[Study based on the WHO Monika program on the connection between psychosocial risk factors and ischemic heart disease in men aged 25-64 in Novosibirsk]

AIM

To study correlations between coronary heart disease (CHD) and psychosocial risk factors.

MATERIAL AND METHODS

CHD affected more frequently workers engaged in hard physical labour, in poorly educated persons; the least CHD morbidity was recorded in managers and highly educated persons. CHD males think of their health much worse than males free of CHD. The former smoked much more before CHD diagnosis, but when CHD comes they quit and reduce smoking much more frequently. This fact explains why smokers are encountered among CHD patients two times less frequently than in CHD-free males. In spite of stronger motivation for adequate diet, CHD males changed their nutrition pattern only in 3.7%. CHD males sleep worse: good sleep was registered in CHD-free males two times more frequently. Psychological risk factors such as personal anxiety, sleep disorders were reported much more frequently in CHD patients proving the fact of social stress involvement in development of CHD. So-called coronary behavior was observed in both groups of males with the same rate. Thus, the coronary behavior is not associated with CHD.

CONCLUSION

Development of CHD is associated not with the behavior but its components (depression, anxiety, etc.).

Symptoms, myocardial ischaemia and quality of life in women: results from the NHLBI-sponsored WISE Study

AIMS

Our goal was to evaluate health-related quality of life (QOL) in women undergoing angiography for suspected ischaemia.

METHODS AND RESULTS

QOL measurements were obtained in 406 women with chest pain symptoms in the Women's Ischemia Syndrome Evaluation (WISE). QOL measures included a general rating (GR), Duke Activity Status Index (DASI), and the Beck Depression Inventory (BDI). Higher scores on the GR and DASI are indicative of better QOL and functioning. Higher scores on the BDI indicate more symptoms of depression. Women were stratified by the presence and absence of obstructive angiographic coronary artery disease (CAD) and by the presence and absence of myocardial ischaemia. Women with angiographic obstructive CAD had lower DASI and higher BDI scores compared to women without obstructive CAD (both P<0.05). Stratification by the presence and absence of ischaemia demonstrated that women with ischaemia had better QOL, evidenced by higher GR QOL scores and lower BDI scores (both P<0.05) than women without ischaemia. Symptoms of angina were significant independent predictors of QOL scores (P<0.001).

CONCLUSIONS

Chest pain symptoms have a significant impact on health-related QOL in women undergoing coronary angiography for suspected myocardial ischaemia andare more important determinants of QOL than the underlying conditions of CAD or ischaemia.

Psychosocial distress and impaired quality of life ??? targets neglected in the secondary prevention in women with ischaemic heart disease

BACKGROUND

Secondary prevention in patients with ischaemic heart disease (IHD) focusing on classical risk factors has been less successful in women than in men. Previous studies have suggested that psychosocial factors may be new targets for secondary prevention. In the present study, psychosocial factors have been compared in women with and without IHD.

METHODS AND SUBJECTS

Using a cross-sectional comparison, classical cardiovascular risk factors and self-rated stress behaviour, vital exhaustion, stressful life events and quality of life were assessed in 198 women (age 35-77 years) who had IHD and a population-based sample of 206 women (age 45-74 years) without IHD.

RESULTS

Control of classical risk factors was most often adequate in women with IHD. The prevalence of smoking was 9% in women with versus 18% in women without IHD (P<0.001), blood pressure levels were similar, and a very large share of women with IHD were on treatment with anti-thrombotic, anti-hypertensive and/or lipid-lowering drugs (P<0.001 compared with women free of IHD). In contrast, women with IHD scored significantly worse than women without IHD in self-rated stress behaviour (P=0.003 after adjustment for other possible determinants), and in vital exhaustion (P=0.003). In univariate analyses, quality of life was significantly worse in women with IHD. Stressful life events did not differ between the two groups.

CONCLUSIONS

In this group of women with IHD, control of classical risk factors was good, whereas control of psychosocial risk factors was clearly inadequate. Secondary prevention by psychosocial intervention in women with IHD should be evaluated in randomized controlled trials.

