Influence of patient-related and surgery-related risk factors on cognitive performance, emotional state, and convalescence after cardiac surgery

BACKGROUND

Cardiac surgery may account for complications such as cognitive impairment, depression, and delay of convalescence. This study investigated the influence of different risk factors on cognitive performance, emotional state, and convalescence.

METHODS

We included 83 patients undergoing cardiac surgery who had no indication of postoperative delirium. Psychometric testing was performed 1 day before and 7 days after surgery. Neuron-specific enolase (NSE) levels were measured 1 day before and 36 h after surgery.

RESULTS

Depression score increased after surgery, but patients showed no clinically significant depression. Postoperative cognitive performance correlated with postoperative depression level and preoperative cognitive performance. Forty-three percent of patients showed postoperative decline. Older patients exhibited a higher postoperative increase in NSE concentrations. Patients undergoing coronary artery bypass grafts or combined procedures exhibited more medical risk factors than those undergoing valve surgery alone. The number of bypass grafts was associated with time of hospitalization, and the number of patient-related risk factors correlated with stay in intensive care unit.

CONCLUSIONS

For elderly patients undergoing cardiac surgery, older age, total preexisting medical risk factors, and surgery duration seem to be the most important factors influencing cognitive outcome and convalescence. Results show that, also for patients without postoperative delirium, medical risk factors and intraoperative parameters can result in delay of convalescence.

Quality of life during 18 months after coronary artery bypass grafting

OBJECTIVE

The aim of the present study was to evaluate the change in health related quality of life (HRQoL) among elective coronary artery bypass grafting (CABG) patients.

METHODS

A total of 302 CABG patients were included in the study. Complete pre-, peri- and postoperative data were collected comprehensively in a database. HRQoL was measured by the 15D instrument. The 15D is a non-disease-specific, 15-dimensional, standardized and self-administered measure of HRQoL that can be used both as a profile and single index score measure. Baseline assessment was carried out before coronary angiography and assessment was repeated 6 and 18 months after surgery. Data were analysed by gender and in three age groups, i.e. patients <65 years, 65-74 years and > or = 75 years.

RESULTS

Thirty day mortality was 1.0%, and the survival rate at 6 and 18 months was 99.0% and 96.7%, respectively. Preoperative HRQoL of CABG patients was lower in comparison to age- and gender-standardized Finnish population (P<0.001). HRQoL of the patients improved significantly after CABG and the positive change lasted over the whole observation period, despite a slight decrease of 15D scores until 18 months. Although male patients had a higher preoperative HRQoL than women (P=0.005), both genders benefited similarly from the operation. In the patients > or = 75 years, the initial improvement of HRQoL returned to the preoperative level 18 months after the surgery.

CONCLUSIONS

CABG patients experience a significant improvement in their HRQoL within 6 months after the operation and the effect remains through a mid-term observation time. However, expectations of improved HRQoL may have a limited value in decision making for surgery of coronary artery disease (CAD) for patients more than 75 years old.

A comparative study of patient perceived quality of life pre and post coronary artery bypass graft surgery

OBJECTIVE

Traditionally, evaluation of outcome post cardiac surgery has focused on objective measures of cardiovascular status. The emphasis has shifted to examining an individual's quality of life (QoL). However a gap in Australian prospective research assessing QoL from a pre-operative period to the early stage of six weeks post-operatively exists. The aim of this study was to investigate recovery from coronary artery bypass graft surgery (CABGS) on the basis of patient perceived QoL and in particular, physical and mental health.

DESIGN AND SETTING

Prospective longitudinal quasi-experimental study in a tertiary hospital in Melbourne, Australia.

SUBJECTS

Fifty four patients undergoing their first or second CABGS completed pre- and post-operative questionnaires.

MAIN OUTCOME MEASURES

The Short Form 36 (SF-36) questionnaire was used to measure physical and mental QoL pre- and post CABGS and gives eight domain scores as well as a physical (PCS) and mental component summary score (MCS).

