The association of depression following percutanous coronary intervention with adverse cardiovascular events: Protocol for a systematic review and meta-analysis

INTRODUCTION

Percutanous coronary intervention (PCI) has been increasingly used for patients suffered from severe coronary artery disease. However, physical trauma and potential adverse events related to the procedure often result in detrimental psychological stress. Accumulating evidences have shown that depression is closely related to coronary artery disease. However, the association of depression following percutanous coronary intervention with adverse cardiovascular events is still unknown.

OBJECTIVE

This review is designed to assess the prognostic association of depression following PCI with adverse cardiac events.

METHODS AND ANALYSIS

The following databases will be searched, PubMed, the EMBASE, CINAHL and Web of Science of English-language publications from inception to 30 October 2018. Cross-referencing from retrieved studies will be conducted additionally, and observational studies were included. Two independent review authors will do the study selection on the basis of the study eligibility criteria. Extracted data will be used for quantitative and qualitative evidence synthesis as well as to assess methodological quality of studies using the Newcastle-Ottawa checklist. The primary objective of this review is adverse cardiac events, presented as a composition of myocardial infarction, repeat coronary revascularization, cardiac readmission, and cardiac death. The accumulated evidence is evaluated and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS AND CONCLUSIONS

This review will explain the association of depression following percutanous coronary intervention with adverse cardiovascular events, and provide physicians with scientific evidence for psychological intervention in patients after PCI.

PROSPERO REGISTRATION NUMBER

CRD42018112486.

A challenge for psychocardiology: Addressing the causes and consequences of patients' perceptions of enduring somatic threat

The enduring somatic threat (EST) model of posttraumatic stress disorder (PTSD) due to life-threatening medical events suggests that PTSD-like symptoms represent patients' sensitization to cues of ongoing threat in the body. In this article, we review research on the prevalence and consequences of such reactions in cardiovascular disease patients, discuss early tests of the EST model, and then report a new test of the EST model in 143 patients enrolled during their first acute coronary syndrome (ACS; i.e., non-ST elevation myocardial infarction or unstable angina-colloquially, "heart attack"). Invasive coronary revascularization procedures are commonly used to reduce secondary ACS risk and may reduce patients' EST, as revascularized patients often report being "cured." We assessed ACS patients' initial threat perceptions during emergency department (ED) evaluation and followed them for 1 month for PTSD symptoms (specific for ACS, by telephone). We compared PTSD symptoms in participants who were revascularized (n = 65), catheterized but not revascularized (n = 35), and medically managed (n = 43). PTSD symptoms were lower for revascularized versus medically managed participants (B = -5.32, 95% confidence interval [-9.77, -0.87]), t(98.19) = -2.37, p = .020. In a multiple regression model adjusted for clinical and psychosocial covariates, the interaction of threat perception in the ED and ACS management group was significant (greater ED threat predicted greater 1-month PTSD symptoms only in medically managed participants). These findings offer further support for the EST model and suggest that psychological interventions to preempt patients' development of EST should be considered in the hospital. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

[Informed consent for patients undergoing surgery for ischemic cardiomyopathy]

The prognosis of patients with ischemic cardiomyopathy after medical treatment remains poor, despite advances in various therapeutic strategies. In addition to the poorer prognosis, they face higher operative risk, and complex, unestablished operative procedures should be addressed when obtaining preoperative informed consent from patients with ischemic cardiomyopathy. Although the established indications for revascularization in patients with ischemic heart failure pertain to those with angina and significant coronary artery disease, the management of patients with ischemic heart failure without angina is a challenge because of the lack of evidence in this population. The possibility of combining myocardial revascularization with surgical ventricular reconstruction (SVR) to reverse left ventricular remodeling or with mitral valve plasty to repair the incompetence of mitral valve coaptation has been examined in many trials, although little difference in the long-term outcomes between the simple revascularization and the combined procedure groups have been observed. The therapeutic guidelines for patients with ischemic cardiomyopathy state that choosing to add SVR and/or mitral surgery to revascularization should be based on a precise, careful evaluation and should be performed only by surgeons with a high level of surgical expertise.

[Evaluation of the clinical, psychological and socio-environmental factors, affecting disability of elderly people undergoing surgical myocardial revascularization]

Factors significant for clinical-and-labor prognosis in elderly patients with ischemic heart disease after surgical myocardial revascularization are considered in the article. The authors demonstrate that for each level of the problem there are their own significant factors. Besides, the most essential correlations between investigated factors are marked out. The results obtained will enable to determine more correctly clinical-and-labor prognosis for patients with ischemic heart disease and develop their efficient rehabilitation programs. It is demonstrated that elderly patients have some features of vital activity restriction which are necessary to take into account while medical social expertise and rehabilitation program development.

