 [12.2] years) for the propensity to participate in CR and comparing the groups using linear, mixed-effects models, mean differences in the SAQ and SF-12 domain scores were similar at 6 and 12 months between the 2012 patients participating in CR (3 were unable to be matched) and the 2894 who did not participate (20 were unable to be matched). At 6 months, the mean difference was -0.76 (95% CI, -2.05 to 0.52) for the SAQ quality of life score, -1.53 (95% CI, -2.57 to -0.49) for the SAQ angina frequency score, 0.38 (95% CI, -0.51 to 1.27) for the SAQ treatment satisfaction score, -0.42 (95% CI, -1.65 to 0.79) for the SAQ physical limitation score, 0.50 (95% CI, -0.22 to 1.22) for the SF-12 physical component score, and 0.13 (95% CI, -0.53 to 0.79) for the SF-12 mental component score. At 12 months, the mean difference was -0.89 (95% CI, -2.20 to 0.43) for the SAQ quality of life score, -1.05 (95% CI, -2.12 to 0.02) for the SAQ angina frequency score, 0.38 (95% CI, -0.54 to 1.29) for the SAQ treatment satisfaction score, -0.14 (95% CI, -1.41 to 1.14) for the SAQ physical limitation score, 0.17 (95% CI, -0.57 to 0.92) for the SF-12 physical component score, and 0.12 (95% CI, -0.56 to 0.80) for the SF-12 mental component score. In contrast, the hazard rate of all-cause mortality (up to 7 years) associated with participating in CR was 0.59 (95% CI, 0.46-0.75).

Conclusions and Relevance

In a cohort of 4929 patients with AMI, we found that those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit. These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR.

Association of Smoking Status With Angina and Health-Related Quality of Life After Acute Myocardial Infarction

BACKGROUND

Smoking cessation after acute myocardial infarction (AMI) decreases the risk of recurrent AMI and mortality by 30% to 50%, but many patients continue to smoke. The association of smoking with angina and health-related quality of life (HRQOL) after AMI is unclear.

METHODS AND RESULTS

Patients in 2 US multicenter AMI registries (n=4003) were assessed for smoking and HRQOL at admission and 1, 6, and 12 months after AMI. Angina and HRQOL were measured with the Seattle Angina Questionnaire and Short Form-12 Physical and Mental Component Scales. At admission, 29% never had smoked, 34% were former smokers (quit before AMI), and 37% were active smokers, of whom 46% quit by 1 year (recent quitters). In hierarchical, multivariable, regression models that adjusted for sociodemographic, clinical and treatment factors, never and former smokers had similar and the best HRQOL in all domains. Recent quitters had intermediate HRQOL levels, with angina and Short Form-12 Mental Component Scale scores similar to never smokers. Persistent smokers had worse HRQOL in all domains compared with never smokers and worse Short Form-12 Mental Component Scale scores than recent quitters.

CONCLUSIONS

Smoking after AMI is associated with more angina and worse HRQOL in all domains, whereas smokers who quit after AMI have similar angina levels and mental health as never smokers. These observations may help encourage patients to stop smoking after AMI.

The Association Between Complementary and Alternative Medicine and Health Status Following Acute Myocardial Infarction

BACKGROUND

Complementary and alternative medicines (CAM) are commonly used in patients with cardiovascular disease. Although there is lack of evidence regarding the benefit of CAM on cardiovascular morbidity and mortality, health-status benefits could justify CAM use.

HYPOTHESIS

Adoption of mind-body CAM after acute myocardial infarction (AMI) is associated with improved health status, though other forms of CAM are not associated with health-status improvement.

METHODS

Patients with AMI from 24 US sites were assessed for CAM use (categorized as mind-body, biological, and manipulative therapies) prior to and 1 year after AMI. Among patients who reported not using CAM prior to their AMI, association of initiating CAM on patients' health status at 1 year after AMI was assessed using Angina Frequency and Quality of Life domains from the Seattle Angina Questionnaire and the Short Form-12 Physical and Mental Component scales. Multivariable regression helped examine association between use of different CAM therapies and health status.

RESULTS

Among 1884 patients not using CAM at the time of their AMI, 33% reported initiating ≥1 forms of CAM therapy 1 year following AMI: 62% adopted mind-body therapies, 42% adopted biological therapies, and 15% began using manipulative therapies. In both unadjusted and adjusted analyses, we found no association between different types of CAM use and health-status improvement after AMI.

CONCLUSIONS

There was no association between CAM use and health-status recovery after AMI. Until randomized trials suggest otherwise, these findings underscore the importance of focusing on therapies with proven effectiveness after AMI.

Association of smoking status with health-related outcomes after percutaneous coronary intervention

BACKGROUND

Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. We sought to compare the health status outcomes of those who did and did not quit smoking after PCI with those who were not smoking before PCI.

