Gender and psychosomatic aspects of ischemic heart disease

What is gender awareness in health? A scoping review of the concept, its operationalization, and its relation to health outcomes

Gender awareness emerged in the 1990s and aimed to provide awareness and sympathy toward the needs of women, measuring health-care providers' attitudes toward them and understand if providers possessed the knowledge for appropriate care. According to Miller et al.'s seminal model, gender awareness incorporates three sub-dimensions: gender sensitivity, gender ideology, and knowledge. Gender awareness has the potential to minimize gender bias in health care, improving the ecological validity of research. This scoping review provides an analysis of how gender awareness has been conceptualized, operationalized, and investigated in its relationship with health-related outcomes. A search was conducted on PubMed, PsycINFO, and ERIC. The relevance of 2.589 articles was assessed and 14 empirical studies were selected and included. Difficulties conceptualizing gender awareness were found and gender awareness and gender sensitivity were often presented as interchangeable. Most papers aimed to measure and compare levels of gender awareness among health professionals and the relationship between gender awareness and relevant health-related outcomes was not studied. Drawing upon a critical analysis of our findings, a proposal for a revised gender awareness conceptualization and operationalization is put forth as to inform novel research on its association with gender bias in health and health care.

Disease composition and epidemiological characteristics of primary care visits in Pudong New Area, Shanghai: a longitudinal study, 2016-2018

OBJECTIVES

This study aims to analyse the disease composition of primary care visits rather than specialist visits, the former of which had scarcely been studied. We adopted specific disease classification (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), disease system and communicable/non-communicable/injury disease classification, and variations of sex and age were also analysed.

SETTING

We extracted data from all community health service centres (CHSCs) and community health service stations in Pudong, Shanghai, from 2016 to 2018 using the electronic health record systems of the Pudong health information centre.

PARTICIPANTS

Our data included all 46 720 972 primary care visits from 2016 to 2018 in CHSCs in Pudong.

RESULTS

We found that the top five diseases in primary care visits continued to be primary hypertension, problems related to medical facilities, chronic ischaemic heart disease, unspecified diabetes mellitus and acute upper respiratory infection. Lipoprotein metabolism disorder visits continued to increase over the study years. The numbers and proportions of patients with hypertension and unspecified diabetes were higher among men than women, and other cerebrovascular diseases were higher among women than men. The top five disease systems were circulatory system diseases, respiratory system diseases, endocrine/nutritional/metabolic diseases, factors influencing health status and digestive system diseases. The rankings of respiratory system and endocrine/nutritional/metabolic diseases rose over time. Non-communicable diseases (NCDs) accounted for approximately 90% of the primary care visits-a much higher percentage than other causes. The top five NCDs in primary care visits were cardiovascular and circulatory diseases, musculoskeletal disorders, diabetes, digestive diseases and urogenital diseases. Compared with women, men suffered from cardiovascular diseases at an earlier age.

CONCLUSIONS

Different from specialist visits, common diseases, especially NCDs, were the main disease composition of current primary healthcare visits while the former focused on intractable diseases such as tumours, indicating that primary healthcare had played the role of gatekeeper of the healthcare system.

Heart disease management by women: does intervention format matter?

A randomized controlled trial of two formats of a program (Women Take PRIDE) to enhance management of heart disease by patients was conducted. Older women (N = 575) were randomly assigned to a group or self-directed format or to a control group. Data regarding symptoms, functional health status, and weight were collected at baseline and at 4, 12, and 18 months. The formats produced different outcomes. At 18 months, the self-directed format was better than the control in reducing the number (p ≤ .02), frequency (p ≤ .03), and bothersomeness (p ≤ .02) of cardiac symptoms. The self-directed format was also better than the group format in reducing symptom frequency of all types (p ≤ .04). The group format improved ambulation at 12 months (p ≤ .04) and weight loss at 18 months (p ≤ .03), and group participants were more likely to complete the program (p ≤ .05). The availability of different learning formats could enhance management of cardiovascular disease by patients.

Support groups and cardiac rehabilitation: effects of partner participation on anxiety and depression

This study analyzes the effect on levels of patient anxiety and depression of a partner joining a cardiac rehabilitation program support group, also taking into account the sex of the patient. The study was undertaken using a two-group comparison design with pre-and post-test measures in non-equivalent groups. The sample comprised patients in the cardiac rehabilitation program (CRP) at the Ramón y Cajal Hospital, Madrid (Spain). Analysis of covariance (ANCOVA) showed direct effects of sex and partner participation in support groups on the anxiety trait. Similarly, interaction effects were observed between the sex variable and partner participation. These results indicate the pertinence of designing separate groups for patients and partners.

Gender differences and determinants of health related quality of life in coronary patients: a follow-up study

Background

The role of gender differences in Health Related Quality Life (HRQL) in coronary patients is controversial, so understanding the specific determinants of HRQL in men and women might be of clinical importance. The aim of this study was to know the gender differences in the evolution of HRQL at 3 and 6 months after a coronary event, and to identify the key clinical, demographic and psychological characteristics of each gender associated with these changes.

Methods

A follow-up study was carried out, and 175 patients (112 men and 63 women) with acute myocardial infarction (AMI) or unstable angina were studied. The SF-36v1 health questionnaire was used to assess HRQL, and the GHQ-28 (General Health Questionnaire) to measure mental health during follow-up. To study the variables related to changes in HRQL, generalized estimating equation (GEE) models were performed.