[Evaluation of anxiety and depression in the perioperative period in patients subjected to myocardial revascularization]

AIM

The aim of the paper is to define a relationship between the anxiety level and depression intensification, as well as to define the impact of: age, sex, education level and family situation on the anxiety level and depression intensification in the pre- and postoperative period in patients subjected to myocardial revascularisation (CABG).

METHOD

Prospective studies were carried out in a group of 100 patients qualified for the surgical myocardial revascularisation in the planned course. The Polish version of the STAI questionnaire was applied to study anxiety as a state and as a trait. Depression intensification was evaluated with the Beck depression scale.

RESULTS

1. The intensity of depression significantly correlates with anxiety as a state and anxiety as a trait before and after CABG surgery. 2. When assessing anxiety as a state, its negative correlation with male patients and with age before CABG were found. A negative correlation of anxiety as a state with a patient's age was identified after CABG. 3. When assessing anxiety as a trait, its negative correlation with male patients before CABG was found. 4. The intensity of depression correlates significantly and negatively with the educational background of the patient before and after CABG surgery. 5. There is no statistically significant correlation between anxiety, depression and family situation in the perioperative period.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Effect of intense lifestyle modification and cardiac rehabilitation on psychosocial cardiovascular disease risk factors and quality of life

This study examined the effect of the Ornish Program for Reversing Heart Disease and cardiac rehabilitation (CR) on psychosocial risk factors and quality of life in patients with confirmed coronary artery disease. Participants had previously undergone a revascularization procedure. The 84 patients self-selected to participate in the Ornish Program for Reversing Heart Disease (n = 507 28), CR (n = 28), or a control group (n = 28). Twelve psychosocial risk factors and quality of life variables were collected from all three groups at baseline, 3 months, and 6 months. At 3 and 6 months, Ornish group participants demonstrated significant improvements in all 12 outcome measures. The rehabilitation group improved in 7 of the 12, and the control group showed significant improvements in 6 of the variables. Intensive lifestyle modification programs significantly affect psychosocial risk factors and quality of life.

[Myocardial revascularization surgery, depressive symptoms and labeling effect]

INTRODUCTION

The individual awareness of one's own disease, the so called labeling effect, may result in a reduction of one's sense of perceived health. In patients submitted to coronary artery bypass surgery it has been reported that the diagnosis of depression is associated with a higher rate of hospitalization and it's an independent risk factor for cardiac events. The aim of this study was to evaluate the modification of depressive symptoms induced by the information of medical indication for myocardial revascularization surgery.

METHODS

We studied the presence of depressive symptoms, socio-demographic variables, cardiovascular status and therapeutic procedures in two groups of consecutive patients admitted for acute coronary syndrome. In the labeled group the BDI-1 was performed after clinical stabilization and the BDI-2 after the information of myocardial revascularization surgery need. In the control group the BDI-1 was answered after clinical stabilization and the BDI-2 48-72 hours later. The Mann-Whitney test was used to compare the difference of depressive symptoms between the groups.

RESULTS

Distribution by age, marital status and education level was similar between the two groups. The cardiovascular risk profile was alike. The difference between BDI-1 and BDI-2 was significantly higher in the labeled group (4.6-/+4.2 vs 0.8-/+3.2; p=0.005). There were no significant differences between the final diagnosis (unstable angina in the labeled group 50% vs control group 45.5%; AMI without Q wave 30% vs 27.3%; AMI with Q wave 20% vs 27.3%) and in hospital clinical evolution.

CONCLUSION

The individual awareness of the need to coronary bypass surgery was associated with a clinical and statistical significant increase of depressive symptoms. Hence, routine evaluation of depressive symptoms as a part of a preoperative protocol, may allow identification of the patients, who may benefit from therapeutic intervention.

Role of spousal anxiety and depression in patients' psychosocial recovery after a cardiac event

OBJECTIVE

The purposes of this study were to a) compare emotional responses and perception of control of patients and their spouses to myocardial infarction or coronary revascularization; and b) examine the relationship between spouses' emotional distress and patients' emotional distress and psychosocial adjustment to the cardiac event.