RESULTS

SF-36 scores following CABGS were significantly improved in three of the eight domains: physical functioning (p < 0.001); general health perception (p < 0.001); energy/vitality (p < 0.005); and PCS (p < 0.001). No statistical difference was found in patients' MCS pre- and post-operatively. Of importance, patients reported higher levels of pain at six weeks post-operatively compared to their pre-operative levels but scores were not significantly different.

CONCLUSIONS

The SF-36 demonstrates improvements in physical QoL six weeks after CABGS compared to preoperative results but no difference in mental QoL suggesting psychological adaptation. An increase in the pain score at six weeks suggests inadequate pain management in these patients.

A randomised controlled trial of cardiac rehabilitation after revascularisation

BACKGROUND

It is unclear if psycho-education on top of physical training is of additional value regarding quality of life in revascularised patients.

DESIGN

Prospective randomised study comparing two types of cardiac rehabilitation: exercise based versus a more comprehensive approach including psychological therapy.

METHODS

One hundred and thirty-seven male patients who underwent an uncomplicated coronary revascularisation procedure and who were mentally in a good condition, were randomised to one of two types of cardiac rehabilitation: physical training plus information about their disease ('Fit' program) during 6 weeks or comprehensive cardiac rehabilitation which, on top of the Fit-program, included weekly psycho-education sessions and relaxation therapy ('Fit-Plus' program) for 8 weeks. One hundred and four patients were analysed. Quality of life was measured by the 'Leiden Quality of Life questionnaire' and by the RAND-36 (quality of life) questionnaire.

RESULTS

Quality of life improved in both treatment groups in the course of time up to 9 months after cardiac rehabilitation and there was no difference between the two types of cardiac rehabilitation. Exercise capacity improved likewise, blood lipid profile was unaffected and energy intake decreased in each treatment group but, again, there were no inter-group differences.

CONCLUSION

After an uncomplicated revascularisation procedure, physical training plus information results in a comparable outcome on quality of life when compared to a more comprehensive program including additional psycho-education and relaxation therapy.

Quality of life can both influence and be an outcome of general health perceptions after heart surgery

BACKGROUND

Our aim was to investigate the existence of a reciprocal relationship between patients' assessment of quality of life and their appraisal of health. If present, this relationship will interfere with the interpretation of heart surgery's effect on overall quality of life.

METHODS

Path analysis was used to investigate reciprocal causal relationships between general health perceptions and overall quality of life before and after heart surgery. Longitudinal data from a study of coronary artery bypass surgery were used to model lagged, cross-lagged, and simultaneous paths over four time-points of assessment from before surgery to one year afterwards. The conceptual framework for the analysis was the Wilson and Cleary causal pathway model. General health perceptions were measured with the Short Form 36. Overall quality of life was measured with i) a single question regarding life satisfaction and ii) the multi-item Quality of Life Survey.

RESULTS

Acceptable model fit was obtained for reciprocal causation between general health perceptions and overall quality of life. Regression coefficients changed over different phases of rehabilitation. Serial correlation accounted for much of the variance within variables over time.

CONCLUSION

The present analysis demonstrates that unidirectional models of causality are inadequate to explain the effect of heart surgery on overall quality of life. Overall quality of life can causally influence as well as be an outcome of health status after coronary artery bypass surgery.

Infection, depression, and immunity in women after coronary artery bypass: a pilot study of cognitive behavioral therapy

CONTEXT

Depression is common after coronary artery bypass graft (CABG) surgery, but little is known about its effect on post-CABG inflammation or infection or about the most effective treatment for post-CABG depression.

OBJECTIVES

(1) To determine ifpost-CABG depression is associated with increased infectious illness and (2) to test effects of cognitive behavioral therapy (CBT) on depressive symptoms, inflammatory biomarkers, and post-CABG infections in depressed post-CABG women.

DESIGN

Randomized, controlled trial.

SETTING

Two urban tertiary care centers.

PATIENTS

Fifteen clinically depressed women in the first month after CABG, along with a comparison group of 37 non-depressed postCABG women, were studied. Inclusion criteria were: < or = 75 years old, English-speaking, undergoing first-time CABG, available for 6 months offollow-up, and without malignancy or autoimmune disorders.

