Mental illness and ischemic heart disease: analysis of psychiatric morbidity

In this study we analyze from a cardiologic and psychiatric point of view a consecutive sample of 194 patients treated in a cardiology outpatient unit. A psychiatric morbidity of 44.8% is found, expressing itself fundamentally as depression and anxiety neurosis. It is observed how the presence of chest pain significantly conditions the appearance of psychiatric disturbance, there being, moreover, a tendency in the same direction with increasing degrees of impairment of cardiac function. Certain personal and sociocultural factors also play a significant role in the development of mental illness in these patients.

Cognitive function after coronary bypass surgery: effect of decreased cerebral blood flow

The effect of regional cerebral blood flow during coronary bypass surgery on performance on the Mini-Mental State Examination was studied in 14 patients. No association between lowered regional cerebral blood flow and cognitive scores was found.

Coronary artery bypass surgery--impact upon a patient's wife--a pilot study

A pilot study of the wives of 19 coronary artery surgery patients assessed levels and predictors of affective symptoms. A substantial proportion of wives (40 to 50%) reported levels of depression (but not anxiety) severe enough to warrant treatment, and many attributed this to the effects of their husband's operation. Neither the wives' expectations of patient outcome, nor the objectively assessed surgical outcome bore any relationship to the wives' affective state. A previous psychiatric history in a wife was possibly related to her affective state, but her 'N' score (emotionality) on the Eysenck Personality Questionnaire was very strongly related to her state.

Psychosocial outcome after coronary artery by-pass surgery

Thirty-six patients with obstructive coronary artery disease were interviewed before by-pass graft surgery, and again a mean period of 12.3 months (n = 34) after the operation. The operation was successful in providing relief from chest pain in 31 patients. Psychiatric outcome was related to preoperative mental state, social maladjustment, neuroticism, Bortner Type A score, and previous psychiatric history. One quarter of those employed preoperatively failed to return to work after operation, even though they were improved in terms of symptoms and functional capacity. No association was found between measures of either psychiatric morbidity, or employment status at follow-up, and pre-operative physical variables.

Appraisal of values in the choice of treatment

The Gortner Values in the Choice of Treatment Inventory is a set of declarative statements to which respondents can indicate agreement or disagreement in a Likert-type format. The statements are based on the moral principles of Autonomy, Beneficence/Nonmaleficence, and Justice as conceptualized by Beauchamp and Childress (1979). The first trial was reported for 15 families in 1980. The second trial was part of a larger study in June 1981 to April 1982 of 100 families, of whom 70 had a member undergoing coronary artery bypass surgery, and 30 had a member under medical treatment for coronary artery disease. Spearman rank order correlations were used to evaluate responses within families and between groups at Time 1 and Time 2. Surgical family correlations for Autonomy were weak, but were moderately strong for Beneficence/Nonmaleficence. A highly significant main-effect finding, using repeated measures ANOVA, was that all patients and spouses showed mean Autonomy scores that were significantly higher than those for Beneficence/Nonmaleficence and Justice. Principal components factor analysis followed by varimax rotation supported two of the three hypothesized constructs. Surgical families emerged as the key reference group for further analysis.

Psychiatric aspects of coronary artery surgery. A prospective study

A psychiatric assessment was carried out before operation, and at three months and 12 months after operation, in 77 men undergoing coronary artery bypass graft surgery. Neither psychiatric assessment before the operation nor perioperative surgical assessment could predict the physical outcome of surgery. The physical results of surgery were good, but there was a 20% decrease in the number of patients who were in employment after the operation. Abnormally high scores on measures of anxiety and depression were present in about 50% of patients before the operation, and in about one-third of patients after the operation. Impairment in various aspects of personality-functioning since surgery was reported by 7%-29% of patients. These complaints were not correlated with the surgical result. Attention is drawn to this area of persisting postoperative morbidity.

Coping with transient intellectual dysfunction after coronary bypass surgery

In summary, we believe that the impact of our findings on the patient and clinician includes recognition and acknowledgment that transient cognitive dysfunction frequently follows coronary bypass surgery. With this recognition comes the reassurance to the patient and his family that it is a temporary phenomenon that should resolve in time. To help the patient comply with his postoperative instructions during this difficult time period, there should be individual, slow-paced presentation of material with intentional repetition of information to help him remember the specific details of his postoperative instruction; the individual most involved with assisting in the patient's postoperative recovery should be included in all teaching sessions; and instructive audiovisual material should be used in postoperative home care.

Psychological adjustment to coronary artery surgery

In a study of psychological adjustment to coronary artery bypass surgery 23 patients who underwent surgery were seen pre-operatively, prior to discharge and one year after surgery. A comparison sample of 19 patients not tested pre-surgically was contacted by postal questionnaire one year post-operatively. An hierarchical grouping analysis carried out on seven outcome variables yielded a two-group solution for the study sample and this was replicated in the comparison sample. Group 1 indicated change for the better and Group 2 change for the worse since surgery. Discriminant function analysis of 23 pre-operative and operative variables for the first sample indicated ability to cope with stressful events and neuroticism were significant predictors of outcome. Patients in the comparison sample did not differ from the study sample in outcome measures, indicating no effect of assessment prior to operation for the study sample.