METHODS

A total of 417 patient-spouse pairs were recruited after the patient was hospitalized for either acute myocardial infarction or coronary revascularization. We compared emotional responses of patients and spouses. The relationship between spouse anxiety and depression, and patient psychosocial distress was then determined.

RESULTS

Spouses had higher levels of anxiety (p <.001) and depression (p <.001) than did patients, but there were no differences in level of hostility. Patients also expressed higher levels of perceived control than did spouses (p <.001). Spouse anxiety, depression, and perceived control remained correlated with patient psychosocial adjustment to illness, even when patient anxiety and depression were kept constant. Patients' psychosocial adjustment to illness was worse when spouses were more anxious or depressed than patients, and it was best when patients were more anxious or depressed than spouses, whereas psychosocial adjustment to illness was intermediate to these 2 extremes when patient and spouse anxiety and depression levels were similar (p =.001).

CONCLUSION

Spouses often experience greater anxiety and depression and less perceived control than patients themselves. Attention to the psychological distress experienced by spouses of patients who have suffered a cardiac event may improve outcomes in patients.

Impact of different patterns of invasive care on quality of life outcomes in patients with non-ST elevation acute coronary syndrome: results from the GUSTO-IIb Canada-United States substudy

BACKGROUND

Comparing American and Canadian practice patterns and outcomes offers a natural experiment to examine the relative benefits of aggressive versus conservative management of coronary artery disease. In a prospective substudy of the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial, differences in the management of non-ST elevation acute coronary syndrome, and the associated impact on quality of life (QOL) outcomes, were examined in the two countries.

METHODS AND RESULTS

The patient population, selected randomly from the parent trial population, comprised 390 Canadian and 1122 American patients for whom both baseline and one-year data were available. Validated instruments were used to assess QOL, including the Duke Activity Status Index (DASI) and scales from the SF-36 questionnaire. At baseline, American patients had significantly higher cardiac catheterization rates (83% versus 45%), percutaneous coronary intervention rates (39% versus 24%) and coronary bypass surgery rates (19% versus 12%) than did Canadian patients, respectively. However, at one year, Canadian coronary bypass surgery rates were at par with those in the United States (24% versus 26%, respectively). At baseline, the mean DASI score was 24.6 among Canadian patients and 23.4 among American patients (P=0.14). At one year, neither cohort reported any significant change in functional scores and there was no intercountry difference in DASI scores, even after accounting for baseline risk. Canadian patients had significantly worse mental health scores than American patients at baseline (mean score 71.6 versus 75.4, respectively; P=0.02), but by one year, Canadian patients had better scores (mean score 80.1 versus 76.2, respectively; P=0.01). After adjusting for baseline characteristics, Canadian patients continued to report better mental health status scores than did American patients (4 points higher, P<0.01). When asked to rate their health state on a scale from 0 to 100, both cohorts reported similar values at baseline. However, after adjusting for baseline characteristics, American patients' perception of their health state was better than that reported by Canadians (3 points higher, P<0.01).

CONCLUSION

Despite higher rates of invasive procedures in the American cohort, one-year QOL outcomes in the cohort were similar to those in the more conservatively managed Canadian cohort. These results suggest that routine cardiac catheterization and increased procedure use may be associated with diminishing marginal returns with respect to improving QOL outcomes among patients with non-ST elevation acute coronary syndromes.

Physicians' perceptions of the effect of nonclinical factors on coronary revascularization

The main objective of this study was to determine if physicians perceive that extracardiac or nonclinical factors such as patients' financial status, lifestyle, or trust in the physician impact coronary revascularization decisions. A self-administered questionnaire was developed and mailed to a random sample of 1200 family physicians, internists, cardiologists, and cardiothoracic surgeons who were active members of well-respected medical organizations in the United States. Survey questions were rated on a 4- and 5-point Likert scale to determine whether physicians perceive that nonclinical factors impede or facilitate coronary revascularization, respectively. The survey response rate was 70%. Family physicians were most likely to perceive that unhealthy lifestyle (51%), financial barriers (48%), and lack of social support (31%) probably or definitely precluded revascularization. White physicians (52%) were more likely to perceive that distrust in the physician affected revascularization, compared with black (33%), Hispanic (38%) and Asian (40%) physicians. Mean responses regarding how often (1 = rarely to 5 = most of the time) nonclinical factors facilitate revascularization revealed that women and Hispanic physicians were more likely to perceive male patients had easier access to the procedure (mean response, 2.8 for women versus 2.1 for men; 2.8 for Hispanics versus 2.4 for blacks and 2.1 for whites). Physicians perceived that nonclinical factors influence decision making for coronary revascularization. What needs to be further explored is whether such factors affect actual patient outcomes or contribute to disparities in the utilization of cardiac interventions.