METHODS AND RESULTS

A cohort of 2765 PCI patients from 10 US centers were categorized into never, past (smoked in the past but had quit before PCI), quitters (smoked at time of PCI but then quit), and persistent smokers. Health status was measured with the disease-specific Seattle Angina Questionnaire and the EuroQol 5 dimensions, adjusted for baseline characteristics. In unadjusted analyses, persistent smokers had worse disease-specific and overall health status when compared with other groups. In fully adjusted analyses, persistent smokers showed significantly worse health-related quality of life when compared with never smokers. Importantly, of those who smoked at the time of PCI, quitters had significantly better adjusted Seattle Angina Questionnaire angina frequency scores (mean difference, 2.73; 95% confidence interval, 0.13-5.33) and trends toward higher disease specific (Seattle Angina Questionnaire quality of life mean difference, 1.97; 95% confidence interval, -1.24 to 5.18), and overall (EuroQol 5 dimension visual analog scale scores mean difference, 2.45; 95% confidence interval, -0.58 to 5.49) quality of life when compared with persistent smokers at 12 months.

CONCLUSIONS

Smokers at the time of PCI have worse health status at 1 year than those who never smoked, whereas smokers who quit after PCI have less angina at 1 year than those who continue smoking.

Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

OBJECTIVES

To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers.

DESIGN

Cross sectional study.

SETTING

10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011.

PARTICIPANTS

991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention.

MAIN OUTCOME MEASURES

Patients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios.

RESULTS

The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site.

CONCLUSION

Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

Abstract 332: Association of Body Mass Index with Health Status Outcomes in Patients Undergoing Percutaneous Coronary Intervention

Background: An obesity paradox, with better long-term survival in obese patients undergoing percutaneous coronary intervention (PCI), has been well described. The association between obesity and health status outcomes after PCI is unknown.

Methods: We prospectively enrolled 3,281 PCI patients in a 10-center observational cohort study and categorized their body mass index (BMI) into normal (18.5 to <25), overweight (25 to <30), obese (30 to <35) and morbidly obese (≥ 35).Generalized linear models were used to describe the association between BMI and health status measures at 6 & 12 months, after adjusting for baseline characteristics and health status scores. Health status outcomes included; Seattle Angina Questionnaire [SAQ] Angina Frequency (AF), and Quality of Life (QL) scores, as well as the EQ-5D visual analogue scale (EQ-5D VAS). Interaction with time was not significant, so an estimate of the average benefit over time was generated.

Results: The distribution of patients’ BMI revealed that 17% were normal, 35% overweight, 28% obese and 20% morbidly obese. Compared with normal weight patients, morbidly obese individuals were younger (mean 60.8 yr vs. 67.9 yr) and had a higher prevalence of diabetes, hypertension and heart failure. They underwent radial artery access (12.0% vs. 7.0%) and drug eluting stent implantation (80.4% vs. 76.0%) more frequently. Unadjusted changes in scores were lower (worse) among morbidly obese as compared with normal weight patients for SAQ AF (mean difference [MD] -1.52; 95% Confidence Interval [CI] -3.05, -0.02), SAQ QL (MD -2.51; CI -4.48, -0.54), and EQ-5D VAS (MD -5.74;CI -7.52, -3.96). After adjustment, these differences were no longer significantly different for SAQ AF and SAQ QL (figure), although EQ-5D VAS scores remained lower among obese and morbidly obese patients.

Conclusion: The overall health status was mildly worse among obese and morbidly obese individuals after PCI, but the benefits of PCI on patients’ disease-specific health status were similar across weight categories. This suggests that PCI is equally effective in improving angina and disease-specific quality of life, independent of patients’ weight.

Abstract 27: Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction

Background: Cardiac rehabilitation (CR) is a class Ia recommendation and endorsed performance measure for the quality of care in acute myocardial infarction (AMI) survivors. While participation in CR after AMI is associated with reduced mortality, conflicting data exists on its association with health status outcomes.

Methods: Using data from 2 prospective AMI registries (TRIUMPH and PREMIER), we identified patients for whom baseline and follow-up health status scores and documentation of CR participation (attendance of 1 or more sessions within 6 months post-AMI) were available. Health status was assessed by four Seattle Angina Questionnaire (SAQ) domain scores (quality of life [QoL], angina frequency [AF], treatment satisfaction [TS], and physical limitation [PL]), as well as SF-12 physical and mental health composite scores ( PCS & MCS ). We created propensity matched cohorts of CR participants and non-participants to examine the association between CR participation with health status (6 and 12 months) and all-cause mortality (up to 7 years), using conditional repeated measures and proportional hazards models, respectively.

Results: Among 3,957 AMI patients from 31 sites, 2,015 patients (51%) participated in CR after discharge. Compared to non-participants, CR participants were more often Caucasian (83.6% vs. 65.4%), had higher rates of health insurance (90.6% vs. 79.3%), but clinically similar baseline SAQ and SF-12 scores in all domains. After propensity matching, all covariates were well-balanced (Standardized Difference <10 for all patient characteristics) between CR participants and non-participants. In the repeated measures analysis, the mean SAQ and SF-12 domain scores were clinically similar for both groups at 6 and 12 months after hospital discharge (Table). Using a conditional proportional hazards model, a decrease in all-cause mortality was noted in the CR participant group (HR 0.59, 95% CI [0.46, 0.75]).

Conclusion: In a large, multi-center AMI cohort, we found that although CR participation seemed to improve survival, CR participants had similar health status improvements after AMI as non-participants. Further investigation is required to identify how CR programs can further maximize the health status benefits to post-AMI participants.