Results

Follow-up data were available for 55 men and 25 women at 3 months, and for 35 men and 12 women at 6 months. Observations included: a) Revascularization was performed later in women. b) The frequency of rehospitalization between months 3 and 6 of follow-up was higher in women c) Women had lower baseline scores in the SF-36. d) Men had progressed favourably in most of the physical dimensions of the SF-36 at 6 months, while at the same time women's scores had only improved for Physical Component Summary, Role Physical and Social Functioning; e) the variables determining the decrease in HRQL in men were: worse mental health and angina frequency; and in women: worse mental health, history of the disease, revascularization, and angina frequency.

Conclusions

There are differences in the evolution of HRQL, between men and women after a coronary attack. Mental health is the determinant most frequently associated with HRQL in both genders. However, other clinical determinants of HRQL differed with gender, emphasizing the importance of individualizing the intervention and the content of rehabilitation programs. Likewise, the recognition and treatment of mental disorders in these patients could be crucial.

Depression and the cardiovascular system: increasing evidence of a link and therapeutic implications

This review explores the epidemiological evidence for the relationship between depression and cardiovascular disease from a mechanistic standpoint. It is important to examine the biological, behavioral and social mechanisms to improve outcomes for depressed cardiac patients. A number of plausible biobehavioral mechanisms linking depression and cardiovascular disease have been identified. Tricyclic antidepressants have various effects on the cardiovascular system, while selective serotonin reuptake inhibitors are not associated with adverse cardiac effects and should, therefore, be the preferred choice for the treatment of most patients with comorbid depression and cardiovascular disease.

Longitudinal evaluation of sleep-disordered breathing and sleep symptoms with change in quality of life: the Sleep Heart Health Study (SHHS)

STUDY OBJECTIVES

Findings from population studies evaluating the progression and incidence of sleep disordered breathing have shown evidence of a longitudinal increase in the severity of sleep disordered breathing. The present study evaluates the association among changes in sleep disordered breathing, sleep symptoms, and quality of life over time.

DESIGN

Prospective cohort study. Data were from the Sleep Heart Health Study.

SETTING

Multicenter study.

PARTICIPANTS

Three thousand seventy-eight subjects aged 40 years and older from the baseline and follow-up examination cycles were included.

MEASUREMENTS

The primary outcomes were changes in the Physical Component Summary and Mental Component Summary scales obtained from the Medical Outcomes Study Short-Form Health Survey. The primary exposure was change in the respiratory disturbance index obtained from unattended overnight polysomnograms performed approximately 5 years apart. Other covariates included measures of excessive daytime sleepiness and difficulty initiating and maintaining sleep.

RESULTS

Mean respiratory disturbance index increased from 8.1 +/- 11 SD at baseline to 10.9 +/- 14 (P < 0.0001) at follow-up. The mean Physical Component Summary and Mental Component Summary scores were 48.5 and 54.1 at baseline and 46.3 and 54.8 at follow-up. No associations between change in respiratory disturbance index and changes in Physical Component Summary or Mental Component Summary scores were seen. However, worsening of difficulty initiating and maintaining sleep and excessive daytime sleepiness were significantly associated with lower quality of life.

CONCLUSIONS

A slight increase in severity of sleep disordered breathing was seen over 5 years; this was not associated with worsening of quality of life. However, subjective symptoms of quality of sleep and daytime sleepiness were associated with declining quality of life.

Depression and the metabolic syndrome: gender-dependent associations

This study was designed to test the extent to which depressive symptoms are associated with the presence of the metabolic syndrome (MS) and each of its components, and whether these relationships are gender dependent. Participants were apparently healthy employed men (N=2,355) and women (N=1,525) who underwent a routine health check between the years 2003 and 2005. We used logistic regression analysis, predicting the MS by depressive symptoms, as assessed by the Patient Health Questionnaire, and the following control variables: age, education, smoking status, physical exercise, anxiety, and burnout. As hypothesized, we found that depression among women, but not men, was associated with a 1.94-fold risk of having the MS, and with an elevated risk of having two of its five components: elevated waist circumference (odds ratio, OR=2.23) and elevated glucose levels (OR=2.44). In addition, a positive trend was observed toward an association with the other three components: low high-density lipoprotein, hypertension, and elevated triglycerides. Among men depression was associated with elevated waist circumference only (OR=1.77). These findings suggest that especially among women, the association between depression and cardiovascular diseases might be linked to metabolic processes. If replicated in longitudinal studies, these findings may have important health-care policy implications with regard to depression management interventions.

Gender bias in medical textbooks: examples from coronary heart disease, depression, alcohol abuse and pharmacology

OBJECTIVES

This study aimed to review the availability and accessibility of gender-specific knowledge in current medical textbooks used in Dutch medical schools. Medicine has been criticised as being gender-biased by assuming male and female bodies to be generally the same. The authors wondered whether current nationally and internationally accepted medical textbooks reflect the state of the art on gender-specific knowledge.