The use of cholesterol-lowering medications after coronary revascularization

BACKGROUND

In clinical trials, cholesterol-lowering medications have been proven to decrease mortality and morbidity and are strongly recommended as secondary prevention for patients with established coronary artery disease. Whether physicians and patients follow this recommendation is unknown. Our objective was to determine the rate at which patients fill at least one prescription for cholesterol-lowering medications after coronary revascularization.

METHODS

Using the computerized administrative databases of the Régie de l'assurance maladie du Québec, we identified all elderly patients (older than 65 years) who had a coronary revascularization procedure (percutaneous coronary intervention or coronary artery bypass graft) between Apr. 1, 1995, and Dec. 31, 1997, and who survived until hospital discharge. We also determined the percentage of these patients who filled one or more prescriptions for cholesterol-lowering drug therapy before Dec. 31, 1999, or death, whichever date came first. We used multivariate logistic regression models to examine the independent associations between filling a prescription for a cholesterol-lowering drug, patient characteristics and the type and year of coronary revascularization.

RESULTS

We identified 11 958 elderly patients who had a coronary revascularization between Apr. 1, 1995, and Dec. 31, 1997. During a follow-up period that averaged 3 years, 4443 (37.2%) patients did not fill a prescription for a cholesterol-lowering medication. Patients who were male, of advanced age, who had diabetes or congestive heart failure were less likely to fill a prescription for a cholesterol-lowering medication. Patients whose initial revascularization procedure was coronary artery bypass grafting were also less likely than those who had angioplasty to start cholesterol-lowering medication (relative risk [RR] 0.77, 95% confidence interval [CI] 0.73 - 0.81). Use of cholesterol lowering medications before the revascularization procedure was very strongly associated with future drug use (RR 7.20, 95% CI 6.83-7.58).

INTERPRETATION

In this population-based study of revascularized patients, we observed a substantial underutilization of cholesterol-lowering medications after revascularization. Our observations suggest an important role for continuity of care in the treatment of cardiovascular patients undergoing revascularization procedures.

Quality of life and self-efficacy: gender and diagnoses considerations for management during cardiac rehabilitation

PURPOSE

Outcome measurement research has extended beyond traditional clinical and physiologic parameters to include psychosocial aspects. Accordingly, the purpose of this study was to investigate quality-of-life (QOL) and self-efficacy disparities for gender and diagnoses during participation in cardiac rehabilitation.

METHODS

For this study, 472 patients (114 women and 358 men) were stratified by gender and then again by diagnosis to include surgical revascularization, myocardial infarction, and percutaneous coronary intervention. Measures obtained at baseline and at the end of the study assessed quality of life (QOL-o = total score), including emotional (QOL-e) and limitation (QOL-l) domains; self-efficacy (SE-o = total score), including ambulatory (SE-a) and muscular (SE-m) domains; and caloric expenditure.

RESULTS

Both self-efficacy and QOL were greater at the end of the study across genders (P <.05). The men had greater self-efficacy values for all domains (P <.05). There was a significant gender-time interaction for QOL-e (P <.05) among the women, and for QOL-o, QOL-l, and all self-efficacy domains (P <.05) among the surgical revascularization patients. Percutaneous coronary intervention patients had higher self-efficacy scores throughout. Caloric expenditure was a consistent positive predictor of self-efficacy and QOL-e (P <.05).

CONCLUSIONS

Quality of life and self-efficacy improve during cardiac rehabilitation across gender and diagnoses. Female and revascularized patients present with low QOL and self-efficacy scores initially, but improvements in scores similar to or greater than the men can be expected. Because the self-efficacy scores of percutaneous coronary intervention patients are higher and their physical limitations are less prohibitive, these patients can be progressed more aggressively. Improvements in self-efficacy scores parallel caloric expenditure increases.

Depression predicts revascularization procedures for 5 years after coronary angiography

OBJECTIVE

Depression has been reported to increase cardiac event rates and functional impairment in patients with coronary disease. This article describes the impact of depression on subsequent healthcare utilization for such patients.

METHODS

One hundred ninety-eight health maintenance organization patients with stable coronary disease were interviewed after elective angiography using a structured psychiatric diagnostic scale. Cardiac events, hospitalizations, procedures, and costs were monitored for the next 5 years through automated data. Subjects were classified at the time of angiography by modified DSM-IV criteria into those with major, minor, and no depression.