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.

Abstract 202: Insulin Resistance as an Independent Predictor of Atherosclerosis Burden in Nondiabetic Patients with Acute Myocardial Infarction

Introduction: Experimental evidence suggests that insulin resistance (IR) is a major risk factor for accelerated atherosclerosis through indirect effects on systemic risk factors and direct effects on insulin signaling in vascular endothelium and plaque macrophages.

Hypothesis: IR in persons without diabetes mellitus is associated with multi-vessel coronary artery disease (CAD) in acute myocardial infarction (AMI) patients.

Methods: We examined 1111 non-diabetic AMI patients (HbA1c ≤ 6.5) enrolled in the multicenter TRIUMPH (years 2004-2008) registry. IR was estimated using the homeostasis model assessment of IR (HOMA-IR: fasting insulin (mU/l) x fasting blood glucose (mmol/l)]/22.5). The primary outcome was the extent of angiographic atherosclerosis (≤1-vessel vs. multi-vessel disease). Modified Poisson regression models were used to examine the association between IR and multi-vessel CAD.

Results: Subjects were divided into quartiles based on HOMA-IR values (quartile 1: male <=1.35, female <=1.26; quartile 4: male >4.00, female >3.64). After adjusting for age, sex, hypertension, smoking, family history of CAD, LDL, HDL, and body mass index (BMI), IR was independently associated with multi-vessel CAD (Figure). As compared to the lowest quartile of IR, the highest quartile had more multi-vessel CAD [RR (95% CI)- 1.35 (1.11-1.64)].

Conclusion: In a large cohort of non-diabetic AMI patients, IR was associated with more advanced, multi-vessel CAD, independent of lipid levels and other components of the metabolic syndrome. This association is consistent with established experimental evidence and supports IR as a potential target for preventing atherosclerosis.

Adherence to risk factor management instructions after acute myocardial infarction: the role of emotional support and depressive symptoms

BACKGROUND

Emotional support and depression may influence adherence to risk factor management instructions after acute myocardial infarction (AMI), but their role requires further investigation.

PURPOSE

To examine the longitudinal association between perceived emotional support and risk factor management adherence and assess depressive symptoms as a moderator of this association.

METHODS

Among 2,202 AMI patients, we assessed adherence to risk factor management instructions over the first recovery year. Modified Poisson mixed-effects regression evaluated associations, with adjustment for demographic and clinical factors.

RESULTS

Patients with low baseline support had greater risk of poor adherence over the first year than patients with high baseline support (relative risk [RR] = 1.20, 95% confidence interval [CI] = 1.02-1.43). In stratified analyses, low support remained a significant predictor of poor adherence for non-depressed (RR = 1.41, 95% CI = 1.23-1.61) but not depressed (RR = 1.01, 95% CI = 0.78-1.30) patients (p for interaction < 0.001).

CONCLUSIONS

Low emotional support is associated with poor risk factor management adherence after AMI. This relationship is moderated by depression, with a significant relationship observed only among non-depressed patients.

Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH): design and rationale of a prospective multicenter registry

BACKGROUND

Black patients with myocardial infarction (MI) have worse outcomes than white patients, including higher mortality rates, more angina, and worse quality of life. The Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study was designed to examine whether racial differences in socioeconomic, clinical, genetic, metabolic, biomarker, or treatment characteristics mediate observed disparities in outcomes.

METHODS AND RESULTS

Between April 11, 2005, and December 31, 2008, 31 567 patients with MI were prospectively screened; 6152 had an eligible MI, and 4340 (71%) were enrolled from 24 US centers. Consenting patients had detailed chart abstractions of their medical history and processes of inpatient care, supplemented with a detailed baseline interview. Detailed genetic and metabolic data were obtained at hospital discharge in 2979 (69%) and 3013 patients (69%), respectively. In a subset of patients, blood and urine samples were obtained at 1 month (obtained in 27% of survivors) and blood samples at 6 months (obtained in 19% of survivors). Centralized follow-up interviews sought to quantify patients' postdischarge care and outcomes, with a focus on their health status (symptoms, function, and quality of life). At 1, 6, and 12 months, 23%, 27%, and 24%, respectively, were lost to follow-up. Vital status was available for 99% of patients at 12 months.

CONCLUSIONS

TRIUMPH is a novel MI registry with detailed information on patients' sociodemographic, clinical, treatment, health status, metabolic, and genetic characteristics. The wealth of patient data collected in TRIUMPH will provide unique opportunities to examine factors that may mediate racial differences in mortality and health status after MI and the complex interactions between genetic and environmental determinants of post-MI outcomes.

Abstract 6: What Fundamental Factors Underlie Measures of Socio-Economic Status?

Background: Numerous studies have examined socio-economic (SES) disparities in cardiovascular outcomes. However, these studies often use different metrics to quantify SES (e.g. zip code, income, education, questionnaires). Consequently, the field suffers from the lack of a unifying conceptual model through which these different assessment techniques can be integrated. We sought to explore what fundamental factors may be present in a number of SES items collected within an MI registry.

Methods: In the 19-center PREMIER registry of 2481 post-MI patients, we collected data on 9 items measuring different aspects of patients' SES and used exploratory factor analysis to identify underlying constructs measured by these items.