METHODS

The authors selected medical textbooks recommended by at least two medical schools in the Netherlands in the academic years 2004-05 and 2005-06. Investigated disciplines were internal medicine/cardiology, psychiatry and pharmacology. The textbooks were screened on the following topics: coronary heart disease; depressive disorders; alcohol abuse, and pharmacology. We defined evidence-based, gender-specific aspects of each of the topics on which information should be accessible in current textbooks for medical students.

RESULTS

Eleven textbooks were screened, including four on internal medicine/cardiology, four on pharmacology and three on psychiatry. Results show that gender-specific information is scarce or absent, and hardly accessible via index or layout. The scarce gender-specific information mainly applies to epidemiological data and reproductive items.

CONCLUSIONS

Current medical textbooks are still gender-biased. They lack somatic and psychosocial information relevant to good medical practice. As a consequence, future doctors will be unaware of relevant differences between men and women in the presentation, diagnosis and treatment of illnesses.

A prospective examination of antidepressant use and its correlates in patients with acute coronary syndrome

BACKGROUND

Depression has been implicated in the occurrence of recurrent coronary events and cardiac or all-cause mortality in acute coronary syndrome (ACS) patients.

OBJECTIVE

The authors describe the frequency and type of antidepressant use and its correlates 18 months after ACS hospital discharge.

METHOD

A sample of 661 ACS inpatients, recruited from three hospitals, completed a sociodemographic survey and the Hospital Anxiety and Depression Scale (HADS), and clinical data were extracted from charts. A mailed survey 9 months and 18 months post-discharge assessed self-reported antidepressant use, and the HADS was re-administered.

RESULTS

Approximately 9% of participants reported antidepressant use both 9 and 18 months post-hospitalization, with 77% concordance in usage over time. Participants most frequently reported using selective serotonin reuptake inhibitors and least often tricyclics. Logistic regression revealed that antidepressant users were more likely to be anxious and have more comorbidity, and were less likely to work full-time, whereas number of medications, age, and marital status were not related.

CONCLUSION

Patients with comorbid physical and mental conditions who are unemployed may be more likely to receive an antidepressant because of greater depression symptoms or greater exposure to healthcare providers, which increases the potential for symptom recognition and treatment.

A prospective, controlled multisite study of psychosocial and behavioral change following women's cardiac rehabilitation participation

BACKGROUND

Despite its proven benefits and need, women are significantly less likely than men to participate in and complete cardiac rehabilitation (CR). Thus, there are few reports of CR outcomes among women, particularly when compared with women who do not participate in CR. The purpose of this study was to prospectively assess psychosocial and behavioral changes, comparing women who participated in CR with those who did not.

METHODS

One hundred fifty-seven female cardiac inpatients from three hospitals consented to participate in a prospective study, and 110 (79%) were retained 18 months postdischarge. A mailed survey discerned CR participation 9 months postdischarge. Quality of life (Short-Form Health Survey Physical and Mental Component Summary [SF-12 PCS and MCS]), exercise behavior (Health-Promoting Lifestyle Profile II [HPLPII]), Exercise Benefits and Barriers Scale (EBBS), and anxiety and depressive symptoms (Hospital Anxiety and Depression Scale [HADS]) were assessed in hospital and 18 months postdischarge.

RESULTS

Fifty-one (45.1%) women self-reported participating in CR at 1 of 18 sites, and site-verified participation was 82.43% +/- 29.97% of prescribed sessions. For CR participants, paired t tests assessing change from hospitalization to 18 months postdischarge revealed significant improvements in physical quality of life (p < 0.001), anxiety (p < 0.05), and exercise behavior (p = 0.01). Women who did not participate in CR experienced significant improvements in physical quality of life (p = 0.02), and depressive symptoms (p = 0.03) but not exercise behavior.

CONCLUSIONS

Following a cardiac event, female patients improved their physical quality of life and affect, but only patients who participated in CR increased their exercise behavior. Given the cardiac benefits of exercise and that women are often sedentary and given that this exercise behavior was sustained post-CR, these findings are significant. Randomized controlled trials of women's CR outcomes are needed.

Is disturbed sleep a mediator in the association between social support and myocardial infarction?

The objective of this study was to investigate a mediating relationship between social support and disturbed sleep in cases surviving myocardial infarction. The case-referent studies, Stockholm Heart Epidemiological Program (SHEEP) and Västernorrland Heart Epidemiological Program (VHEEP) were used comprising 6231 participants (2046 women). Referents were randomly selected. Disturbed sleep was operationalized by the Karolinska Sleep Questionnaire, network support by the Availability of Social Integration Index and emotional support by the Availability of Attachment Index. Mediating associations were tested with logistic regression. The results show that disturbed sleep may act as a mediator between low network support and myocardial infarction in women.

Heart disease management by women: does intervention format matter?

A randomized controlled trial of two formats of a program (Women Take PRIDE) to enhance management of heart disease by patients was conducted. Older women (N = 575) were randomly assigned to a group or self-directed format or to a control group. Data regarding symptoms, functional health status, and weight were collected at baseline and at 4, 12, and 18 months. The formats produced different outcomes. At 18 months, the self-directed format was better than the control in reducing the number (p < or = .02), frequency (p < or = .03), and bothersomeness (p < or = .02) of cardiac symptoms. The self-directed format was also better than the group format in reducing symptom frequency of all types (p < or = .04). The group format improved ambulation at 12 months (p < or = .04) and weight loss at 18 months (p < or = .03), and group participants were more likely to complete the program ( p < or = .05). The availability of different learning formats could enhance management of cardiovascular disease by patients.