INTERVENTION

Eight weeks of individual home-based CBT.

MAIN OUTCOME MEASURES

(1) Depressive symptoms measured by the Beck Depression Inventory, (2) natural killer cell cytotoxicity (NKCC) measured by 51Cr-release assay, (3) infectious illness episodes measured by the Modified Health Review, (4) interleukin (IL)-6 and C reactive protein (CRP) measured by enzyme immunoabsorbent assay.

RESULTS

Clinically depressed post-CABG women exhibited decreased NKCC and a higher incidence of in-hospital fevers and infectious illness in the first 6 months after CABG. Among depressed women, CBT yielded moderate to large effects for improved NKCC (D=0.67) and decreased IL-6 (D=0.61), CRP (D=0.85), and postoperative infectious illnesses (D=0.93). CBT holds promise for improving depression and immunity and reducing infection and inflammation after CABG.

Preexisting Cognitive Impairment in Patients Scheduled for Elective Coronary Artery Bypass Graft Surgery

BACKGROUND

An accurate assessment of the prevalence of cognitive impairment in patients scheduled for coronary artery bypass graft (CABG) surgery is necessary if valid assumptions regarding cognitive change are to be made. Such an assessment requires the use of a healthy control group free of cardiovascular disease.

METHODS

In a retrospective observational study, 349 patients scheduled for CABG surgery underwent neuropsychological testing. We compared the results with those from a group of 170 healthy controls without cardiovascular disease and containing more female patients who were matched for age and IQ score. Cognitive impairment was defined as test scores > or =2 sd less than the controls on two or more of the seven tests.

RESULTS

The CABG surgery patients performed significantly worse than the control group on all tests except the Grooved Pegboard test (nondominant). When analyzed by group, performance on the verbal learning test was the most impaired. Cognitive impairment was present in 122 (35%) of CABG surgery patients before their procedure. Prior myocardial infarction, age, and IQ were independent predictors of cognitive impairment.

CONCLUSIONS

Cognitive impairment is prevalent in patients presenting for CABG surgery. Impaired cognition before surgery must be considered when assessing the effects of CABG surgery on cognitive performance.

Stressors and anxiety in patients undergoing coronary artery bypass surgery

BACKGROUND

Patients undergoing coronary artery bypass surgery who have increased anxiety levels have poorer outcomes than patients with lower levels, yet few studies have identified the concerns associated with this anxiety.

OBJECTIVE

To describe the concerns of patients undergoing coronary artery bypass surgery and to identify concerns that were associated with higher levels of anxiety.

METHOD

Patients (n = 172) were interviewed to determine their concerns and anxiety levels before surgery, before discharge, and 10 days after discharge. Multiple regression was used to determine the predictors of anxiety.

RESULTS

Although individual concerns changed over time, anxiety levels did not change from before to after surgery, remaining low to moderate. Being female and having more concerns about waiting for the surgery, being in pain/discomfort, and resuming lifestyle were predictors of increased anxiety before surgery. Predictors of increased anxiety while hospitalized after the surgery included taking anxiolytic or antidepressant medications, higher anxiety levels before surgery, concerns about personal things being inaccessible, and difficulty sleeping. Patients with higher anxiety levels after discharge were older, more anxious before surgery, and had concerns about being in pain/discomfort.

CONCLUSION

Patients waiting for coronary artery bypass surgery should be routinely assessed for anxiety before the procedure, and interventions to prevent or reduce anxiety should be provided. Interventions must be multifactorial, including information and support for pain management and realistic information about surgery schedules and resuming lifestyle after the surgery. Women and older patients may need to be targeted for intervention.

Utility of observer-rated and self-report instruments for detecting major depression in women after cardiac surgery: a pilot study

BACKGROUND

Major depression is common after coronary artery bypass graft surgery and is associated with increased mortality and morbidity. Clinicians have few practical options for detecting depression, especially in women, who are at higher risk for depression than men.

OBJECTIVES

To evaluate the clinical utility of common self-report and observer-rated instruments for detection of major depression in women after coronary artery bypass graft surgery.