Results: Two factors emerged (see figure), “general SES” (GSES) and “healthcare-related SES” (HSES), which explained 63% of the variability among the 9 items. Four items loaded on GSES, 6 loaded on HSES and one (end-of-month financial reserves) was shared by both factors. Although wide in range, all loadings were very strong and highly significant. There was a strong correlation between the 2 factors (r = .49).

Conclusion: SES is primarily comprised of 2 distinct factors and different modes of assessing SES are variably associated with these constructs. The commonly used SES measures of zip code median income and insurance status had some of the weakest associations with these factors. Future work is needed to validate these factors, to correlate these with outcomes, and to define the most efficient method for measuring these factors so that researchers can more consistently explore SES disparities in outcomes and develop interventions to overcome them.

Abstract P206: Changes in Social Support Within the Early Recovery Period and Outcomes After Acute Myocardial Infarction

Background: Baseline social support is associated with outcomes after AMI. However, little is known about changes in social support during the early AMI recovery period and whether changes influence outcomes over the first year.

Methods: Using data from 1951 AMI patients enrolled in the 19-center PREMIER study, we longitudinally examined whether changes in social support between baseline (index hospitalization) and 1 month post-AMI were associated with health status and depressive symptom outcomes. Using 5 items from the ENRICHD Social Support Inventory, we categorized patients into low (score <=18) and high (score >18) support and examined changes between these categories during the first month of recovery. Health status and depressive symptoms were assessed at baseline, 6, and 12 months using the Seattle Angina Questionnaire (SAQ), Short Form-12 (SF-12), and the Patient Health Questionnaire-9 (PHQ-9). Associations were evaluated using hierarchical repeated-measures regression, adjusting for site, baseline health status, depressive symptoms, and other sociodemographic and clinical factors.

Results: During the first month of recovery, 5.6% of patients had persistently low support, 6.4% had worsened support, 8.1% had improved support, and 80.0% had persistently high support. In risk-adjusted analyses, patients with persistently low or worsened support (versus those with persistently high support) had greater risk of angina, worse SAQ quality of life (QOL), worse SF-12 mental component summary (MCS), and more PHQ-9 depressive symptoms ( table ). Patients with improved support had outcomes consistent with those of patients with persistently high support ( table ). Similarly, patients with worsened support had outcomes comparable to patients with persistently low support (p>0.50 for all comparisons).

Conclusion: Changes in social support within the early recovery period are not uncommon and are important for predicting patient-centered outcomes.

Outcome Social Support Status at 1 Month Persistently Low Worsened Improved Persistently High SAQ Angina * 1.39 (1.09, 1.78) 1.46 (1.08, 1.97) 1.13 (0.89, 1.43) reference SAQ QoL † -7.63 (-10.96, -4.30) -7.44 (-10.54, -4.34) -0.85 (-3.49, 1.80) reference SF-12 PCS † -0.14 (-2.20, 1.91) -0.20 (-2.14, 1.73) -0.44 (-2.07, 1.18) reference SF-12 MCS † -5.63 (-7.33, -3.92) -4.82 (-6.42, -3.22) -1.54 (-2.88, -0.20) reference PHQ-9 † 2.29 (1.51, 3.06) 1.94 (1.22, 2.66) 0.81 (0.19, 1.43) reference *

Abstract P70: Social Network Characteristics Are Associated With Long Term Outcomes After Myocardial Infarction

Background: Lack of social support is associated with worse outcomes after myocardial infarction (MI). Social support is a complex concept that includes the quality of perceived support and the size and quality of one's social network. It is not known if having a geographically close social network affects outcomes post-MI. We hypothesized that patients with a greater number of close network contacts would have better post-MI outcomes.

Methods: From contacts listed by subjects in TRIUMPH, a prospective registry of MI patients from 24 US centers, we characterized social network size (number of contacts listed) and closeness (number of nuclear family contacts and number of contacts residing in the same area code). We assessed univariate relationships between these indices and outcomes (mortality and health status by the EQ-5D Visual Analogue Scale [VAS], an overall assessment of patients' quality of life), and scores from the ENRICHD Social Support Instrument (ESSI). We created multivariable Cox proportional hazards and linear regression models with mortality and VAS as dependent variables and with demographic, clinical, treatment and social support measures as independent variables.

Results: Of 4340 subjects enrolled, 472 died over a median of 28.6 months. Mean 12-month VAS score was 75.4 ± 21.1. Having no same area code contacts (19.3% vs. 15.9%) (p=0.025 for trend), no nuclear family contacts (40.9% vs. 33.8%) (p=0.010 for trend), and living alone (33.0% vs. 23.6%, p<0.001) were associated with higher mortality on univariate analysis; total number of contacts and ESSI tertile were not. Univariate relationships with VAS were similar. In a multivariable model, age, prior stroke, diabetes, kidney disease, ejection fraction <40%, and living alone were significantly associated with mortality. In the multivariable VAS model, fewer area code contacts was additionally significant (p=0.023 for trend across number of contacts). Subjects with no area code contacts had a VAS score 3.2 ± 2.0 points lower than those with 4 near contacts.

Conclusions: Geographic closeness of patients' social networks is weakly associated with outcomes after MI. Further investigation is warranted before proposing interventions designed to compensate for low network-based support.