RESULTS

In univariate analyses, the no depression group (N = 136) was most likely to receive coronary artery bypass grafting (CABG) (61% vs. 36% in the major depression group vs. 27% in the minor depression group, p =.001), and the major depression group (N = 25) was most likely to receive percutaneous transluminal coronary angioplasty (PTCA) (44% vs. 14% in the minor depression group vs. 24% in the no depression group). The minor depression group (N = 37) was least likely to be hospitalized for cardiac reasons during follow-up (54% vs. 80% in the major depression group vs. 80% in the no depression group, p =.005). Five-year rates of myocardial infarction and death did not differ significantly between groups. Proportional hazard models showed that those in the depression groups differed in time from catheterization to CABG (chi2(2) = 11.9, p =.003) and time to PCTA (chi2(2) = 7.74, p =.02) after controlling for relevant covariates. Median regression showed that patients with no depression had higher costs during the first year but tended to have lower costs in years 2 through 5 than patients with minor or major depression.

CONCLUSIONS

Depression status at angiography is associated with the need for revascularization and total healthcare costs for the following year.

[The powerlessness psycho-social response in the postoperative period in cardiac surgery patients]

AIMS

To describe powerlessness on postoperative cardiac surgery patients according to frequency, intensity, defining characteristics and to compare powerlessness between valvular surgery patients (VAL) and coronary artery bypass surgery patients (CAB).

METHODS

Powerlessness was defined through the analyses of interviews of 75 patients (60% VAL and 40% CAB).

RESULTS

58.7% patients presented powerlessness. There were not differences according to powerlessness frequency (p = 0.84) and intensity (p = 0.73) between VAL and CAB patients. The defining characteristics most frequent on powerless patients were: "verbal expressions of having no control or influence over situation" (77.3%), "doubts regarding planning future and stating objectives" (75%), "expressions of doubt regarding role performance" (63.6%), and "expressions of dissatisfaction and frustration over inability to perform previous tasks and/or activities" (56.8%).

Assessing depression in the cardiac patient. When is the appropriate time to assess depression in the patient undergoing coronary revascularization?

Depression is a well-established risk factor for cardiovascular disease-related morbidity and mortality. It is common to screen for depression in patients undergoing coronary revascularization prior to revascularization; however, the validity of this assessment is unclear as some patients may experience transient, reactive depression rather than persistent depression. The authors evaluated whether an initial or 1-month postprocedure screen was optimal for identifying consistently depressed patients. Depression at 1-month postprocedure was a stronger predictor of depression at months 2 to 6 than baseline depression. After adjusting potential confounding variables, there was a much stronger relationship between 1-month and 6-month depression status (OR = 28.7 if depressed at 1 month, p < .001) than between baseline and 6-month depression status (OR = 6.5 if depressed at baseline, p < .001). Screening for depression at the time of revascularization is not as predictive of depression at 6 months as it is 1 month postprocedure.

Coronary bypass surgery in women: a long-term comparative study of quality of life after bilateral internal mammary artery grafting in men and women

BACKGROUND

Coronary bypass surgery carries a higher operative mortality and less favorable long-term clinical benefits for women than men. The impact of arterial revascularization on long-term results, including quality of life (QOL) in women, compared with men, has not been clearly defined.

METHODS

A retrospective analysis was performed comparing 261 consecutive women patients from a single surgical practice receiving bilateral internal mammary artery (IMA) and supplemental vein grafts between January 1972 and October 1994 with a computer-matched cohort of 261 men undergoing bilateral IMA surgery during the same time period. Univariate analysis confirmed the homogeneity of the two groups based on multiple preoperative variables. The SF-36 QOL assessment tool was completed for all patients at follow-up, which ranged from 1 month to 25 years, with a mean follow-up of 9.1 years for women and 8.6 years for men.

RESULTS

There was no significant difference in operative mortality, nor in the incidence of any of 10 postoperative complications evaluated. The actuarial survival at 15 years was 53.7% +/- 4.8% for women and 50.9% +/- 5.6% for men (p = 0.218). At follow-up, 97.0% of women and 94.3% of men were free of angina and in Canadian Cardiovascular Society (CCS) class I or II. The need for reoperation (1.8% vs 1.9%) and PTCA (4.8% vs. 3.2%) was comparable in both groups. However, a higher rate of late myocardial infarction was found in women than men (1.8% vs 0.6, p = 0.021). The long-term event-free survival was found to be no different in men than women (p = 0.084). QOL as measured by the SF-36 was compared with the general population corrected for age and gender. Men and women scored as well or better than the general population in a majority of the eight health scales. Moreover, with regard to the health summary scores, men scored significantly higher (p = 0.001) in physical health, whereas women scored significantly higher (p = 0.011) in mental health when compared with age-adjusted norms.