Type-D personality predicts chronic anxiety following percutaneous coronary intervention in the drug-eluting stent era

BACKGROUND

Anxiety is an often overlooked risk factor in coronary artery disease (CAD). Hence, little is known about predictors of unremitting chronic anxiety in CAD patients. We examined whether the distressed personality (type-D) predicts chronic anxiety post percutaneous coronary intervention (PCI).

METHODS

Unselected patients (n=167) treated with PCI using sirolimus-eluting or bare metal stents as part of the RESEARCH registry, who were anxious 6 months post-PCI, qualified for inclusion. Patients completed the Hospital Anxiety and Depression Scale at 6 and 12 months and the Type-D Scale (DS14) 6 months post-PCI.

RESULTS

Of 167 patients anxious at 6 months, 108 (65%) were still anxious 12 months post-PCI. Significant univariable predictors of chronic anxiety were type-D personality (OR: 3.17; 95% CI: 1.64-6.14) and sirolimus-eluting stent implantation (OR: 0.51; 95% CI: 0.27-0.98), with sirolimus-eluting stent showing a protective effect. In multivariable analyses, type-D personality (OR: 3.31; 95% CI: 1.59-6.87) and sirolimus-eluting stent implantation (OR: 0.44; 95% CI: 0.21-0.92) remained significant independent predictors of chronic anxiety adjusting for depressive symptoms at 6 months, demographic and clinical risk factors.

LIMITATIONS

All psychological measures were based on self-report, and we had no information on cardiac rehabilitation or use of pharmacotherapy; however our sample represented patients seen in daily clinical practice.

CONCLUSIONS

These findings suggest that type-D personality is a risk factor and sirolimus-eluting stent implantation a protective factor for the occurrence of chronic anxiety. The protective effect of sirolimus-eluting stents in relation to anxiety warrants replication in future studies.

Beta-blocker medication usage in older women after myocardial infarction

PURPOSE

The purpose of this study was to assess demographic characteristics of women prescribed beta-blocker (beta-blocker) medication and compare to those not using beta-blocker medication, and to determine if there are differences in depression and fatigue among women who used beta-blockers compared to nonusers 6-12 months after myocardial infarction (MI).

DATA SOURCES

This was a descriptive cross-sectional study of 84 women (61 using beta-blockers and 23 not using beta-blockers) aged 65 and older who were 6-12 months post-MI. Women had their height and weight measured and completed a Demographic Health Form, the Geriatric Depression Scale, and the Revised Piper Fatigue Scale (RPFS).

CONCLUSIONS

While most of the women were taking beta-blockers after MI (74%), significantly fewer Black women were taking beta-blockers (chi(2) = 5.086, p = 0.032). Most of the beta-blocker users were overweight or obese. There were no significant differences in age, t(82) = 0.7, p = 0.486; body mass index, t(82) = 0.76, p = 0.445; income, chi(2)(df = 2) = 3.219, p = 0.075; mean depression, t(82) = 1.648, p = 0.103; or fatigue scores, t(82) = 0.993, p = 0.324, between beta-blocker users and nonusers. More of those not taking beta-blockers reported fatigue with significantly higher fatigue in the affective meaning dimension of the RPFS, t(82) = 2.272, p = 0.03.

IMPLICATIONS FOR PRACTICE

beta-Blocker medication continues to be underutilized in older women. Because no difference was noted in fatigue and depression in the two groups, these may mean that these side effects are not barriers in prescribing this medication post-MI. Nurse practitioners are in pivotal positions to monitor the ongoing physiological and psychological sequelae post-MI and implement interventions to improve their outcomes.

Depression and thyroid axis function in coronary artery disease: impact of cardiac impairment and gender

BACKGROUND

Increased rates of depression are reported in coronary artery disease (CAD). In heart disease, depression increases disability, reduces quality of life, and increases mortality.

HYPOTHESIS

The study was undertaken to examine the relationship between depression and thyroid axis function in patients with CAD.

METHODS

In all, 73 patients with CAD, consecutively admitted to a cardiac rehabilitation hospital, were assessed for depression using the Hospital Anxiety and Depression scale (HADS). Blood was drawn for assessment of thyroid axis hormones and the N-amino terminal fragment of the pro-B-type natriuretic peptide (NT-pro BNP).

RESULTS

The patients with CAD with depressive symptoms had a higher prevalence of cardiac failure (p = 0.04), higher NT-pro BNP concentrations (p = 0.02), and lower free triiodothyronine (T3) concentrations (p = 0.04) than patients with CAD but without depressive symptoms. They also showed a strong trend (p = 0.058) toward a higher incidence of the low T3 syndrome. Higher NT-pro BNP concentrations were related to lower total T3 concentrations (r = -0.294, p = 0.011) and to higher reverse T3 concentrations (r = 0.353, p = 0.002). In men, higher scores of depression were related to lower total T3 concentration (r = -0.289, p = 0.034) and to higher NT-pro BNP concentration (r = 0.380, p = 0.005).

CONCLUSION

These findings suggest that symptoms of depression in patients with CAD are associated with changes in thyroid axis function and with cardiac impairment, especially in men.