Abstract P26: Depression Recognition and Disease-Specific Health Status in AMI Patients: Insights from the TRIUMPH Registry

Background: Recognizing depression in acute myocardial infarction (AMI) offers an opportunity to treat this burdensome comorbidity, and could improve the risk stratification of AMI patients. Whether depression recognition is associated with health status after AMI is unknown.

Methods: In the 24-center prospective TRIUMPH study, 4062 patients completed the Patient Health Questionnaire-9 (PHQ-9) during their index AMI admission and the Seattle Angina Questionnaire (SAQ) for quality of life (QOL) and angina frequency during the index admission and at 1-year. Patients were defined as depressed based on a PHQ-9 score ≥10, and depression was defined as recognized if the treating team documented any of the following in the patients' chart: depression diagnosis at discharge; anti-depressant medications administered at discharge; or referral for counseling. We examined the association between depression recognition and impaired quality of life (SAQ QOL score <75) and angina (SAQ angina frequency score <100) at 1 year using multivariable Poisson regression analyses adjusted for demographics, AMI severity, risk factors, and baseline quality of life, or angina frequency, as appropriate.

Results: Of 4062 patients, 3303 (81.3%) were not depressed, 528 (13.0%) had unrecognized depression, and 231 (5.7%) had recognized depression. Patients with unrecognized depression were just as likely to have increased risk of 1-year adverse QOL and angina, as compared to patients with recognized depression. (Table)

Conclusion: Depression in AMI is a comorbidity that is frequently missed in routine care. Regardless of being recognized, however, depression is associated with adverse 1-year AMI-specific health status. Although depression recognition has the potential to identify patients at risk of persistent angina and poorer QOL that might benefit from more aggressive treatment of their coronary disease, recognition in itself will not be sufficient to optimize their outcomes.

Abstract P124: Perceived Stress in Acute Myocardial Infarction: Associations with Long-Term Health Status Outcomes

Background: Chronic stress is associated with adverse prognosis in cardiovascular disease, but little is known about its link with health status. We studied the association between chronic stress and health status following acute myocardial infarction (AMI).

Methods: In the 24 center US TRIUMPH registry, 4204 AMI patients completed the Perceived Stress Scale-4 (scores range 0-16) during hospitalization. Moderate/high stress over the prior month was defined as scores in the top 2 quintiles (scores=6-16). Patients were assessed at 1 year for disease-specific health status with the Seattle Angina Questionnaire (SAQ) and for generic health status with a Visual Analog Scale (VAS) and the SF-12. Multivariable logistic regression evaluated the independent association between moderate/high stress and poor health status (defined as SAQ angina frequency <100; SAQ physical limitations <75; SAQ QOL <75; VAS <65; SF-12 physical <35; and SF-12 mental <45).

Results: After extensive adjustment for demographic, socio-economic and clinical characteristics (including depressive symptoms), AMI patients with moderate/high stress had a greater likelihood of angina and poor disease-specific and generic health status (Figure; p<0.01 for all).

Conclusion: Moderate/high stress at the time of an AMI is associated with poor post-AMI health status, even after adjustment for important confounders. Future studies need to examine whether stress mediates observed racial and socio-economic disparities, and whether novel interventions targeting chronic stress can improve post-AMI health status.

Abstract P73: Social Support and Adherence to Cardiac Risk Factor Management Instructions during the First Year after Acute Myocardial Infarction

Background: Adherence to risk factor management (RFM) instructions after AMI can promote recovery. The prognostic importance of social support for adherence is not well understood. We examined the relationship between baseline social support and post-AMI RFM adherence, and tested whether depression moderates this association.

Methods: Using data from 2202 AMI patients enrolled in the 19-site PREMIER study, we longitudinally examined whether low baseline social support (index hospitalization; score <=18 on 5 items from ENRICHD Social Support Inventory) is associated with poor adherence to 13 RFM instructions (medication adherence, warfarin use, follow-up plan/appointments, whom to call, cholesterol monitoring and therapy, diabetes management, weight monitoring and loss, smoking cessation, diet, exercise, cardiac rehabilitation) within the first year of recovery. Patients were asked at 1, 6, and 12 months if they received any of the RFM instructions since their last interview. Poor adherence was defined a priori as adhering “very carefully” to less than 50% of the patient-appropriate instructions. Hierarchical repeated-measures Poisson regression evaluated the association between support and adherence, with adjustment for site, sociodemographics, clinical history and presentation, hospital and outpatient care, and depression. Whether depression (PHQ-9 score >=10) modified the association was evaluated by stratifying the risk-adjusted model by depression status and including a support*depression interaction term.

Results: Patients with low social support had greater unadjusted risk of poor adherence than patients with high social support (RR 1.46, 95% CI 1.27-1.67). This association did not vary with time and remained significant after full risk adjustment (RR 1.24, 95% CI 1.05-1.47). In depression-stratified analyses, the risk-adjusted association of low support with poor adherence was significant among nondepressed (RR 1.44, 95% CI 1.26-1.66) but not depressed (RR 1.03, 95% CI 0.79-1.33) patients (p<0.001 for support*depression interaction).