CONCLUSIONS

Men and women undergoing coronary revascularization using bilateral internal mammary artery conduits experience comparable outcomes, excellent long-term results, and enjoy a QOL comparable to or better than the general population as measured by the SF-36.

[Preoperative expectations and clinical outcome of transmyocardial laser treatment in patients with angina pectoris]

BACKGROUND

The aims of this study were to evaluate the effect of transmyocardial laser treatment on quality of life and to assess the correlation between preoperative expectations and clinical improvement after one year.

MATERIAL AND METHODS

13 patients (median age 56 years) with disabling angina pectoris were subjected to transmyocardial holmium: YAG laser. Quality of life was assessed preoperatively and at three and 12 months by Hospital Anxiety and Depression Scale (HAD), Physical Symptom Distress Index (PSDI) and Life Satisfaction Index (LSI). Expectations were evaluated by Leedham's scale.

RESULTS

A significant improvement in Canadian Cardiovascular Society Score (CCS) from 3.4 +/- 0.5 (mean +/- SD) preoperatively to 1.6 +/- 1.0 and 1.7 +/- 0.8 three and 12 months after treatment was observed (p < 0.01). Quality of life (PSDI and LSI) improved. No significant changes in ejection fraction or exercise performance were found. Preoperative expectations were generally high, but did not correlate significantly with improvements in CCS or quality of life.

INTERPRETATION

Although no changes in objective parameters were found, the lack of significant correlations between preoperative expectation and subjective clinical improvement indicate that the improvement of angina pectoris only partly can be explained by placebo effects.

[Gender perspective can result in better research on sex differences and revascularization]

This article focuses on how sex differences in revascularization, PTCA and CABG, are discussed in medical research. We selected and analyzed 10 articles identified through Medline, for the purpose of studying such discussions. Three explanatory models were identified by qualitative analysis: biological, psychosocial and discriminatory. Although the articles focused on sex differences in revascularization, the discussions in the articles on this issue were sparse. We demonstrate how a gender perspective can generate new questions and theories and contribute to a better prognosis for women and men with heart disease.

Modeling women's quality of life after cardiac events

Quality of life (QOL) is presented as a global, unidimensional, and subjective assessment of one's life. This study examined the impact of perceived health status, hope, and optimism on QOL in 93 women after suffering a cardiac event. Construct validity was examined by estimating a model where QOL was measured with four indicators, and perceived health was measured with the SF-36 Health Survey. Hope was measured with the Herth Hope Index and dispositional optimism was measured with the Life Orientation Test. The unidimensionality of QOL and its response to health status, hope, and optimism were tested. Fit indices suggested that the theoretical relations posited were compatible with the data, (chi 2(42) = 44.125, p = .382, RMSEA = .0001, GFI = .942). The model explained 66% of the variance in QOL. Modeling suggested the presence of a complex latent concept composed of hope and optimism that influenced QOL.

Impact of cardiopulmonary resuscitation training on perceived control in spouses of recovering cardiac patients

The objectives of this study were to determine whether there are differences in emotional distress among spouses of recovering cardiac patients based on level of perceived control, and to determine whether perceived control can be enhanced by cardiopulmonary resuscitation (CPR) training. A total of 219 spouses of cardiac patients recovering from an acute cardiac event were enrolled and 196 completed the study. Spouses were assigned to either a no-treatment control group or one of two CPR training groups. Perceived control and emotional adjustment were measured at baseline and again 1 month after subjects received CPR training. Spouses with high perceived control were less anxious, less depressed, and less hostile at baseline. Perceived control increased significantly in spouses after both CPR training groups, but was unchanged in the control group. After a partner's cardiac event, perceived control is important for psychological recovery in spouses and can be increased by CPR training.