A gender perspective on sleeplessness behavior, effects of sleep loss, and coping resources in patients with stable coronary artery disease

OBJECTIVE

The primary aim of this study was to systematically compare perceived sleep quality, sleeplessness behavior, sense of mastery, self-esteem, depression, subjective health, and effects of sleep loss in men and women with stable coronary artery disease (CAD). Further aims were to determine possible predictors of poor sleep quality and sense of mastery, as well as the consequences of too little sleep.

METHODS

Comparative-correlation and predictive design were used. Patients with a history of stable angina pectoris scheduled to undergo coronary angiography at Linköping University Hospital in Sweden were included. There were 47 women and 88 men (mean age 62.4 years) with CAD. Structured interviews using validated questionnaires covered sleep quality and sleep habits, effects of sleep loss, psychologic resources, and depression.

RESULTS

Multiple stepwise regression analysis showed that sleeplessness behavior, depressed mood, female gender, and pharmacologic treatments with inflammation inhibitors significantly (P<.0001) accounted for the variance of poorer sleep quality. The analysis also showed that the following factors in descending order significantly accounted (P<.0001) for the outcome of sleep quality: inability to feel refreshed by sleep, difficulty in maintaining sleep, gastrointestinal problems, too little sleep, final morning awakening time, sleep onset latency, lying down because of daytime tiredness, and daytime physical tiredness.

CONCLUSIONS

Compared with men, women with stable CAD may be especially at risk of experiencing poor sleep quality, even when sleeplessness behavior and pharmacologic treatments with inflammation inhibitors are controlled. It is also possible that they may be more at risk of depressed mood.

Incidence of recognized and unrecognized myocardial infarction in men and women aged 55 and older: the Rotterdam Study

AIMS

Contemporary data on the incidence of unrecognized myocardial infarction (MI) among subjects aged 55 and older are limited.

METHODS AND RESULTS

We studied the incidence of recognized and unrecognized MI in the Rotterdam Study, a population-based cohort of men and women aged 55 and older. The baseline examination was performed during 1990-93, with follow-up examinations during 1994-95, and 1997-2000. Baseline and follow-up 12-lead ECGs were analysed by the Modular ECG Analysis System. The 5148 participants who had no evidence of prevalent infarction were the subjects for analysis. Incident recognized infarction was defined as the occurrence of a fatal or non-fatal event coded as I21 according to the International Classification of Diseases, 10th edition. A repeat ECG was available in 4187 subjects. An unrecognized infarction was considered to have occurred if there was electrocardiographic evidence in the absence of a clinically recognized event. During a median follow-up of 6.4 years, 141 incident recognized infarctions occurred and the incidence rate of this event was 5.0 per 1000 person years. The incidence was higher in men (8.4) than in women (3.1). The incidence rate of unrecognized infarction was 3.8 per 1000 person years. Men (4.2) and women (3.6) had approximately similar incidence. Hence, the proportion of unrecognized infarction was lower in men (33%) than in women (54%). This difference in proportion of unrecognized infarctions was independent of age.

CONCLUSION

A high proportion of incident MIs remains clinically unrecognized. As a history of MI is associated with an increased risk of repeat cardiovascular complications, our data suggest a need for periodical electrocardiographic screening to recognize (prevalent) infarctions and to install effective preventive treatment in those aged 55 and older.

Effect of depression on five-year mortality after an acute coronary syndrome

Previous research has established a relation between depression at the time of cardiac hospitalization and patient mortality. The objective of this study was to examine the role of depressive history and symptomatology during hospitalization on 5-year all-cause mortality after admission for an acute coronary syndrome. We recruited 750 patients who had unstable angina pectoris and myocardial infarction from 12 coronary care units between 1997 and 1999. Measurements included sociodemographic and clinic data and the Beck Depression Inventory (BDI). Data were linked to an administrative database to determine 5-year all-cause mortality. Survival data were adjusted using a Cox's proportional hazards model. One hundred seventy-four participants (23.2%) self-reported a history of depressed mood for >2 weeks, 235 (31.3%) had elevated BDI scores at index hospitalization, with 105 (14.0%) reporting persistent depressive symptomatology. One hundred fifteen participants (15.3%) died by 5 years after hospitalization. After adjusting for prognostic indicators, such as cardiac disease severity, medical history, and smoking, depressive symptomatology during hospitalization was significantly predictive of mortality, but depressive history was not. Hazard ratios associated with BDI scores <10 versus those > or =10 at hospitalization ranged from 1.90 (95% confidence interval 1.12 to 3.24) at 2 years to 1.53 (95% confidence interval 1.04 to 2.24) at 5 years. In conclusion, the significance of depressive symptomatology at the time of, but not before, hospitalization underlines the need for early identification of increased distress and renews calls to identify treatments that not only improve quality of life but also decrease the risk of mortality.

Coping, social support and quality of life over time after myocardial infarction

AIM

This paper describes gender differences in perceived coping, social support and quality of life 1, 4 and 12 months after myocardial infarction.

BACKGROUND

There is a shortage of studies with a longitudinal research design investigating coping, social support and quality of life in women and men after myocardial infarction.

