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

Prospective correlates of early (30 day) readmissions on a Cardiothoracic Surgery Service

Known to vary widely among hospitals for unclear reasons, early readmissions are associated with higher mortality and are suspected to frequently be due to inadequate discharge preparation/planning. It has been previously documented that the strongest and most consistent predictor of early readmissions in CHF patients is chronic cognitive impairment, and compensatory assistance with adherence on discharge improves early readmission rates. Prospective observational study. The present investigation examined multiple putative perioperative predictors of early readmission in a hospitalized Cardiothoracic Surgery Service. A subtest of the Mini-Cog, Short Term Memory, was the strongestunivariate predictor of early readmissions (p < .001), but the overall Mini-Cog (p = .024), Age (p = .045), Number of Admissions over the Preceding Year (p = .036), an Anxiety Scale (p = .035), Years of Education (p = .055) and a Depression Scale (p = .056) also demonstrated covariation. In a Logistic Regression, only Short Term Memory survived as a predictor variable (p = .007), correctly classifying 76% of patients. Chronic cognitive impairment is a predictor of early readmissions in Cardiothoracic patients. A brief bedside exam interpreted in medical context may permit identification of patients requiring familial assistance for adherence on discharge.

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.

An interactive model of pain and myocardial ischemia

The biopsychosocial model has been used to describe the intertwined factors that may act as mechanisms in cardiovascular disease, as well as those found in pain conditions. This model may also prove useful in understanding a diagnosis that overlaps these two areas, angina. This article reviews the literature related to biological, psychological, and social mechanisms of painful ischemic episodes and discusses the interactions of those variables. We propose an integrated model that incorporates the biopsychosocial mechanisms that may be responsible for the variability in pain reporting with ischemic episodes. We show how sex differences manifested in various biopsychosocial factors may interact to influence the presence of painful versus silent myocardial ischemia. We present a plan for future research to elucidate this interaction.

The impact of angina and cardiac history on health-related quality of life and depression in coronary heart disease patients

OBJECTIVE

To prospectively examine the contribution of angina and cardiac history to health-related quality of life (HRQoL) and depression in cardiac patients, over 6 months post-hospitalization.

METHODS

Participants were myocardial infarction (MI), percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) outpatients under the age of 70 years. One hundred and seventy-one patients consented to participate, with 121 patients being retained 6 months later (71% response rate). The impact of the patient's cardiac history and the presence of angina on physical, social and emotional HRQoL and depression was examined.

RESULTS

At baseline, cardiac history was not significantly related to any of the dimensions of HRQoL or depression. At 6-month follow-up, cardiac history significantly predicted a higher level of depression, and angina was predictive of a significantly worse emotional, physical and social HRQoL and a higher level of depression.

DISCUSSION

The presence of a cardiac history is associated with depression 6 months post-cardiac event, and angina is associated with both an adverse HRQoL and higher levels of depression. As past research has demonstrated that depression is a risk factor for mortality in patients with established heart disease, it is important from both a clinical and a research perspective to address these issues.

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.

Biomedical and psychosocial predictors of anginal frequency in patients following angioplasty with and without coronary stenting

This study examined the contribution of biomedical and psychological variables in the report of anginal frequency at 6-week, 6- and 12-month follow-up in patients who received angioplasty with and without stent. Patients (N = 70) completed a battery of standardized questionnaries, including measures of depression, anxiety, and anger. Principal components analysis computed a single factor of negative emotion for use as a predictor in regression analyses. For the 6-week model, only baseline anginal frequency predicted anginal frequency. Negative emotion joined baseline anginal frequency in the prediction model for 6-month anginal frequency, and collectively accounted for 23% of the variance. For the 12-month model, baseline anginal frequency, female sex, and negative emotions remained in the model, accounting for 46% of the variance in anginal frequency. These results highlight the importance of biomedical and psychosocial variables in predicting anginal frequency with psychological variables sustaining predictive value over the course of recovery.

Men deny and women cry, but who dies? Do the wages of "denial" include early ischemic coronary heart disease?

OBJECTIVES

In this study patients with documented ischemic coronary heart disease (ICHD; prior MI or CAD per catheterization) were tested for the association of various measures of emotional distress with Age at Initial Diagnosis.

METHODS

The measures were chosen because of a published track record at predicting mortality in this population. Females were oversampled to achieve equivalent numbers of each sex (n=50), and thus equivalent statistical power. In a subset of patients (38 males and 32 females), Spouse/Friend Ketterer Stress Symptom Frequency Checklists (KSSFCs) were received.

RESULTS

Females reported more depression and anxiety than males. However, spouses or friends reported more anger for males. Denial (spouse/friend minus self-ratings) was greater in males for all three scales of the KSSFC (Anger, P=.005; Depression, P=.024; Anxiety, P=.001). Although females showed the same trend, self and spouse or friend ratings of distress were significantly associated with Age at Initial Diagnosis only in males. When split at the sample mean on the Spouse/Friend KSSFC AIAI (Anger) scale, Age at Initial Diagnosis occurred 14.2 years earlier in males.

CONCLUSIONS

Use of a significant other in assessing psychosocial/emotional distress in males may confer greater accuracy, and therefore predictive power for clinical endpoints.