METHODS

In 66 women being discharged after coronary artery bypass graft surgery, 4 instruments were completed: the Hamilton Depression Rating Scale, Beck Depression Inventory, Beck Depression Inventory Short Form, and Beck Depression Inventory for Primary Care. For each instrument, receiver-operating-characteristic curves were analyzed, and positive and negative predictive values were calculated for cutoff points determined from the curves.

RESULTS

At hospital discharge, all 4 instruments yielded highly accurate curves. Compared with cutoffs suggested for patients without medical illness and hospitalized nonsurgical patients, identified cutoffs for screening were higher when all types of depressive symptoms (cognitive, affective, behavioral, somatic) were measured with the Hamilton Depression Rating Scale and the Beck Depression Inventory but lower when only cognitive and/or affective symptoms were measured with the 2 subscales of the Beck Depression Inventory.

CONCLUSIONS

The Hamilton Depression Rating Scale and both subscales of the Beck Depression Inventory may be useful for detecting major depression in women shortly after coronary artery bypass graft surgery. Further study is warranted to confirm cutoffs in these patients.

Uncertainty, symptom distress, anxiety, and functional status in patients awaiting coronary artery bypass surgery

OBJECTIVE

The study's objective was to (1) describe uncertainty, anxiety, the symptom distress experience, and functional status of patients on a coronary artery bypass graft (CABG) waiting list and express the relationship between these concepts; (2) explore whether length of time waited has an influence on the psychosomatic condition of patients; and (3) explore the use of semistructured interviews within the context of a theoretic framework and compare open-ended responses to quantitative results.

DESIGN

A descriptive, correlational, cross-sectional design was used with supplementary telephone interviews using semistructured questions. Quantitative data were collected with a mailed questionnaire. Study instruments included the Mishel Uncertainty in Illness Scale (Community), Symptom Frequency and Symptom Distress Scale, Graphical Anxiety Rating Scale, and Kansas City Cardiomyopathy Questionnaire (Physical and Social Limitation). The Mishel Uncertainty in Illness Theory was used as the guiding theoretic framework.

SETTING

The study took place in one large tertiary care hospital in Winnipeg, Manitoba, Canada.

SAMPLE

The study included a convenience sample of 42 patients undergoing first-time elective CABG only, 25 of whom participated in the telephone interview.

RESULTS

Average uncertainty and anxiety were present at moderate levels and were associated with moderate deterioration of functional status. Reported symptom distress was low; however, presence of symptoms showed a strong relationship with anxiety (P=.0002), and this relationship was confirmed through semistructured interviews. Although the relationship between uncertainty and anxiety was nonsignificant, the interviews suggest positive views of uncertainty as an opportunity may have muted the relationship between uncertainty and anxiety, and that it is possible to experience uncertainty as a danger and an opportunity simultaneously. No statistically significant relationship was found between the study variables and waiting time; however, there was a nonsignificant trend toward deterioration of psychologic and physical condition with longer waits, which may be clinically significant.

CONCLUSION

Psychosocial distress and physical condition among patients on CABG waiting lists should be continually assessed in all patients regardless of how long they have been waiting. Each patient will have a unique presentation of symptoms and a corresponding unique psychologic response.

Comorbid depression and health-related quality of life in patients with coronary artery disease

OBJECTIVE

This article reviews recent studies relating to the impact of depression and its treatment on the health-related quality of life (HRQOL) of patients with coronary artery disease (CAD).

METHODS

Articles for the primary review were identified via MEDLINE and PsycINFO (1995-2006).

RESULTS

Evidence suggests that depression has an aversive impact on the HRQOL of patients with stable CAD as well as on patients hospitalized for acute myocardial infarction and coronary artery bypass graft surgery. Unfortunately, there are few depression treatment studies in patients with CAD that make use of standardized HRQOL measures, but the limited evidence suggests that successful treatment has positive implications for HRQOL in these patients. The mechanisms through which depression impacts on HRQOL require further study but are likely to be behavioral.