METHODS

A longitudinal, descriptive and comparative design was used for the study, which included 74 women and 97 men. At 12 months, 60 women and 88 men remained. Data were collected using the Jalowiec Coping Scale, a social support questionnaire, the SF-36 Health Survey (health-related quality of life) and the Quality of Life Index-Cardiac version (quality of life). The data were collected during the period 1999-2001.

RESULTS

No statistically significant changes over time in coping assessments emerged in the study group, except for fatalistic coping, which diminished over time in men. Women used more evasive coping than men at 4 and 12 months. The perceived efficiency in coping with physical aspects of the heart disease increased. More women than men perceived available support from grandchildren and staff of the church. Health-related quality of life increased in women and men in physical functioning, role-physical, vitality, social functioning, and role-emotional scales. Moreover, an improvement in the mental health scale was evident in women and a reduction in pain in men. No statistically significant gender differences were found for quality of life at any point in time.

CONCLUSIONS

The findings can be used to inform caregivers that optimistic, self-reliant and confrontational coping were the most frequently used by both women and men over the first year after myocardial infarction, and that confrontational coping has been shown to have positive outcomes in the longer term. Nurses should tell women about the importance of seeking prompt treatment and discuss health problems with caregivers and significant others. Care planning should include family members and significant others so that they can support and encourage patients to cope with problems in daily life.

Illness perceptions among cardiac patients: relation to depressive symptomatology and sex

OBJECTIVE

This study examined cardiovascular disease (CVD) illness perceptions and how they relate to depressive symptomatology among women and men.

METHODS

Acute coronary syndrome (ACS) patients at two hospitals were approached, and 661 consented to participate (504 men, 157 women; 75% response rate). Participants completed a survey including the Hospital Anxiety and Depression Scale (HADS) and Illness Perception Questionnaire (IPQ).

RESULTS

Women perceived a significantly more chronic course (P<.001) and more cyclical episodes (P<.05) than men did, while men perceived greater personal control (P<.001) and treatability (P<.05) than women did. Participants perceived diet, heredity, and stress as the greatest CVD causes. For women (F=5.49, P<.001), greater depressive symptomatology was significantly related to younger age (P<.05), lower activity status (P<.001), and perceiving a chronic time course (P<.01). For men (F=7.68, P<.001), greater depressive symptomatology was significantly related to being non-white (P<.05), lower activity status (P<.001), less exercise behavior (P=.01), and three illness perceptions, namely, perceiving a chronic course (P<.05), greater consequences (P<.001), and lower treatability (P<.05).

CONCLUSION

Women, compared with men, are more likely to attribute CVD to causes beyond their control and to perceive CVD as a chronic, untreatable condition. Illness perceptions were related to depressive symptomatology, which suggests that interventions to reframe these perceptions may be warranted to improve emotional health in the context of CVD.

Longitudinal course of depressive symptomatology after a cardiac event: effects of gender and cardiac rehabilitation

OBJECTIVE

Recent research has linked depression to cardiac mortality, and shown a high burden of persistent depressive symptomatology among cardiac patients. The objective of this study was to longitudinally examine the prevalence and course of depressive symptomatology among women and men for 1 year after a cardiac event, and the effect of cardiac rehabilitation (CR) on this trajectory.

METHODS

Nine hundred thirteen unstable angina (UA) and myocardial infarction patients from 12 coronary care units were recruited, and follow-up data were collected at 6 and 12 months. Measures included CR participation, medication usage, and the Beck Depression Inventory (BDI). The longitudinal analysis was conducted using SAS PROC MIXED.

RESULTS

At baseline there were 277 (31.3%) participants with elevated depressive symptomatology (BDI > or = 10), 131 (25.2%) at 6 months, and 107 (21.7%) at 1 year. Overall, approximately 5% were taking an antidepressant medication, and 20% attended CR over their year of recovery. Participants with greater depressive symptomatology participated in significantly fewer CR exercise sessions (r = -0.19, p = .02), and minimal psychosocial interventions were offered. The longitudinal analysis revealed that all participants experienced reduced depressive symptomatology over their year of recovery (p = .04), and younger, UA participants with lower family income fared worst (ps < 0.001). CR did not have an effect on depressive symptomatology over time, but women who attended CR were significantly more depressed than men (p = .01).

CONCLUSION

Depressed cardiac patients are undertreated and their symptomatology persists for up to 6 months. CR programs require greater resources to ensure that depressed participants adhere to exercise regimens, and are screened and treated for their elevated symptomatology.

Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors

Comprehensive cardiac rehabilitation reduces mortality and morbidity but is utilised by only a fraction of eligible cardiac patients, with the participation rate of women being only about half that of men. This quantitative review assesses 32 studies meeting inclusion criteria, describing 16,804 patients, 5882 of whom were female. It was found that the main predictor of referral to a cardiac rehabilitation programme was the physician's endorsement of the effectiveness of such a programme. Patients were more likely to participate in rehabilitation programmes when they were actively referred, educated, married, possessed high self efficacy, and when the programmes were easily accessible. Patients were less likely to participate when they had to travel long distances to participate in a cardiac rehabilitation programme, or experienced guilt over family obligations. Women were less often referred and participated less often even after referral. In conclusion, many of the observed predictors, including those particular to women, are potentially modifiable with the help of health professionals.