Conclusion: Good social support may improve adherence among nondepressed AMI patients, but more research is needed to understand the role of social support among depressed patients.

Abstract P212: How Much Do Psychosocial Factors Mediate the Association Between Socioeconomic Status and 1-Year Angina After Myocardial Infarction?

Background: Low socioeconomic status (SES) is associated with worse cardiovascular (CV) outcomes. The Reserve Capacity Model (RCM) is a published, but not yet fully tested, framework linking SES, psychosocial factors and health outcomes. “Reserve capacity” is one's inter-/intrapersonal resources for managing stress. We tested the RCM to determine what portion of the association between SES and angina frequency 1 year post-MI is attributable to psychosocial factors.

Methods: In 2481 post-MI patients enrolled in the 19-center PREMIER registry, we used confirmatory factor analysis to create latent variables of health-related SES and reserve capacity (including social support, optimism, and internal health locus of control). Structural equation modeling was used to test the associations between baseline SES, 1-month psychosocial factors (perceived stress, reserve capacity, and depressive symptoms) and 1-yr angina, adjusting for age, sex, and baseline angina.

Results: The overall correlation between SES and 1-yr angina was significant (r = -.21*). Of this, 37% was explained by psychosocial factors. (See figure.) Higher SES was associated with greater reserve capacity (r = .43*), which was strongly and inversely associated with stress (r = -.68*) and depressive symptoms (r = -.36*). Depressive symptoms were directly associated with angina (r = .12*). (*p < .05)

Conclusion: These results validate the RCM, showing that perceived stress, reserve capacity, and depressive symptoms partially mediate the link between SES and 1-yr angina post-MI. This identifies possible areas for intervention to reduce SES-related disparities in angina and potentially other CV outcomes.

The prevalence of chronic pain and pain-related interference in the Canadian population from 1994 to 2008

Introduction

Estimates of the prevalence of chronic pain worldwide and in Canada are inconsistent. Our primary objectives were to determine the prevalence of chronic pain by sex and age and to determine the prevalence of pain-related interference for Canadian men and women between 1994 and 2008.

Methods

Using data from seven cross-sectional cycles in the National Population Health Survey and the Canadian Community Health Survey, we defined two categorical outcomes, chronic pain and pain-related interference with activities.

Results

Prevalence of chronic pain ranged from 15.1% in 1996/97 to 18.9% in 1994/95. Chronic pain was most prevalent among women (range: 16.5% to 21.5%), and in the oldest (65 years plus) age group (range: 23.9% to 31.3%). Women aged 65 years plus consistently reported the highest prevalence of chronic pain (range: 26.0% to 34.2%). The majority of adult Canadians who reported chronic pain also reported at least a few activities prevented due to this pain (range: 11.4% to 13.3% of the overall population).

Conclusion

Similar to international estimates, this Canadian population-based study confirms that chronic pain persists and impacts daily activities. Further study with more detailed definitions of pain and pain-related interference is warranted.

The prevalence of chronic pain and pain-related interference in the Canadian population from 1994 to 2008

INTRODUCTION

Estimates of the prevalence of chronic pain worldwide and in Canada are inconsistent. Our primary objectives were to determine the prevalence of chronic pain by sex and age and to determine the prevalence of pain-related interference for Canadian men and women between 1994 and 2008.

METHODS

Using data from seven cross-sectional cycles in the National Population Health Survey and the Canadian Community Health Survey, we defined two categorical outcomes, chronic pain and pain-related interference with activities.

RESULTS

Prevalence of chronic pain ranged from 15.1% in 1996/97 to 18.9% in 1994/95. Chronic pain was most prevalent among women (range: 16.5% to 21.5%), and in the oldest (65 years plus) age group (range: 23.9% to 31.3%). Women aged 65 years plus consistently reported the highest prevalence of chronic pain (range: 26.0% to 34.2%). The majority of adult Canadians who reported chronic pain also reported at least a few activities prevented due to this pain (range: 11.4% to 13.3% of the overall population).

CONCLUSION

Similar to international estimates, this Canadian population-based study confirms that chronic pain persists and impacts daily activities. Further study with more detailed definitions of pain and pain-related interference is warranted.

Real-world lessons from the implementation of a depression screening protocol in acute myocardial infarction patients: implications for the American Heart Association depression screening advisory

BACKGROUND

The American Heart Association (AHA) statement has recommended routine screening for depression in coronary artery disease with a 2-stage implementation of the Patient Health Questionnaire (PHQ). Because there is little evidence on feasibility, accuracy, and impact of such a program on depression recognition in coronary patients, the AHA recommendation has met substantial debate and criticism.