CONCLUSIONS

Depressive symptoms significantly undermine HRQOL in patients with CAD despite successful medical and surgical management. Although successful treatment of depression has not been shown to reduce mortality rates in patients with CAD, further study may find that the HRQOL benefits of such treatment are equally valuable.

Rehabilitation and guidance as reported by women and men who had undergone coronary bypass surgery

AIMS AND OBJECTIVES

The purpose of this study was to describe the experience of rehabilitation reported by coronary artery disease patients who had undergone coronary artery bypass surgery. A further purpose was to describe the kind of guidance on rehabilitation that they were given during this period.

METHODS

The data consisted of thematic questionnaires completed by six women and eight men who had undergone coronary artery bypass surgery. They had recorded their experiences on these questionnaires at one-month intervals for a year after the surgery. The data were analysed using the method of content analysis.

RESULTS

On the basis of the results, women had experienced the most balanced period of physical, mental and social rehabilitation during the six months following surgery. Their recovery, however, suffered a setback after the first six months. On the basis of the results, men attained a better balance of physical, mental and social rehabilitation only after the six-month period following surgery. Even men had various problems in their rehabilitation, but their recovery proceeded more smoothly than that of women. Women hoped for more guidance throughout the process of rehabilitation. The support and help from wives had a positive impact on the process of men's recovery. Peer support was another significant source support.

CONCLUSIONS

A person undergoing rehabilitation needs special guidance from health care professionals, especially when his/her rehabilitation does not proceed optimally. The findings suggest that, especially, the guidance of women should be improved because women seemed to suffer from many problems during their process of rehabilitation, including loneliness, insecurity, uncertainty, fears, depression and anxiety.

RELEVANCE TO CLINICAL PRACTICE

Expanding the role of practical nurses to provide both preventive and rehabilitation guidance should be seen as an important strategy in health care. Individual needs, gender differences and support from families and peers should be taken into consideration when planning and implementing guidance.

Does the experimental design capture the effects of complementary therapy? A study using reflexology for patients undergoing coronary artery bypass graft surgery

AIM

Our purpose was to pilot test whether reflexology may reduce anxiety in patients undergoing Coronary Artery Bypass Graft Surgery in Iceland.

BACKGROUND

Nurses need to study the effects of complementary therapies in general and particularly those that may be beneficial to decrease patients' anxiety. It has been assumed that reflexology lessens anxiety, but research is needed to substantiate such expectations.

DESIGN

A pilot study using randomized design with experimental and control groups.

METHODS

Nine patients were recruited and randomly assigned into groups with five patients assigned into an experimental group receiving reflexology for 30 minutes and four patients into control group which rested for 30 minutes. Anxiety and physiological variables were measured pre- and post-reflexology sessions once a day over five days.

RESULTS

The anxiety scores were lower for patients in the control group on all measures. Systolic blood pressure lowered significantly more in the control group than in the treatment group. No significant changes were observed for other variables. Patients' comments and responses overwhelmingly suggested increased well-being due to both experimental and control intervention.

CONCLUSION

This study showed little evidence to support reflexology as a mean of reducing anxiety in CABG patients. Several methodological problems were identified that need to be considered further.

RELEVANCE TO CLINICAL PRACTICE

It is suggested that reflexology should be tailored to individual needs and research methods used that allow for capturing its holistic nature. Further scholarly work is warranted to explore several methodological issues in studying complementary therapies in a highly complex treatment situation.

Effects of a home-based intervention program on anxiety and depression 6 months after coronary artery bypass grafting: a randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the effects of a home-based intervention program (HBIP) on anxiety and depression 6 months after coronary artery bypass grafting (CABG).

METHODS

In a prospective randomized controlled trial, 203 elective CABG patients were included. An HBIP structured for respondents in the intervention group was performed 2 and 4 weeks after surgery. Anxiety and depression symptoms were measured by the Hospital Anxiety and Depression Scale (HADS) in both patient groups before surgery, 6 weeks after surgery, and 6 months after surgery.