Investigating the effect of anxiety sensitivity, gender and negative interpretative bias on the perception of chest pain

Research suggests that anxiety sensitivity may be an important component in the negative response to pain sensations, especially those with cardiopulmonary origin. Furthermore, there is experimental evidence to suggest that such effects may be stronger in women than men. The primary aim of the current investigation was to determine the relative roles that anxiety sensitivity and gender have on the pain reports of patients referred to a hospital clinic with chest pain. A total of 78 female and 76 male adults were recruited on entry to a Rapid Access Medical Clinic. All patients had been referred with chest pain, and were administered a range of pain and anxiety measures prior to diagnosis. Results indicate that males were more likely to receive a diagnosis of cardiac chest pain, whereas females were more likely to receive a diagnosis of non-cardiac chest pain. Additionally, anxiety sensitivity was related to pain in women but not men. Finally, evidence was found for the mediating effect of negative interpretative bias on the relationship between anxiety sensitivity and pain. However, this mediating effect was only found in women. These results not only confirm that anxiety sensitivity is related to greater negative pain responses in women, but that this may be due to an increased tendency to negatively interpret sensations.

Cardiovascular Disease

Health Issue

Cardiovascular disease (CVD) is the leading cause of death in Canadian women and men. In general, women present with a wider range of symptoms, are more likely to delay seeking medial care and are less likely to be investigated and treated with evidence-based medications, angioplasty or coronary artery bypass graft than men.

Key Findings

In 1998, 78,964 Canadians died from CVD, almost half (39,197) were women. Acute myocardial infarction, which increases significantly after menopause, was the leading cause of death among women.

Cardiovascular disease accounted for 21% of all hospital admissions for Canadian women over age 50 in 1999. Admissions to hospital for ischemic heart disease were more frequent for men, but the mean length of hospital stay was longer for women.

Mean blood pressure increases with age in both men and women. After age 65, however, high blood pressure is more common among Canadian women. More than one-third of postmenopausal Canadian women have hypertension.

Diabetes increases the mortality and morbidity associated with CVD in women more than it does in men. Depression also contributes to the incidence and recovery from CVD, particularly for women who experience twice the rate of depression as men.

Data Gaps and Recommendations

CVD needs to be recognized as a woman's health issue given Canadian mortality projections (particularly heart failure). Health professionals should be trained to screen, track, and address CVD risk factors among women, including hypertension, elevated lipid levels, smoking, physical inactivity, depression, diabetes and low socio-economic status.

Gender differences in the perception of chest pain

This study investigated gender differences in pain perception as characterized by pain symptoms in patients diagnosed with unstable angina pectoris. Twenty-nine women and 32 men were asked to characterize their chest pain using a semi-open questionnaire assessing pain intensity (by numerical rating), pain location, pain characteristics, complaints following chest pain, factors that evoked or reduced chest pain, and whether the chest pain was related to heart disease. Significant gender differences were found. Women scored the intensity of their chest pain significantly higher than men (Chi-square 14.8, P < 0.0001), and related their chest pain less to heart disease (Chi-square 24.6, P < 0.0001). The women described an atypical clinical picture of chest pain that was significantly different from men's. The results are discussed in light of pschological theories regarding gender differences in pain perception. These findings imply the need for special attention to the unique clinical pictures that appear for women and men.

Anxiety and well-being in first-time coronary angioplasty patients and repeaters

INTRODUCTION

Preparatory information before an invasive procedure has positive effects (e.g. on recovery, well-being and anxiety). However, preparation of patients for a repeat procedure is hardly investigated. The question is whether these patients benefit from the same preparatory information.

AIMS

To determine whether there are differences in terms of anxiety and well-being between patients undergoing their first percutaneous transluminal coronary angioplasty (PTCA) and those undergoing a repeat PTCA.

DESIGN

Descriptive correlational study with a quantitative and qualitative research component.

METHOD

First-time PTCA patients (n=46) and re-PTCA patients (n=40) were asked to complete three psychological self-report questionnaires (HADS, HPPQ and VAS) before the procedure. Five re-PTCA patients were interviewed the day after the procedure.

RESULTS

We were not able to show statistically significant differences between the two groups. On the anxiety scales re-PTCA patients scored 6.5 (HADS) and 4.0 (VAS) vs. 5.0 (P=0.25) and 2.6 (P=0.30) for first-time PTCA patients. On well-being (HPPQ) these differences were 18.0 vs. 19.0 (P=0.40). Once the interview data were coded, four themes were apparent, namely: recurrent symptoms, information, experience and future prospects.

CONCLUSION

A trend is seen towards a worse condition in the re-PTCA group with respect to anxiety and well-being. However, the differences are not statistically significant, they seem to be clinically relevant. The interviews point out that the return of symptoms and future prospects, rather than the procedure itself, are an important part in preparing for a repeat intervention. This aspect is currently no part of the provided preparatory information. Future research will have to determine the most beneficial method of preparing these patients (e.g. tailored preparation, emotional support, coaching).

