Chest pain self-management training for patients with coronary artery disease

Refractory Angina-Unsolved Problem

The article discusses pharmacologic and interventional therapeutic options for patients with refractory angina. Refractory angina refers to long-lasting symptoms (≥3 months) due to established reversible ischemia in the presence of obstructive coronary artery disease, which cannot be controlled by escalating medical therapy with second-line and third-line pharmacologic agents, bypass grafting, or stenting. Due to an aging population, increased number of comorbidities, and advances in coronary artery disease treatment, incidence of refractory angina is growing. Although the number of therapeutic options is increasing, there is a lack of randomized clinical trials that could help create recommendations for this group of patients.

Impact of self-management interventions on stable angina symptoms and health-related quality of life: a meta-analysis

Background

Chronic stable angina (CSA) has a major negative impact on health-related quality of life (HRQL) including poor general health status, psychological distress, and inability to self-manage.

Methods

We used meta-analysis to assess the effectiveness of self-management interventions for improving stable angina symptoms, HRQL and psychological well-being. Nine trials, involving 1,282 participants in total, were included. We used standard inverse-variance random-effects meta-analysis to combine the trials. Heterogeneity between trials was evaluated using chi-square tests for the tau-squared statistic and quantified using the I² statistic.

Results

There was significant improvement in the frequency of angina symptoms (Seattle Angina Questionnaire [SAQ], symptom diary) across trials, standardized mean difference (SMD): 0.30 (95% Confidence interval [CI] 0.14, 0.47), as well as reduction in the use of sublingual (SL) nitrates, SMD: -0.49 (95% CI -0.77, -0.20). Significant improvements for physical limitation (SAQ), SMD: 0.38 (95% CI 0.20, 0.55) and depression scores (Hospital Anxiety and Depression Scale), SMD: -1.38 (95% CI -2.46, -0.30) were also found. The impact of SM on anxiety was uncertain due to statistical heterogeneity across trials for this outcome, I² = 98%. SM did not improve other HRQL dimensions including angina stability, disease perception, and treatment satisfaction.

Conclusions

SM interventions significantly improve angina frequency and physical limitation; they also decrease the use of SL nitrates and improve depression in some cases. Further work is needed to make definitive conclusions about the impact of SM on cardiac-specific anxiety.

Symptoms of anxiety and depression are correlates of angina pectoris by recent history and an ischemia-positive treadmill test in patients with documented coronary artery disease in the pimi study

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain

Cardiac pain arising from chronic stable angina (CSA) is a cardinal symptom of coronary artery disease and has a major negative impact on health-related quality of life (HRQL), including pain, poor general health status, and inability to self-manage. Current secondary prevention approaches lack adequate scope to address CSA as a multidimensional ischemic and persistent pain problem. This trial evaluated the impact of a low-cost six-week angina psychoeducation program, entitled The Chronic Angina Self-Management Program (CASMP), on HRQL, self-efficacy, and resourcefulness to self-manage anginal pain. One hundred thirty participants were randomized to the CASMP or three-month wait-list usual care; 117 completed the study. Measures were taken at baseline and three months. General HRQL was measured using the Medical Outcomes Study 36-Item Short Form and the disease-specific Seattle Angina Questionnaire (SAQ). Self-efficacy and resourcefulness were measured using the Self-Efficacy Scale and the Self-Control Schedule, respectively. The mean age of participants was 68 years, 80% were male. Analysis of variance of change scores yielded significant improvements in treatment group physical functioning [F=11.75(1,114), P<0.001] and general health [F=10.94(1,114), P=0.001] aspects of generic HRQL. Angina frequency [F=5.57(1,115), P=0.02], angina stability [F=7.37(1,115), P=0.001], and self-efficacy to manage disease [F=8.45(1,115), P=0.004] were also significantly improved at three months. The CASMP did not impact resourcefulness. These data indicate that the CASMP was effective for improving physical functioning, general health, anginal pain symptoms, and self-efficacy to manage pain at three months and provide a basis for long-term evaluation of the program.

Effectiveness of Psychoeducational Interventions for Improving Symptoms, Health-Related Quality of Life, and Psychological well Being in Patients with Stable Angina

Several primary trials report the adjunctive value of psychoeducational interventions for improving stable angina symptoms, health-related quality of life (HRQL) and psychological well-being; however, few high-quality meta-analyses have examined the overall effectiveness of these interventions. We used meta-analysis in order to determine the effectiveness of psychoeducational interventions for improving symptoms, HRQL and psychological well-being in stable angina patients. Seven trials, involving 949 participants total were included. Those who received psychoeducation experienced nearly 3 less angina episodes per week, delta (Delta)= -2.85, 95% CI, -4.04 to -1.66, and used sublingual (SL) nitrates approximately 4 times less per week, Delta= -3.69, 95% CI -5.50 to -1.89, post-intervention (3-6 months). Significant HRQL improvements (Seattle Angina Questionnaire) were also found for physical limitation, Delta= 8.00, 95% CI 4.23 to 11.77, and disease perception, Delta= 4.46, 95% CI 0.15 to 8.77, but CIs were broad. A pooled estimate of effect on psychological well-being was not possible due to heterogeneity of measures. Psychoeducational interventions may significantly reduce angina frequency and decrease SL nitrate use in the short-term. These encouraging results must be interpreted with caution due to heterogeneity in methods and small samples. Larger, robust trials are needed to further determine the effectiveness of psychoeducation for stable angina management.