RESULTS

A total of 185 patients completed the study: 93 patients in the intervention group and 92 patients in the control group. On 6-week and 6-month follow-ups, significant improvements in anxiety and depression symptoms were found in both groups. These improvements did not differ significantly between the groups. However, in a predefined subgroup of patients with anxiety and/or depression symptoms at baseline (n=65), improvement was significantly larger in the intervention group (n=29) than in the control group (n=36) after 6 months (P<.05).

CONCLUSIONS

Patients experiencing high levels of psychological distress before CABG surgery benefited from a structured informational and psychological HBIP. Implementation of psychological screens of patients scheduled for CABG might serve to identify patients experiencing anxiety and/or depression. These patients could then be targeted to receive individualized HBIP.

Benefits of cardiac surgery in octogenarians--a postoperative quality of life assessment

OBJECTIVE

Assessment of postoperative quality of life in patients over 80 years after cardiac surgery including coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and combined procedures.

METHODS

Quality of life of n=136 patients over 80 years at operation (82.3+/-2.1 years), undergoing isolated CABG in 61 patients (45%), isolated AVR in 34 patients (25%) and a combination of CABG and AVR in 41 patients (30%) between January 1999 and December 2003 was reviewed. Preoperatively 66.2% presented in NYHA-class III/IV or CCS-class III/IV. Mean ejection fraction (EF) was 59.5%+/-14.0 (range 25-90%). Quality of life assessment was performed via a Seattle Angina Questionnaire. Follow-up was 100% complete for a total of 890 days (69-1853 days).

RESULTS

Five-year survival was 70% for the CABG group, 75% for the AVR group and 65% for the CABG/AVR group. Quality of life was remarkable in all of the three groups after surgery. Overall 97 patients (81%) were not or little disabled in their daily activity. One hundred and twelve patients (93%) were free or considerably less symptomatic. Seventy-eight patients or 65% reported to be very satisfied with their current quality of life and 112 patients (93%) felt very reassured to have continuous full access to medical treatment despite of their advanced age.

CONCLUSIONS

A remarkable quality of life and important improvement in the functional status after cardiac surgery in patients over 80 paired with a satisfactory medium-term survival justify early intervention for heart disease in this age group. Therefore, referral practice for patients over 80 years for heart surgery should be handled liberally.

[The evolution of depressive symptoms in coronary artery disease patients after successful coronary angioplasty]

AIM

The aim of the study was to investigate the spectrum and course of depressive symptoms in cardiac ischemic disease (CAD) patients before and after successful coronary angioplasty (PCI) in one year follow-up.

METHOD

227 patients with CAD selected for PTCA were enrolled. 156 patients with full clinical and angiographic success and without restenosis within 4 weeks after the intervention were included in further analysis. Patients' status was assessed four times (one day before and at 1, 6 and 12 months after the intervention), with Beck's Depression Inventory (BDI), Rosenberg's Self-Esteem Scale (RS), Beck's Hopelessness Scale (HS), Automatic Thoughts Questionnaire (ATQ).

RESULTS

Mild and moderate depressive disorders with the prevalence of non-specific somatic symptoms were observed one day before PTCA in 75 (48%) patients. One month after the PCI, depressive symptoms persisted in 33 subjects. Moreover in the group of patients who were free of depressive symptoms a day before PTCA, twelve patients (15%) developed depressive symptomatology. Depressive symptoms and depressive disorders of thinking (especially hopelessness) recognized 4 weeks after PTCA had a tendency to persist at 6 and 12 months. The tendency was associated with more severe affective-cognitive and somatic symptoms of the depressive syndrome, more frequent negative automatic thoughts and stronger hopelessness detected at the beginning of the study.

CONCLUSIONS

The results of the study suggest that successful PCI is not a sufficient determinant for the improvement of depressive symptoms. Diagnosis of depression in CAD patients needs special attention, because of a tendency to persist.

Effect of Functional Health-Related Quality of Life on Long-Term Survival After Cardiac Surgery

Background— Health-related quality-of-life instruments have become important measures of early health outcomes after cardiac surgery. The relationship between quality of life after recovery from surgery and subsequent long-term survival has not previously been explored. Our objective was to determine whether the Duke Activity Status Index (DASI) was predictive of subsequent time-related survival after recovery from cardiac surgery.