METHODS AND RESULTS

Before the AHA statement was released, the Mid America Heart and Vascular Institute (MAHVI) had implemented a depression screening protocol for patients with acute myocardial infarction that was virtually identical to the AHA recommendations. To (1) evaluate this MAHVI quality improvement initiative, (2) compare MAHVI depression recognition rates with those of other hospitals, and (3) examine health care providers' implementation feedback, we compared the results of the MAHVI screening program with data from a parallel prospective acute myocardial infarction registry and interviewed MAHVI providers. Depressive symptoms (PHQ-2, PHQ-9) were assessed among 503 MAHVI acute myocardial infarction patients and compared with concurrent depression assessments among 3533 patients at 23 US centers without a screening protocol. A qualitative summary of providers' suggestions for improvement was also generated. A total of 135 (26.8%) eligible MAHVI patients did not get screened. Among screened patients, 90.9% depressed (PHQ-9 ≥10) patients were recognized. The agreement between the screening and registry data using the full PHQ-9 was 61.5% for positive cases (PHQ-9 ≥10) but only 35.6% for the PHQ-2 alone. Although MAHVI had a slightly higher overall depression recognition rate (38.3%) than other centers not using a depression screening protocol (31.5%), the difference was not statistically significant (P=0.31). Staff feedback suggested that a single-stage screening protocol with continuous feedback could improve compliance.

CONCLUSIONS

In this early effort to implement a depression screening protocol, a large proportion of patients did not get screened, and only a modest impact on depression recognition rates was realized. Simplifying the protocol by using the PHQ-9 alone and providing more support and feedback may improve the rates of depression detection and treatment.

Comparison of outcomes among moderate alcohol drinkers before acute myocardial infarction to effect of continued versus discontinuing alcohol intake after the infarct

Light-to-moderate alcohol consumption has been previously associated with a lower risk of acute myocardial infarction (AMI) and mortality. The association of changes in drinking behavior after an AMI with health status and long-term outcomes is unknown. Using a prospective cohort of patients with AMI evaluated with the World Health Organization's Alcohol Use Disorders Identification Test, we investigated changes in drinking patterns in 325 patients who reported moderate drinking at the time of their AMI. One-year alcohol consumption, disease-specific (angina pectoris and quality of life) and general (mental and physical) health status and rehospitalization outcomes, and 3-year mortality were assessed. Seattle Angina Questionnaire Angina Frequency and Quality of Life, Short Form-12 Mental and Physical Component Summary Scales were modeled using multivariable hierarchical linear models within site. Of the initial 325 moderate drinkers at baseline, 273 (84%) remained drinking and 52 (16%) quit. In fully adjusted models, Physical Component Scale scores (beta 6.47, 95% confidence interval 3.73 to 9.21, p <0.01) were significantly higher during follow-up in those who remained drinking. Persistent moderate drinkers had a trend toward less angina (relative risk 0.65, 95% confidence interval 0.39 to 1.10, p = 0.11), fewer rehospitalizations (hazard ratio 0.79, 95% confidence interval 0.44 to 1.41, p = 0.42), lower 3-year mortality (relative risk 0.75, 95% confidence interval 0.23 to 2.51, p = 0.64), and better disease-specific quality of life (Seattle Angina Questionnaire Quality of Life, beta 3.88, 95% confidence interval -0.79 to 8.55, p = 0.10) and mental health (Mental Component Scale, beta 0.83, 95% confidence interval -1.62 to 3.27, p = 0.51) than quitters. In conclusion, these data suggest that there are no adverse effects for moderate drinkers to continue consuming alcohol and that they may have better physical functioning compared to those who quit drinking after an AMI.

The role of social support in health status and depressive symptoms after acute myocardial infarction: evidence for a stronger relationship among women

BACKGROUND

Prior studies have associated low social support (SS) with increased rehospitalization and mortality after acute myocardial infarction. However, relatively little is known about whether similar patterns exist for other outcomes, such as health status and depressive symptoms, and whether these patterns vary by sex.

METHODS AND RESULTS

Using data from 2411 English- or Spanish-speaking patients with acute myocardial infarction enrolled in a 19-center prospective study, we examined the association of SS (low, moderate, high) with health status (angina, disease-specific quality of life, general physical and mental functioning) and depressive symptoms over the first year of recovery. Overall and sex-stratified associations were evaluated using mixed-effects Poisson and linear regression, adjusting for site, baseline health status, baseline depressive symptoms, and demographic and clinical factors. Patients with the lowest SS (relative to those with the highest) had increased risk of angina (relative risk, 1.27; 95% confidence interval [CI], 1.10, 1.48); lower disease-specific quality of life (mean difference [beta]=-3.33; 95% CI, -5.25, -1.41), lower mental functioning (beta=-1.72; 95% CI, -2.65, -0.79), and more depressive symptoms (beta=0.94; 95% CI, 0.51, 1.38). A nonsignificant trend toward lower physical functioning (beta=-0.87; 95% CI, -1.95, 0.20) was observed. In sex-stratified analyses, the relationship between SS and outcomes was stronger for women than for men, with a significant SS-by-sex interaction for disease-specific quality of life, physical functioning, and depressive symptoms (all P<0.02).

CONCLUSIONS

Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.

The association of cognitive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction

BACKGROUND

Among patients with acute myocardial infarction (AMI), depression is both common and underrecognized. The association of different manifestations of depression, somatic and cognitive, with depression recognition and long-term prognosis is poorly understood.