Coronary bypass. A personal experience

A little over three years ago David Muecke began to have angina. He hopes this 'patient's view' of the subsequent emergency bypass operation will increase the family doctor's awareness of the emotional and physical aspects of coronary artery disease and surgery.

Functional benefits following coronary artery bypass graft surgery

While some studies of patients who undergo cardiac surgery have included such outcome measures as amounts of symptom reduction and rates of resumption of employment, little attention has been focused on the extent to which these patients have experienced the simple, yet very important, broad range of functional benefits that might be anticipated by clinicians to result from operation. The present report seeks to document the extent of improvement that does exist in terms of physical, sexual, and social-role functioning. In a cohort of 340 patients (age, 32 to 69 years) studied before and six months after coronary artery bypass operation, improvements were noted in each of three dimensions of functional benefit: physical functioning (fewer total activity restrictions or incapacitated days per month), sexual functioning (through increased energy and desire and decreased pain and worry), and role functions (ability to work, social participation, and pursuit of hobbies). Further improvements might be anticipated with additional months of recovery.

Reducing family stress during and after coronary artery bypass surgery

Based on the findings of this study of couples after coronary artery bypass surgery, there are numerous stresses and unmet needs that might be addressed by hospital-based nurses. The study demonstrated that, as a group, the spouses of the bypass patients report higher levels of stress than the patients did while in the hospital. Together, patients and spouses reported high levels of marital conflict, dissatisfaction, and discord during the first 6 months after the surgery. Many indicated that they were unprepared for these experiences. Further, they found it difficult to maintain continuity with a provider who could answer their questions about recovery. As a result of these findings a program of nursing care that focuses on the family during and after coronary artery bypass surgery has been proposed. The model program consists of preparation for surgery, preparation for discharge, and continuous contact with the family after discharge, at least through the first follow-up appointment with the surgeon at 6 weeks. For each phase it is necessary to consider content that is appropriate to the individual patient, but it is essential to include content aimed at reducing the stresses and risk experienced by the family as well. By doing so hospital-based nurses are treating the family as well as nursing the patient through this episode of acute illness.

Early appraisal of coronary revascularization on quality of life

Information available for nurses on counseling cardiac patients about the outcomes of bypass surgery has focused on the time following the first postoperative year. In order to assess earlier impact, two groups of bypass patients--alike in terms of preoperative physical activity, angina level, and type of revascularization--were compared in terms of quality of life and related areas. Seventeen patients were 3 to 5 months (88-141 days) postoperative and 17 patients were 6 to 8 months (161-222 days) post-operative. They were asked to rate themselves on Cantril's Self-Anchoring Scale in relation to past, present, and future life satisfaction. An analysis of variance (ANOVA) indicated that both groups of patients viewed their future life satisfaction to be better than their life satisfaction prior to open heart surgery. Furthermore, the patients 6 to 8 months postoperative viewed their present life satisfaction to be significantly better than their past (p less than .05). Both groups reported a decrease in the level of angina and an increase in the level of physical activity after surgery (p less than .001). They also reported greater satisfaction with family life (p less than .05), social life (p less than .001), and sexual life (p less than .01) following surgery. Overall, there were significant improvements in the quality of life early in the recovery period following surgery. Residual incisional pain may have contributed to any differences between groups.

The effects of coronary bypass surgery on female sexual, psychological, and vocational adaptation

This paper reports the first study of female sexual, psychological, and vocational adaptation to coronary artery bypass surgery (CABG). Semistructured interviews were used to obtain data on 17 women undergoing CABG. Four time periods were examined: prior to and after the onset of cardiac symptoms; four months and one year after CABG. Female sexual response differs from what is known about male adaptation to CABG in three ways: 1) women did not demonstrate a significant and profound decline in frequency of intercourse one year after surgery; 2) the component most vulnerable to disruption in women is desire, in men it is arousal; 3) women do not harbor the sexual fears commonly seen in men such as sudden death during intercourse or performance anxiety. Psychologically, women fared better than men, but were less likely to return to work. This indicates that more attention should be directed toward vocational counseling of working women undergoing CABG.

Patients' evaluation of a teaching booklet for arterial bypass surgery

A descriptive survey was conducted at an urban university medical center to ascertain the opinions of patients undergoing vascular surgery to a booklet used for preoperative teaching. In the postoperative period 21 patients reported their perceived value of the booklet in modifying their feelings about the surgical event, helping them to feel in control of postoperative pain, preparing them to participate in postoperative activities, and providing them with overall preoperative preparation. Patients also identified needs that the booklet did not meet and suggested modifications that might better meet patients' preoperative learning needs. Ninety percent of responding patients described the booklet as helpful in meeting their preoperative learning needs, and 95% said they would recommend the booklet to a friend. Patients who had discussed the booklet with a health-team member consistently described the value of the booklet more favorably than did patients who had not discussed the booklet before surgery. Nurses were identified as the health-team members who most often discussed the content of the booklet with the patient. The findings suggest that patients with no education beyond grammar school might have difficulty appreciating the value of the preoperative teaching booklet.