Methods and Results— We examined survival status among 6305 patients who underwent isolated coronary artery bypass grafting with or without valve procedures or isolated valve procedure between May 1995 and June 1998 who had a preoperative baseline and follow-up DASI. The postoperative DASI was administered nominally at 6 and 12 months. Baseline and perioperative variables and postoperative morbid events were prospectively collected concurrently with patient care. The end point was all-cause mortality. The Social Security Death Index was queried for survival status. Cox proportional-hazards analysis was used to study the associations between DASI, a number of traditional risk factors, and survival. Median follow-up was 8.6 years. The “dose-response” relationship between baseline and follow-up DASI and risk of long-term death was established. Follow-up DASI was associated with risk-adjusted long-term survival hazard ratio of 0.98 per unit increase (confidence limits, 0.97 to 0.98; P <0.0001). Achieving maximum baseline DASI was associated with better risk-adjusted long-term survival (hazard ratio, 0.64; confidence limits, 0.50 to 0.83; P =0.0005).

Conclusions— Poor health-related quality of life after recovery from cardiac surgery identifies patients who are at risk for reduced long-term survival.

Video information combined with individualized information sessions: Effects upon emotional well-being following coronary artery bypass surgery--A randomized trial

OBJECTIVE

To test the efficacy of an information intervention upon emotional recovery following coronary artery bypass surgery.

METHODS

Randomized trial. Video information was combined with individualized information sessions carried out by nurses at admission and at discharge from the hospital. The video was shown pre-operatively and again during the session at admission. Patients were helped to express their questions and worries and congruent information and support was provided. Control group patients received standardized information and no video. Recordings were made at baseline, discharge from hospital and during a 2 years follow-up period.

RESULTS

One hundred and nine patients were randomized to the intervention or the control groups. A MANOVA was used to test of the variance of the outcome variables at each time point. At discharge intervention patients reported less anxiety (p = 0.046) and better subjective health (p = 0.005). They reported better subjective health during the whole follow-up period (0.040 > or = p > or = 0.000), less anxiety up to 1 year (0.042 > or = p > or = 0.004), and less depression from 6 months to 2 years following discharge (0.023 > or = p > or = 0.004).

CONCLUSION

The effects of the intervention probably relate to the combined use of the video and patient centered information sessions.

PRACTICE IMPLICATIONS

The intervention can easily be implemented in clinical practice and nurses strongly identified with its principles.

The influence of different error estimates in the detection of postoperative cognitive dysfunction using reliable change indices with correction for practice effects

The reliable change index (RCI) expresses change relative to its associated error, and is useful in the identification of postoperative cognitive dysfunction (POCD). This paper examines four common RCIs that each account for error in different ways. Three rules incorporate a constant correction for practice effects and are contrasted with the standard RCI that had no correction for practice. These rules are applied to 160 patients undergoing coronary artery bypass graft (CABG) surgery who completed neuropsychological assessments preoperatively and 1 week postoperatively using error and reliability data from a comparable healthy nonsurgical control group. The rules all identify POCD in a similar proportion of patients, but the use of the within-subject standard deviation (WSD), expressing the effects of random error, as an error estimate is a theoretically appropriate denominator when a constant error correction, removing the effects of systematic error, is deducted from the numerator in a RCI.

Donepezil for cognitive decline following coronary artery bypass surgery: a pilot randomized controlled trial

OBJECTIVE

To study the effect of donepezil in treating patients with cognitive decline following coronary artery bypass graft (CABG) surgery.

METHODS

Forty-four patients, with at least a 0.5 SD decline at 1 year post-CABG on at least one cognitive domain compared to their pre-CABG baseline score, were randomized to treatment with donepezil (titrated to 10 mg daily) or placebo in a 12-week double-blind, single center, randomized study. A composite cognitive change score served as the primary outcome. Secondary outcome measures included tests of memory, attention, psychomotor speed, and executive function.