Differences between men and women on the waiting list for coronary revascularization

This study aims to examine the situation for patients on the waiting list for possible coronary revascularization in terms of waiting time, treatment and various aspects of well-being in relation to gender. Patients on the waiting list for coronary angiography, percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in September 1990 were approached with a questionnaire dealing with various aspects as described above. Of the 831 patients who participated in the evaluation, 174 (21%) were women. Although age was similar for men and women, men had a higher prevalence of previous myocardial infarction and a lower prevalence of previous hypertension. In terms of medication, women were more frequently treated with diuretics and sedatives than men. Women reported a higher frequency than men with regard to the following symptoms: chest pain at rest and at night, dyspnoea when walking, tachycardia, tiredness, headache, dizziness and sweating. Women also suffered more frequently from difficulty going to sleep, difficulty waking up, repeated awakening and insomnia. Men, on the other hand, suffered more frequently from restlessness, inability to act and irritability. Among patients on the waiting list for possible coronary revascularization, women differed from men by being more frequently treated with diuretics, reporting a higher frequency of various cardiovascular symptoms including chest pain and dyspnoea and, furthermore, reporting more sleeping disorders. Gender differences were found but they were not consistent.

Quality of life after coronary revascularization in the United States and Canada

Cardiac procedures are performed less frequently in Canada than in the United States (US), yet rates of cardiac death and myocardial infarction are similar. We therefore sought to compare long-term symptoms and quality of life in Canadian and American patients undergoing initial coronary revascularization. The 161 patients enrolled in the Bypass Angioplasty Revascularization Investigation at the Montreal Heart Institute were compared with 934 patients enrolled at 7 US sites. Patients' outcomes were documented for 5 years after random assignment to percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. Functional status was assessed using the Duke Activity Status Index. Canadian patients were significantly younger and had more angina at study entry. Death and nonfatal myocardial infarction were not significantly different between Canadian and US patients after adjustment for baseline risk. Canadian patients had significantly greater improvements in functional status at 1-year follow-up (Duke Activity Status Index score + 13.5 vs. + 6.0, p = 0.002), but this difference progressively narrowed over 5 years. Angina was equally prevalent in Canadian and US patients at 1 year (16% vs. 19%), but significantly more prevalent in Canadian patients at 5 years (36% vs. 16%, p = 0.001). Repeat revascularization procedures were performed less often over 5 years among Canadian patients (26% vs. 34%, p = 0.08), especially coronary artery bypass graft surgery after initial percutaneous transluminal coronary angioplasty (18% vs. 32%, p = 0.03). These results suggest more anginal symptoms are required in Canada before coronary revascularization, but as a result Canadians receive greater improvements in quality of life after the procedure.

Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life

BACKGROUND

The authors examined the importance of the frequency of aerobic exercise training in multidisciplinary rehabilitation in improving health-related quality of life in the short run in patients with documented coronary artery disease.

METHODS

Patients (114 males and 16 females; age range, 32-70 years) were randomized into either a high-frequency or a low-frequency exercise training program (10 versus 2 sessions per week, respectively) as part of a 6-week multidisciplinary cardiac rehabilitation program. The General Health Questionnaire and the RAND-36 were used to assess changes in psychological distress and subjective health status.

RESULTS

After 6 weeks, high-frequency patients reported significantly more positive, change in "psychological distress" (P < 0.05), "mental health" (P = 0.05), and "health change" (P < 0.01), than low-frequency patients. Apart from changes in mean scores, individual effect sizes indicated that a significantly greater percentage of high-frequency patients experienced substantial improvements in "psychological distress" (P < 0.01), "physical functioning" (P < 0.05), and "health change" (P < 0.05), compared with low-frequency patients. In addition, deterioration of quality of life was observed in a considerable number of high-frequency patients (ranging from 1.7% to 25.8% on the various measures).

CONCLUSIONS

The frequency of aerobic exercise has a positive, independent effect on psychological outcomes after cardiac rehabilitation. However, this benefit after high-frequency rehabilitation appears to be limited to a subgroup of patients. Further investigation is required to identify these patients. Results provide input into recent controversies regarding the role of exercise training in cardiac rehabilitation.

Long-term chest wall discomfort in women after coronary artery bypass grafting

OBJECTIVE

The purpose of the study was to determine the occurrence of long-term chest wall discomfort in women after coronary artery bypass grafting.

DESIGN

Prospective repeated-measures design.

SETTING

Posthospitalization.

SAMPLE

Fifty-one women who had undergone coronary artery bypass grafting. Data were collected at 12 and 18 months by self-report and data collection instruments.

INSTRUMENTS

Life Orientation Test, Satisfaction with Life Scale, Profile of Mood States, Sickness Impact Profile, interview schedule, and discomfort scale 0 to 10.