Depression and increased myocardial ischemic activity in patients with ischemic heart disease

BACKGROUND

Depression is relatively common in patients with ischemic heart disease (IHD) and is associated with increased risk of mortality and morbidity. However, the mechanisms by which depression adversely affects clinical outcomes of patients with IHD are unknown. This study examined the relationship between depression and myocardial ischemia during mental stress testing and during daily living in patients with stable IHD.Methods and results The Center for Epidemiological Studies-Depression scale (CES-D) was administered to 135 patients with IHD to evaluate depressive symptoms. Radionuclide ventriculography was used to evaluate the occurrence of left ventricular wall motion abnormality (WMA) during mental stress and exercise testing. Forty-eight-hour ambulatory electrocardiography was used to assess myocardial ischemia during daily living. The mean CES-D score was 8.2 (SD 7.4, range 0-47) with a median of 7. Logistic regression models using restricted cubic splines revealed a curvilinear relation among CES-D scores and the probability of ischemia. For patients with CES-D scores <or=19 (81.5% of study population), a 5-point increment in the CES-D score was associated with roughly a 2-fold increase in the likelihood of ischemia during mental stress. For patients with CES-D scores >19, the relation among scores and ischemia during mental stress tended to be inversely related, but the portion of the sample is very small. Similar patterns of results were noted for CES-D scores and ischemia during daily life.

CONCLUSIONS

Patients with mild to moderate depressive symptoms (CES-D scores <or=19) are more likely to exhibit myocardial ischemia during mental stress testing and during daily living. Myocardial ischemia may be one mechanism by which depression increases the risk of mortality and morbidity in patients with IHD. The observed inverse association between higher level of depressive symptoms and ischemic activity needs to be further assessed in large samples.

Estimation of subjective stress in acute myocardial infarction

BACKGROUND AND AIMS

Mental stress is considered to be a precipitating factor in acute coronary events. We aimed to assess the association of subjective or 'perceived' mental stress with the occurrence of acute coronary events.

SETTINGS AND DESIGN

Prospective case-control survey was carried out in a referral teaching hospital.

SUBJECTS & METHODS

Consecutive patients with acute myocardial infarction and ST elevation on electrocardiogram who were admitted to the Coronary Care Unit of a referral teaching hospital were enrolled in the study as cases. Controls were unmatched and were enrolled from amongst patients with coronary artery disease who did not have recent acute coronary events. Subjective Stress Functional Classification (SS-FC) for the preceding 2-4 weeks was assessed and assigned four grades from I to IV as follows: I - baseline, II - more than usual but not affecting daily routine, III - significantly high stress affecting daily routine and IV - worst stress in life.

STATISTICAL ANALYSIS

Proportions of different characteristics were compared using chi-square test with Yates continuity correction. Student's unpaired t test was applied for mean age. 'p' value of < 0.05 was considered statistically significant.

RESULTS

SS-FC could be reliably (99%) and easily assessed. Eighty (53%) of the total 150 patients with acute MI reported 'high' levels of stress (stress class III and IV). This is in contrast to only 30 (20%) of 150 healthy controls reporting high stress for the same period (p value < 0.001).

CONCLUSION

Patients with acute myocardial infarction report a higher subjective mental stress during 2 to 4 weeks preceding the acute coronary event.

Impact of a home communication intervention for coronary artery bypass graft patients with ischemic heart failure on self-efficacy, coronary disease risk factor modification, and functioning

OBJECTIVE

The purpose of this study is to determine the impact of a home communication intervention (HCI) for ischemic heart failure Coronary Artery Bypass Graft (CABG) patients >/= 65 years of age on self-efficacy, coronary artery disease risk factor modification and functioning posthospitalization.

DESIGN

A randomized clinical trial with repeated measures was used.

SAMPLE

A subsample of ischemic heart failure CABG surgery patients (n = 35) was drawn from the parent study of 180 CABG patients.

RESULTS

HCI participants (n = 18) had significantly higher adjusted mean self-efficacy scores [F(1, 29) = 6.40, P <.05] and adjusted mean levels of functioning (physical, general health, mental, and vitality functioning) compared with the routine care group (n = 17), using repeated measures analysis of covariance with baseline scores as covariates. There were also significant effects of time on bodily pain and role emotional functioning. Significantly higher exercise adherence (t = 3.09, P <.01) and lower reported stress (t = 3.77, P <.01) at 3 months after surgery was reported by HCI subjects.

CONCLUSIONS

Data from this pilot study can be used to strengthen the HCI intervention with more tailored strategies for vulnerable subgroups of CABG patients.