Psychological distress and exertional angina in men and women undergoing thallium scintigraphy

The relation between psychological factors and angina has mostly been studied in male patients with confirmed CAD and few have evaluated this relation during actual provocation of ischemia. This study evaluated gender differences in the association between psychological distress and angina pain experience in 907 Caucasian patients (479 women, mean age = 60 years) undergoing exercise stress testing with thallium scintigraphy. Data were analyzed separately for patients with and without exercise related ischemia using a series of 2 (low/high distress) x 2 (gender) ANOVAs as well as binary logistic regressions. Among all patients, distress and gender were associated with greater risk and intensity of angina pain during testing (p < 0.05) and more angina following exertion (p < 0.05) or stress (p < 0.05) at home.

CONCLUSION

angina pain was more severe in women and individuals with high levels of distress, regardless of their ischemic status. A generalized hypersensitivity to pain/symptoms may be indicated in these patients.

What's “Unstable” in Unstable Angina?

The role of emotional distress (e.g., anger, depression, and anxiety) in anginal chest discomfort (ACD) may have been underestimated. The authors review the empirical studies in this area, which are inconsistent with the standard theory on the ischemia-angina relationship; summarize the substantial evidence indicating a strong and consistent cross-sectional/prospective epidemiological association of emotional distress and ischemia/ACD; review the distress-targeted, interventional evidence confirming a causal relationship (i.e., reduced chest discomfort and health system utilization), thus confirming clinical utility of such interventions; and explore the possible mechanisms that might account for the relationship between emotional distress and chest discomfort. Substantial clinical benefit may be achieved by aggressively detecting and treating emotional distress in ACD patients.

A systematic review of psychoeducational intervention trials for the management of chronic stable angina

BACKGROUND

Chronic stable angina (CSA) is a cardinal symptom of coronary artery disease and has a major impact on health-related quality of life (HRQOL). There are few data on the effectiveness of psychoeducational interventions for CSA patients that target HRQOL-related outcomes.

AIM

To determine the effectiveness of psychoeducational interventions for CSA management based on the best available evidence.

METHODS

A systematic review of randomized controlled trials (RCTs) testing the effects of psychoeducational interventions on angina symptoms, angina symptom-related distress, and physical functioning was conducted. Four primary studies (1994-97) were included that had (a) specified treatment and control conditions, (b) participants with anigna class I-III (Canadian Cardiovascular Society) and (c) psychoeducational interventions. These studies were reviewed for methodological rigour. A pooled common effect could not be determined because of heterogeneity of outcomes, measures and analyses.

RESULTS

While positive effects were reported, methodological problems with respect to sampling, randomization, controls and measurement precluded generalization.

CONCLUSION

The effectiveness of psychoeducation interventions for improving angina outcomes is inconclusive. Future RCTs of psychoeducational programmes require methodologically robust methods to reduce biases and random error, and to enhance the generalizability of findings for CSA management.

Self-management approaches for people with chronic conditions: a review

The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies.

Self-management approaches for people with chronic conditions: a review

The purpose of this paper is to provide an overview of self-management approaches for people with chronic conditions. The literature reviewed was assessed in terms of the nature of the self-management approach and the effectiveness. Findings are discussed under the headings of: chronic conditions targeted, country where intervention was based, type of approach (e.g. format, content, tutor, setting), outcomes and effectiveness. The last of these focused on reports of randomised controlled studies.

Chest pain and the treatment of psychosocial/emotional distress in CAD patients

Treatment of psychosocial/emotional distress as a strategy for diminishing chest pain in such patients remains entirely unutilized in standard care. Sixty-three patients with known or suspected CAD were entered in an aggressive lifestyle modification program. Patients completed the Symptom Checklist 90-Revised (SCL90R) at the diagnostic interview session, at 3 and at 12 months. Statistically significant drops were observed on multiple scales of the SCL90R at both 3 and 12 months. An item from the SCL90R was used as a proxy for angina. Multiple measures of emotional distress at baseline were found to correlate with chest pain at baseline, but not a number of traditional cardiovascular risk factors. The chest pain item displayed improvement at both 3 and 12 months. Improvement on all scales of the SCL90R correlated with improvement in chest pain. It may be possible to control chest pain in some CAD patients with psychosocial interventions.

Cognitive aspects of pain and pain control

The cognitive and cognitive-behavioral approaches have been shown to be very effective in controlling pain and its sequelae both in the laboratory and in the clinical setting. As used in most research and treatment, cognitive approaches are concerned with the way the person perceives, interprets, and relates to his or her pain rather than with the elimination of the pain per se. This article reviews some of the origins of cognitive theory and pain theory, as well as examples of the techniques used and the research support for the approach. Special emphasis is given to self-efficacy, perceived control, and stress inoculation therapy. There is also discussion of some of the limitations of the cognitive approach. The overall conclusion is that the cognitive approach is a powerful and effective one for pain control despite its limitations.