METHODS AND RESULTS

Depression was confirmed in 481 AMI patients enrolled from 21 sites during their index hospitalization with a Patient Health Questionnaire (PHQ-9) score > or =10. Within the PHQ-9, separate somatic and cognitive symptom scores were derived, and the independent association between these domains and the clinical recognition of depression, as documented in the medical records, was evaluated. In a separate multisite AMI registry of 2347 patients, the association between somatic and cognitive depressive symptoms and 4-year all-cause mortality and 1-year all-cause rehospitalization was evaluated. Depression was clinically recognized in 29% (n=140) of patients. Cognitive depressive symptoms (relative risk per SD increase, 1.14; 95% CI, 1.03 to 1.26; P=0.01) were independently associated with depression recognition, whereas the association for somatic symptoms and recognition (relative risk, 1.04; 95% CI, 0.87 to 1.26; P=0.66) was not significant. However, unadjusted Cox regression analyses found that only somatic depressive symptoms were associated with 4-year mortality (hazard ratio [HR] per SD increase, 1.22; 95% CI, 1.08 to 1.39) or 1-year rehospitalization (HR, 1.22; 95% CI, 1.11 to 1.33), whereas cognitive manifestations were not (HR for mortality, 1.01; 95% CI, 0.89 to 1.14; HR for rehospitalization, 1.01; 95% CI, 0.93 to 1.11). After multivariable adjustment, the association between somatic symptoms and rehospitalization persisted (HR, 1.16; 95% CI, 1.06 to 1.27; P=0.01) but was attenuated for mortality (HR, 1.07; 95% CI, 0.94 to 1.21; P=0.30).

CONCLUSIONS

Depression after AMI was recognized in fewer than 1 in 3 patients. Although cognitive symptoms were associated with recognition of depression, somatic symptoms were associated with long-term outcomes. Comprehensive screening and treatment of both somatic and cognitive symptoms may be necessary to optimize depression recognition and treatment in AMI patients.

Predictors of weight change in overweight patients with myocardial infarction

BACKGROUND

Weight loss is recommended among overweight survivors of myocardial infarction (MI). This study describes patterns of weight change among overweight patients with MI and identifies factors associated with weight change.

METHODS

A prospective cohort of 1253 overweight or heavier (body mass index [BMI] > or = 25 kg/m2) post-MI patients were enrolled in the 19-center PREMIER study and followed up for 1 year to determine changes in weight. Patients were categorized at 1 month as overweight (BMI = 25-29.9 kg/m2), obese (BMI = 30-39.9 kg/m2), or morbidly obese (BMI > or = 40 kg/m2). Unadjusted percent weight change was assessed at 1 year, and multivariable linear regression was used to identify independent correlates of change.

RESULTS

Mean weight change was -0.2% and varied by the severity of baseline obesity (+0.4% for overweight patients, -0.5% for obese patients, and -3.7% for morbidly obese patients [P < .001]). Multivariable analyses revealed the following to be significantly associated with weight change: depression 1 month post-MI (+2.7%, P = .001), lack of health insurance (+2%, P = .01), smoking cessation 1 month post-MI (+2.7% vs current smokers, P < .001), morbid obesity (+4.7% vs overweight patients, P < .0001), and increasing age (-0.8% per decade, P = .001). An interaction between smoking cessation and weight class was detected in that overweight patients who quit had a mean increase of 5.3% (95% CI 3.1%-7.4%), whereas no significant change was observed among obese and morbidly obese patients who quit.

CONCLUSIONS

Although post-MI patients had negligible weight loss over 1 year, several sociodemographic, clinical, and lifestyle characteristics were associated with weight change. New, targeted interventions will likely be needed to improve weight management after an MI.

Self-reported use of complementary and alternative medicine in patients with previous acute coronary syndrome

Complementary and alternative medicine (CAM) use is common in patients with cardiovascular disease. Although numerous efforts have sought to understand CAM types and the prevalence of CAM, whether patients preferentially use CAM instead of evidence-based therapies is unknown. Self-reported use of CAM and evidence-based therapies in a prospective registry of hospitalized patients with acute coronary syndrome from March 1, 2001 to October 31, 2002 were examined. Poisson regression models were used to assess whether CAM use was independently associated with lower rates of aspirin, beta-blocker, and statin use in 596 patients with established coronary artery disease (CAD). Overall, CAM use was 19% in patients with CAD. Higher proportions of patients who used CAM were non-Caucasian (31% vs 12%), uninsured (12% vs 7%), economically burdened (58% vs 29%), and had depression (13% vs 6%, p<0.05 for all). Patients who used CAM were more likely to use beta blockers (64% vs 46%, p=0.008) and as likely to use aspirin (73% vs 74%, p=0.90) and statins (71% vs 68%, p=0.76) as non-CAM users. Adjusting for demographic and clinical factors did not change results (CAM users: RR 1.27, 95% confidence interval [CI] 1.01 to 1.60 for using beta blockers, RR 0.97, 95% CI 0.85 to 1.11 for using aspirin, and RR 1.05, 95% CI 0.87 to 1.28 for using statins). In conclusion, although CAM users with established CAD have worse socioeconomic status than nonusers, we found no evidence that they were less compliant with evidence-based therapies.

Suicide: a conceptual model for an avoidable death

Suicide as a premature exit from life is confusing not only for family and friends of the individual who shows suicidal behavior but also for many professionals. This article defines the concept of suicide, clarifies terms associated with suicide, reviews current clinical and research literature on suicide, and proposes a conceptual model that describes suicide as both an event and a process.