Depression and ischemic heart disease: overview of the evidence and treatment implications

In this article, the authors review the evidence that depression is a risk factor for ischemic heart disease and examine the efficacy and safety of depression treatments in patients with ischemic heart disease.

[Guidelines on psychological intervention in cardiac rehabilitation- methodological process]

The development and the role of cardiac rehabilitation in healthcare programs related to cardiovascular diseases has led to the growth of knowledge, experience and specific technical, scientific, organizational and cultural skills on the part of the different health professionals engaged with the cardiologist in the management of rehabilitation programs. The need to define the characteristics of the psychological intervention in cardiac rehabilitation programs on the basis of scientific evidence encouraged the Board of the Italian Group of Cardiac Rehabilitation and Prevention [Gruppo Italiano di Cardiologia Riabilitativa e Preventiva (GICR)] to set up a working group (WG), composed of psychologists chosen on the basis of their proven specific experience in clinical research, with the task of defining the state-of-the-art of the psychological intervention in cardiac rehabilitation on the basis of documented efficacy, as a first step to formulating Guidelines on Psychological Intervention in Cardiac Rehabilitation. The methodology adopted by the WG was in line with the recommendations of the National Guidelines Program of the Italian Ministry of Health; the WG chose, in addition, to exploit a detailed critical review of clinical psychology practice in order to provide systematic evidence for recommendations and clinical approaches at present supported only by expert opinion. The document, which represents the basis upon which the Guidelines on the psychological activity in cardiac rehabilitation will be drawn up, is subdivided into three parts: an introduction, the main body of the text, and some appendices. In the introduction, the theme and context of the Guidelines are defined, preceded by a series of notes and user instructions; also defined in this section are the intended audience. The main body of the document is structured on the basis of the steps that characterize the interactions between the patient suffering from heart disease and the psychologist, through a qualitative analysis of the intervention offered by the psychologist. The phases of this process have been schematized as follows: selection, entry, evaluation, intervention, follow-up. For each of these phases, the evidence is given in support of the evaluative and therapeutic tools at the psychologist's disposition in the context of cardiac rehabilitation. The appendices to the document contain syntheses of the scientific information, some tables, a glossary and a section providing more in-depth information on specific topics. The recommendations contained in the document elaborated by the WG were formulated on the basis of a systematic review of the evidence available in the Italian and international literature, codified according to the National Guidelines Program. Also included is a series of recommendations or working instructions based on the shared clinical experience of the members of the WG. The state of progress of the work of formulating the Guidelines, the objectives, the methodological premises and the deadlines set for the phases of development, diffusion and implementation were presented at the VI National Congress of the GICR which was held in Cosenza, 3-5 October 2002. The base-draft of the document was submitted to the Scientific Committee of Reviewers. In October 2002 the Executive Committee of the GICR announced to the National Guidelines Program of the Ministry of Health, in the persons of the Presidents of the Advanced Institute of Health and of the Regional Health Services Agency, the planning and the timetable for the formulation of the Guidelines. In the course of the first 4 months of 2003 the document produced will be discussed and reviewed jointly by the WG, the Cardiologic Scientific Board instituted by the GICR enlarged to include a delegate of the patient and volunteer no-profit worker associations. The following phases will include the publication by mid 2003 of a position-paper. The final draft of the Guidelines on Psychological Intervention in Cardiac Rehabilitation will be submitted to the Commission of the National Guidelines Program.

Detection and reproducibility of mental stress-induced myocardial ischemia with Tc-99m sestamibi SPECT in normal and coronary artery disease populations

BACKGROUND

Mental stress-induced ischemia, as detected by radionuclide studies, has yielded reversible ischemia in only 30% to 60% of patients with exercise-induced ischemia. Little is known about the reproducibility of myocardial perfusion imaging in detecting mental stress-induced ischemia. The purpose of this study was to further evaluate the occurrence and reproducibility of mental stress-induced ischemia in patients with coronary artery disease (CAD) and in normal control subjects with a low likelihood of CAD by using sestamibi single photon emission computed tomography (SPECT) imaging.