RESULTS

Women who had an internal mammary artery graft had significantly (p = 0.003) more discomfort. Most discomforts were intermittent and did not interfere with daily activities. However, the feelings of numbness and itchiness tended to be continuous.

Distress correlates with the degree of chest pain: a description of patients awaiting revascularisation

AIM

To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain.

DESIGN

All patients were sent a postal questionnaire for symptom evaluation.

SUBJECTS

All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904).

RESULTS

88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing.

CONCLUSIONS

In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.

[Return to work after myocardial revascularization]

Six hundred and seventy-two patients classified in four strata with one hundred sixty-eight in each were evaluated during the fourth month after myocardial revascularization, with coronary artery bypass graft and/or internal mammary artery and coronary angioplasty, in order to verify the return or not to work as well as the conditions under which this was done. The four strata constituted by occupational profile were the following: I--entrepreneurs and managers; II--professionals with university degree; III--technicians; IV--unskilled and semi-skilled professionals. The aim of this research project was to discover how variables like demographics, education, procedure and support after procedure, were related to the return to work. Return to work did not occur in 20.8% of all cases. The non-return contingent in each of the four strata was the following: I = 11.9%; II = 15.5%; III = 26.2% and IV = 29.8%. Among those submitted to angioplasty the proportion of non-return was lower than that of those submitted to surgery.

Quality of life after myocardial revascularization. Effect of increasing age

The effect of increasing age on quality of life, survival, and risk of reoperation was studied in 2479 patients followed up prospectively 2 to 20 years after myocardial revascularization. Quality of life was determined from annual questionnaires, which we used to calculate a health status index from the patient's symptomatic status and subjective response to the operation, which was graded between zero and 1.00 (asymptomatic). Four age groups were studied: age 49 years or less (AG40), 50 to 59 years (AG50), 60 to 69 years (AG60), and 70 years or older (AG70). Associated problems (left ventricular aneurysm, valve disease, acute myocardial infarction) necessitating treatment were present in 17% (61/361) of AG40 patients, 19% (165 of 859) of AG50 patients, 23% (213/927) of AG60 patients, and 31% (102/332) of AG70 patients. The hospital mortality rate was higher in older patients undergoing combined procedures but not in patients undergoing coronary bypass grafts only. Probability of survival and health status indexes were calculated excluding patients with valve disease and cardiogenic shock. Probability of survival was significantly better (p less than 0.001 by the Wilcoxon test) in patients less than age 60 than in those 60 years or older, but in patients with an ejection fraction greater than or equal to 0.40, probability of survival at 12 years was 0.64 (age less than 60) versus 0.62 (age greater than or equal to 60). The actuarial risk of reoperation, calculated as the difference between probability of survival and probability of survival without reoperation, progressively increased in younger patients but not in patients aged 60 years or older. At 15 years, the reoperation rates were 26% (AG40), 14% (AG50), 5% (AG60), and 7% (AG70). Mean health status index for years 1 to 5 was 0.85 in AG40 patients, 0.84 in AG50 patients, 0.89 in AG60 patients, and 0.90 in AG70 patients; for years 6 to 10, 0.81, 0.80, 0.86, and 0.89; and for years 11 to 15, 0.77, 0.78, 0.84, and 0.84, respectively. Thus quality of life after myocardial revascularization is better, improvement lasts longer, and reoperation rate is less in patients aged 60 years or older.

[Changes in the quality of life after coronary revascularization]

The purpose of this study was to evaluate the change of quality of life after coronary revascularization. Out of 189 longterm survivors who underwent coronary revascularization between January 1979 and February 1980, 142 patients (134 men, 8 women) aged 36 to 71 agreed to cooperate in this study and to answer our questions. The questionnaire included 38 questions related to anginal pain, capacity for physical activity, employment, and psychological state. The change in the quality of life was assessed from the sum of changes in the variables. There was a significant improvement of angina in 82.4%, 81% were free of symptoms or in NYHA class I. 69.2% of those questioned claimed increased capacity for physical activity, and depression improved in 55.3%. The subjective improvement did not completely correlate with return to work, only 50.4% were working again after the operation. There was a significant relationship between reemployment and the period of unemployment before operation, as well as with the kind of employment. Quality of life was improved in 80.3% of the patients, unchanged in 10.5%, and poorer in 9.2%. From this study it may be concluded that coronary revascularization can improve the subjective feeling of well-being as well as physical symptoms.