Coronary artery bypass surgery. Physical, psychological, social, and economic outcomes six months later

To evaluate the benefits of coronary artery bypass graft (CABG) surgery, we interviewed and tested 318 patients (268 men and 50 women) younger than age 70 before and six months after elective CABG at four university medical centers. Biomedical, psychoneurological, physical function, role function, occupational, social, family, sexual, emotional, and attitudinal variables were assessed. Quantitative comparisons showed improvement on many factors. Angina was completely relieved for 69% to 85% of persons, depending on whether it had been induced by exertion or other events. Disability days were reduced more than 80%. Seventy-five percent of employed persons had returned to work. Anxiety, depression, fatigue, and sleep problems declined. Vigor and well-being scores rose significantly. When losses were expected (eg, psychoneurological function, marital adjustment), they generally were not found. For none of the more than 60 outcome variables was widespread serious worsening found. The findings suggest that the great majority of patients are able to resume normal economic and social functioning within six months after CABG.

Psychosocial coping strategies and cardiac capacity before and after coronary artery bypass surgery

One hundred patients, eighty-nine men and eleven women, with chronic stable angina who were previously selected for aortocoronary bypass grafting gave informed consent for non-invasive and invasive testing of hemodynamic responses to symptom-limited maximal exercise before surgery. Psychosocial coping strategies were evaluated preoperatively by structured interviews and assessment of patients perceptions of symptoms (Cornell Medical Index) and life changes (Holmes and Rahe Schedule of Recent Experiences). Preoperatively forty-one patients were "compartmentalized," forty-two "generalized" and seventeen "vacillated" according to Josten's classification of coping strategies. The Berle Index of social assets was lower and the prevalence of psychiatric symptoms (Cornell categories M to R) was greater in the vacillators preoperatively. Despite less ischemic ST depression in vacillators, no other significant physiological differences were noted between these categories preoperatively. Postoperatively more of the vacillators refused follow-up evaluation, and of vacillators who returned, only one-half were adequately revascularized at operation. Of sixty-five reevaluated after surgery, eight improved, twelve worsened and forty-five did not change classification of coping strategies, yet physiological variables of cardiac function when invasively measured in sixty patients were significantly improved in all three groups. Amounts of improvement, both absolutely and relative to sex- and age-adjusted normal values, were least in vacillators with virtually normal cardiac capacity, and/or inadequate revascularization. Compartmentalized patients were more frequently working, yet only sixty-four in all psychosocial classifications worked before surgery. After this event only forty-five resumed working; none of the non-workers or retired returned to work. Both physiologic improvement and working status were independent of postoperative psychosocial status.

Psychological and behavioral responses after coronary artery bypass surgery

One hundred consecutive patients who underwent coronary artery bypass surgery at the Columbia-Presbyterian Medical Center from December 1972 through February 1975 were evaluated at surgery and then followed for as long as 4 1/2 years to study their postoperative psychosocial and behavioral course. One patient died during the first 30 days. At 4 1/2 years, 23 patients were reported as deceased, 15 from cardiac causes. The majority of the long-term survivors had substantially less angina and greater exercise capacity; surgery did not increase the number of patients who were employed, but led to substantial improvements in the quality of life, including general pleasure, reduction of anxiety and depression and subjective improvement in job and family roles. Sexual adjustment improved the least; the frequency of sexual relations tended to decrease. Compliance with the medical regimen was relatively good for smoking and exercise, but not for diet or type A behavior, suggesting a need for psychological intervention.

On the quality of life: some philosophical reflections

Quality of life, as a concept pertaining to patients undergoing coronary artery bypass graft surgery, is explored. A theory of life quality, based on the capacity of the patient to realize his own life plans, is proposed, explaining the role of differing factors, general and individualized. Using the proposed theory, three avenues of investigation are suggested, each aimed at the more effective use of surgery in improving life quality.

Cardiovascular and antidepressant effects of imipramine in the treatment of secondary depression in patients with ischemic heart disease

The authors report on 12 men with ischemic heart disease who developed secondary depression following myocardial infarction or coronary artery bypass-graft surgery and were treated with imipramine hydrochloride for 4 weeks. Imipramine had an antiarrhythmic effect, manifested by reduction in premature ventricular contractions during treatment. This drug did not produce clinically significant disturbances in cardiac conduction, but orthostatic hypotension led to early termination of the drug treatment in 1 subject. Imipramine treatment was associated with significant improvement in both observer-rated and patient-rated depression scales.