METHODS AND RESULTS

A total of 40 patients were enrolled in this study: 19 patients with CAD and typical angina or reversible ischemia (positive exercise treadmill study or positive adenosine thallium study) and 21 normal control subjects underwent mental stress testing as well as myocardial perfusion imaging. The subjects were given a speaking task, and SPECT imaging was subsequently performed. Two experienced readers compared mental stress imaging with a resting image using a 20-segment cardiac model. Hemodynamic changes in blood pressure and heart rate with mental stress were also measured in all subjects. Each patient with CAD also underwent repeat mental stress testing and myocardial imaging approximately 2 weeks later. Of the 19 patients with CAD and typical angina or with evidence of reversible ischemia, 16 (84%) demonstrated ischemia with mental stress, as detected by sestamibi SPECT imaging. The mean number of new or worsened perfusion defects attributable to mental stress was 3.5, with a mean severity of 1.7. These results were also reproducible. With repeated mental stress testing and myocardial imaging, 12 of the 16 CAD patients (75%) demonstrated evidence of myocardial ischemia. None of the 21 normal control subjects had evidence of mental stress-induced myocardial ischemia. Mental stress also induced reproducible and significant hemodynamic changes in CAD patients.

CONCLUSIONS

In patients with known CAD with typical angina or with evidence of reversible ischemia despite taking medications, mental stress was very effective in inducing myocardial ischemia, as detected by sestamibi SPECT imaging. Mental stress was also found to elicit significant hemodynamic responses. Furthermore, these findings demonstrated good reproducibility.

[Characteristics of psycho-autonomic correlations and clinical course of ischemic heart disease in men and women]

AIM

To study psychovegetative correlations and clinical course of ischemic heart disease (IHD) in men and women.

MATERIAL AND METHODS

Personality characteristics (MMPI test), reactive and personal anxiety (Spilberger's questionnaire), severity of depression (Back's questionnaire), vegetative status (vegetative disorders questionnaire), variability of cardiac rhythm (cardiovascular tests) were studied in 60 females and 62 males with IHD.

RESULTS

IHD females vs males were characterized by higher neurotization, personal accentuation, more serious anxiety, depression and vegetative disturbances, lower variability of heart rate. IHD in females is more frequent in postmenopause, is characterized by less severe hemodynamically significant coronary stenoses.

CONCLUSION

Emotional disorders make a great contribution to a course of ischemic heart disease.

[Autonomic regulation and emotional status in patients with ischemic heart disease having pain syndrome of various severity]

To study vegetative regulation and emotional status of ischemic heart disease (IHD) patients with various pain severity, 81 patients with IHD were examined. Personality characteristics were studied by the data of MMPI questionnaire, reactive and personal anxiety--of Spilberger questionnaire, depressive changes--of Beck's questionnaire, vegetative status--by vegetative discharge, Seattle angina questionnaire of life quality, heart rhythm variability and cardiovascular tests. All the patients have undergone clinical examination, exercise stress tests, echocardiography. Selective coronary angiography was made in some examinees. The patients were divided into two groups by anginal pain severity. The patients with more severe anginal pain had higher reactive and personal anxiety, neurotization. This was not associated with changes in the vegetative status and hemodynamics at rest. The detected emotional disorders in IHD patients may cause higher sensitivity of these patients to pain, on the one side, and changes in vegetative regulation of cardiovascular system and hemodynamics, on the other.

Quality of life and psychological impact of implantable cardioverter defibrillators: focus on randomized controlled trial data

The defibrillator has been shown to reduce mortality in a number of patient groups with cardiac disease. Given the number of individuals with defibrillators it is important to understand the influence of these devices quality of life. Advances have led to smaller devices, less-invasive implantation, and more refined arrhythmia management. The potential impact of the defibrillator on quality of life continues to evolve with these advances. This review discusses the impact of the defibrillator on psychological well-being and quality of life, particularly the results of recent large randomized trials. Observational studies evaluating the relationship between defibrillator implantation and quality of life have not shown consistent results, but recent data from randomized trials provide important insights. Among patients who have survived life-threatening arrhythmias the defibrillator is associated with similar or perhaps superior quality of life versus antiarrhythmic drug therapy. However, patients who experience shocks have poorer quality of life versus those who do not. The reduction in quality of life with multiple shocks is of similar magnitude to serious side effects from antiarrhythmic drugs. While patients with defibrillators are at risk for poor quality of life. The advantages and disadvantages of defibrillator therapy versus amiodarone or usual medical care should be discussed with patients in whom a defibrillator is recommended. Those undergoing defibrillator implantation should be advised that adverse events and/or multiple shocks occur in a minority of patients, but may lead to reduced quality of life and it is vital that support resources be made available for these individuals.