RESULTS

The composite cognitive outcome did not show significant treatment effects. Secondary measures varied in their sensitivity to donepezil effects with the largest effects seen on the Wechsler Visual Memory Scale-Delayed and Immediate recall tests. More than twice (52% vs. 22%) as many donepezil-treated patients showed a significant improvement compared with placebo patients on Delayed recall. Tests with weak effect sizes and minimal trends favoring donepezil were the Boston Naming and Digit Symbol. However, most of the other instruments (e.g., Digit Span, Trails B, and Controlled Word Association) showed no treatment benefits. More donepezil-treated than placebo-treated patients experienced diarrhea, but other adverse effects and safety measures did not differ between groups.

CONCLUSION

In the post-CABG mild cognitive decline setting, donepezil did not improve composite cognitive performance but improved some aspects of memory. Donepezil was well tolerated and had no significant effects on EKG parameters. Because of limitations such as small sample size and multiplicity of tests, these findings are preliminary but add to our knowledge of cholinergic effects in vascular mild cognitive decline.

Application of a chronic illness model as a means of understanding pre-operative psychological adjustment in coronary artery bypass graft patients

OBJECTIVES

To increase understanding of the factors associated with pre-operative psychological adjustment in coronary artery bypass graft (CABG) patients by assessing the utility of a chronic illness model developed by Scharloo, Kaptein, Weinman, Willems, and Rooijmans (2000).

DESIGN

A cross-sectional design was employed.

METHOD

Elective CABG patients (N=119) completed self-report measures of illness representation, self-rated health, social support, coping methods, and pre-operative adjustment (depression and post-traumatic stress disorder (PTSD) symptomatology) an average of 30 days prior to surgery. Hierarchical multiple regression was used to assess the mediational relationships proposed by the chronic illness model.

RESULTS

Five 3-variable mediational chains were assessed. In all instances, the results conformed to the relationships suggested by the chronic illness model where the strength of the relationship between the independent and dependent variables was reduced when the mediator variable was controlled. However, a significant reduction of this relationship was found in three of the five chains examined. The most rigorous support for the model occurred, where increased use of avoidance coping mediated the relationship between poorer self-rated health and increased PTSD symptomatology, and also where increased use of avoidance coping partially mediated the relationship between a more negative illness representation and increased PTSD symptomatology, and poorer self-rated health and increased depression.

CONCLUSIONS

The chronic illness model of Scharloo and colleagues shows potential in explaining pre-operative adjustment in CABG patients. Longitudinal examination of the model is recommended.

Cardiac rehabilitation in Austria: short term quality of life improvements in patients with heart disease

BACKGROUND

The goal of cardiac rehabilitation programs is not only to prolong life, but also to improve physical functioning, symptoms, wellbeing and health-related quality of life (HRQL). The aim of the study was to document short-term outcomes of cardiac rehabilitation programs in Austria.

METHODS

Consecutive patients (N = 487, 64.7% male, age 60.9 +/- 12.5 SD years) after myocardial infarction (MI), with or without percutaneous interventions (PCI), coronary artery bypass grafting (CABG) or heart valve surgery (HVS), referred to the six inpatient rehabilitation centers of the Austrian PVA insurance company, were included in the study. Exercise capacity, risk factors and HRQL (MacNew Heart Disease Quality of Life Instrument [MacNew] and EuroQoL-5D [EQ-5D]) were measured at the beginning and end of the 4-week inpatient cardiac rehabilitation program.

RESULTS

Global HRQL (MacNew) improved significantly over time in all patients combined (+0.75 +/- 0.88 SD, T = -16.99, df = 394, p < .001) and exceeded the minimal important difference. Patients with CABG, HVS or MI without PCI showed the greatest improvements in global HRQL after cardiac rehabilitation (p < .02). Blood pressure, cholesterol, triglyceride, body mass index, waist circumference improved significantly (all p < .001).

CONCLUSION

These findings provide evidence that the improvements in HRQL and risk factors following cardiac rehabilitation in Austria are clinically important. HRQL should become a standard outcome parameter in cardiac rehabilitation.