Epidemiology of comorbid coronary artery disease and depression

This article reviews the epidemiology of comorbid coronary artery disease and unipolar depression. Both major depression and subsyndromal depressive symptoms will be considered; unless otherwise specified, the term depression will be used to designate all depressive states, including major depressive disorder, minor depression, dysthymia, and other subsyndromal forms of depression. While 17% to 27% of patients with coronary artery disease have major depression, a significantly larger percentage has subsyndromal symptoms of depression. Patients with coronary artery disease and depression have a twofold to threefold increased risk of future cardiac events compared to patients without depression, independent of baseline cardiac dysfunction. The relative risk for the development of coronary artery disease conferred by depression in patients initially free of clinical cardiac disease is approximately 1.5, independent of other known risk factors for coronary disease. In the discussion, special attention will be paid to the interactions of both gender and age with depression and coronary artery disease risk. Scrutiny of the role of confounding risk factors is presented, such as global burden of comorbid medical illness and modification of traditional risk factors, which may, in part, mediate the effect of depression on coronary artery disease.

An international perspective on gender differences in anxiety early after acute myocardial infarction

OBJECTIVE

Higher anxiety is linked to poorer outcomes after acute myocardial infarction (AMI), including increased in-hospital reinfarction and potentially life-threatening complications. If clinicians can identify patients at greatest risk for anxiety after AMI, they can institute early treatment. Previous research on the influence of gender on the incidence of anxiety post-AMI reflects inconsistent findings, and differences across cultures have not been studied. Therefore, the purposes of this study were to determine: 1) whether there are gender differences in anxiety in a diverse international sample of AMI patients, and 2) whether there was an interaction between gender and sociodemographic and clinical variables thought to influence anxiety.

METHODS

In this prospective, comparative study, 912 AMI patients were enrolled from Australia, South Korea, Japan, England, and the United States. Anxiety was assessed, using the Brief Symptom Inventory, within the first 72 hours of admission to the hospital for AMI symptoms.

RESULTS

Women had higher anxiety levels than men (0.76 +/- 0.90 vs. 0.57 +/- 0.70, p =.005), and this pattern of higher anxiety in women was seen in each country studied. Neither sociodemographic nor clinical variables interacted with gender to influence anxiety.

CONCLUSION

Across a variety of cultures, women have higher anxiety than men after AMI and this relationship is independent of age, education level, marital status, or presence of comorbidities or severity of AMI.

Gender differences in pain characteristics of chronic stable angina and perceived physical limitation in patients with coronary artery disease

Chronic stable angina pectoris, the chest pain associated with reversible myocardial ischemia has detrimental effects on health-related quality of life, particularly in women. The limited research on gender differences in chronic stable angina suggests that angina may be experienced differently in women and that women report greater functional disability related to angina symptoms. No studies have examined gender differences in chronic stable angina from a multidimensional pain perspective or have included reliable and valid measures of pain that would facilitate comparing chronic angina patients with other chronic pain populations. The purpose of this descriptive study was to examine gender differences in characteristics of chronic stable angina using the short-form McGill pain questionnaire (SF-MPQ) and to explore relationships among these pain characteristics and perceived limitation in performing physical activities in patients with coronary artery disease (CAD) (physical limitation subscale of the Seattle angina questionnaire). One hundred and twenty-eight subjects (30.5% women) with stable CAD and angina pectoris documented by a cardiologist completed study questionnaires in an outpatient cardiology clinic. Results of the study suggest that men and women with chronic stable angina had more similarities than differences in chest pain characteristics. No significant gender differences were demonstrated in total sensory or affective intensity scores, the present pain intensity index, or the number of pain words chosen. However, women did report significantly greater pain intensity on the SF-MPQ visual analogue scale. Women were also significantly more likely to describe their chronic angina as 'hot-burning' and 'tender' and to have greater intensity of pain for these two descriptors. Despite the similarities in pain characteristics, women reported greater physical limitation related to anginal pain. The variables of social status and years diagnosed with CAD significantly interacted with gender in predicting physical limitation suggesting that gender-specific models of physical limitation in angina patients need to be explored. To our knowledge, this is one of the first studies that has assessed chronic anginal pain using a reliable and valid generic pain instrument. More research is needed to better understand the nature of gender differences in functional limitation secondary to anginal pain and the physiologic, cognitive-perceptual and psychosocial mechanisms that lead to angina-related functional disability.

Depressive symptoms and mortality in a prospective study of 2,558 older adults

OBJECTIVE

The authors report results from a 7-year prospective study of depression and mortality in 2,558 Medicare recipients age 65 and older.

METHODS

This report is based on a secondary data analysis of a randomized controlled trial that evaluated the cost-effectiveness of preventive services for older enrollees in an HMO.

RESULTS

Subjects with mild-to-moderate depression at baseline did not have an increased risk of mortality compared with those without significant depression. The 3% of older adults with the most severe depressive syndromes, however, had significant increases in mortality, even after adjusting for demographics, health risk behaviors, and chronic medical disorders.

CONCLUSION

The increase in mortality in this group of older adults was comparable to that in participants with chronic medical disorders such as emphysema or heart disease.

Cardiac rehabilitation I: review of psychosocial factors

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. There are gender differences in recovery from coronary events, which may be due physiological, sociodemographic, or psychosocial factors. Cardiac rehabilitation programs have beneficial effects on coronary recovery. The following presents a review of the literature from MedLine (1997-2001) and PsychInfo (1984-2001) on gender differences in participation in cardiac rehabilitation programs, with a focus on depression, anxiety, self-efficacy and social support. A critical analysis of gaps in the literature as well as areas for future research are presented.