[Pyrazidol in the treatment of depression in patients with ischemic heart disease]

AIM

To study efficacy and safety of pirazidol administration in depressive patients with ischemic heart disease (IHD).

MATERIAL AND METHODS

Pirazidol was given in a dose 0.15-0.3 g/day for 4 weeks to 30 IHD patients aged 21-65 years. 21 of them had nosogenic depression, 9 patients had dysthymia. The efficacy of the antidepressive action was assessed by the Hamilton scale.

RESULTS

The trend to a decrease in Hamilton scale scores was manifest by the end of the treatment week 2. To the end of the study the overall score median lowered from 17 to 9, most of the patients had the score sum under 11. Side effects were insignificant. In pirazidol combination with beta-blockers, blockers of calcium channels, antiaggregant, diuretic drugs, nitrates and other cardio- and angiotropic drugs unfavorable interactions were not registered.

CONCLUSION

Pirazidol can be effectively used in the treatment of psychosomatic disorders in patients with cardiovascular diseases.

[Is the negative T-wave on the ECG always a sign of ischemia? (human stress cardiomyopathy?) ]

A 74-year-old woman was admitted on account of chest pain which developed after a death in the family. On the ECG on admission there were negative T waves (the picture of extensive subapicardial ischaemia). Coronarography made on the subsequent day was quite normal. The laboratory finding (CK, CK-MB, AST) did not suggest an acute coronary attack. Ultrasound examination of the heart revealed only slight hypokinesia of the anterior wall. ECG returned to normal within 3 months. Four years later the patient is asymptomatic. The ECG finding and clinical course suggest the clinical entity of "stress cardiomyopathy", which is not a well known and unequivocally accepted diagnosis.

Constructing a coronary scale for ischemic heart disease: case-control study

AIM

To develop a scale measuring proneness to ischemic heart disease.

METHODS

Ischemic heart disease was angiographically documented in 187 men. In 187 matched controls the diagnosis of ischemic heart disease was ruled out by examination of medical records and history data, and when necessary, clinical examination and specialized diagnostic procedures. Item analysis of the Eysenck Personality Questionnaire (EPQ) was performed on 100 men with ischemic heart disease and their male controls, and then a replication study was performed on the remaining 87 pairs.

RESULTS

A Coronary Scale was constructed from 8 EPQ items significantly and consistently different between the groups. Most of these items were drawn from the neuroticism scale. The Coronary Scale yielded significant correlations with emotionally saturated psychological variables.

CONCLUSION

Coronary Scale may be useful in everyday practice to select patients with ischemic heart disease and those who are at higher risk to develop disease. It could be used for detecting a high-risk group of emotionally labile subjects to concentrate efforts for prevention of coronary disease.

[Panic disorder in clinical picture of ischemic heart disease]

The article reports a case of ischemic heart disease (IHD) diagnosed in a patient admitted to hospital because of recurrent paroxysms of panic disorder. Clinical follow-up determined some significant risk factors of IHD, the clinical picture of which was overlapped by dominating anxiophobic and tanatophobic syndrome. Diagnosis of IHD and coronary atherosclerosis was made at radionuclide single photon computed tomography of the myocardium, which had detected hypoperfusion of the posteroseptal left ventricle, followed by coronaroventriculography. This case illustrates the necessity of the integrative (psychosomatic) approach to diagnosis and choice of treatment policy.

[The process of moulding knowledge about illness in patients with ischaemic heart disease]

The presented work handles the problem of the process of moulding knowledge about illness on the example of cardiologic patients. The papers cognitive frames are pointed out by the conception of transfer of knowledge. The author acknowledges that the patients convictions and behaviours can be understood more thoroughly if the following aspects are analysed: doctors convictions and attitudes, their skills in transferring the medical knowledge (to the patients) and ability to recognize the capacities and limitations of patients. Considering social changes, we can respect the gradual evolution of the present models of relations between patients and medical staff to the forms closer to the recommended ones.

Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study

BACKGROUND

Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates.

METHODS AND RESULTS

To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5+/-0.4 years and 5.2+/-0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P=0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36; P=0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P=0.9) and did not predict death even after adjusting for resting ejection fraction (P=0.63), which was similar in both groups (mean, 56.4 versus 59.7; P=0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise.

CONCLUSIONS

In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress-induced ischemia predicts subsequent death.