Intensive rehabilitation of emotionally distressed patients after coronary by-pass grafting

Comparison of Reconstructive Plastic Surgery Rates and 30-Day Postoperative Complications Between Patients With and Without Psychiatric Diagnoses

BACKGROUND

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery.

OBJECTIVES

The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses.

METHODS

This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression.

RESULTS

Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67).

CONCLUSIONS

Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

LEVEL OF EVIDENCE: 4

Cardiac Home Education and Support Trial (CHEST): a pilot study

BACKGROUND

Coronary artery bypass graft (CABG) surgery is performed more frequently in individuals who are older and sicker than in previous years. Increased patient acuity and reduced hospital length of stays leave individuals ill prepared for their recovery.

OBJECTIVES

To test the feasibility of a peer support program and determine indicators of the effects of peer support on recovery outcomes of individuals following CABG surgery.

METHODS AND RESULTS

A pre-post test pilot randomized clinical trial design enrolled men and women undergoing first-time nonemergency CABG surgery at a single site in Ontario. Patients were randomly assigned to either usual care or peer support. Patients allocated to usual care (n=50) received standard preoperative and postoperative education. Patients in the peer support group (n=45) received individualized education and support via telephone from trained cardiac surgery peer volunteers for eight weeks following hospital discharge. Most (93%) peer volunteers believed they were prepared for their role, with 98% of peer volunteers initiating calls within 72 h of the patient's discharge. Peer volunteers made an average of 12 calls, less than 30 min in duration over the eight-week recovery period. Patients were satisfied with their peer support (n=45, 98%). The intervention group reported statistical trends toward improved physical function (physical component score) (t [89]=-1.6; P=0.12) role function (t [93]=-1.9; P=0.06), less pain (t [93]=1.30; P=0.20) and improved cardiac rehabilitation enrollment (chi2=2.50, P=0.11).

CONCLUSIONS

These preliminary results suggest that peer support may improve recovery outcomes following CABG. Data from the present pilot trial also indicate that a home-based peer support intervention is feasible and an adequately powered trial should be conducted.

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.

Stress, depression and cardiovascular dysregulation: a review of neurobiological mechanisms and the integration of research from preclinical disease models

Bidirectional associations between mood disorders and cardiovascular diseases are extensively documented. However, the precise physiological and biochemical mechanisms that underlie such relationships are not well understood. This review focuses on the neurobiological processes and mediators that are common to both mood and cardiovascular disorders. The discussion places an emphasis on the role of exogenous stressors in addition to: (a) neuroendocrine and neurohumoral changes involving dysfunction of the hypothalamic-pituitary-adrenal axis and the activation of the renin-angiotensin-aldosterone system, (b) immune alterations including activation of pro-inflammatory cytokines, (c) autonomic and cardiovascular dysregulation including increased sympathetic drive, withdrawal of parasympathetic tone, cardiac rate and rhythm disturbances, and altered baroreceptor reflex function, (d) central neurotransmitter system dysfunction involving the dopamine, norepinephrine and serotonin systems, and (e) behavioral changes including fatigue and physical inactivity. The review also discusses experimental investigations using preclinical disease models to elucidate the neurobiological mechanisms underlying the link between mood disorders and cardiovascular disease. These include: (a) the chronic mild stress model of depression, (b) a model of congestive heart failure, (c) a model of cardiovascular deconditioning, (d) pharmacological manipulations of body fluid and sodium balance, and (e) pharmacological manipulations of the central serotonergic system. In combination with an extensive human research literature, the investigation of mechanisms underlying mood and cardiovascular regulation using animal models will enhance understanding the association between depression and cardiovascular disease. This will ultimately promote the development of better treatments and interventions for individuals with co-morbid psychological and somatic pathologies.

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

AIMS AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Cardioprotective Strategies to Improve Long-Term Outcomes Following Coronary Artery Bypass Surgery

BACKGROUND AND AIM

Cardioprotective strategies implemented to prevent ischemic events in patients at risk for cardiovascular disease have decreased morbidity and prolonged survival. In this review, we have used evidence-based medicine and number-needed-to-treat (NNT) analyses to determine which interventions are most beneficial in minimizing ischemic events and prolonging survival following coronary artery bypass graft (CABG) surgery.

METHODS

Therapeutic interventions available to minimize ischemic events in the post-CABG patient were analyzed using ACC/AHA Classifications and Level of Evidence Criteria. Based on these recommendations, NNT analyses were performed to determine the effectiveness of each intervention compared to the number of patients needed to be treated before a benefit was apparent.

RESULTS

The most beneficial intervention to improve mortality following CABG was the use of high tissue angiotensin-converting enzyme inhibitors, followed by statins and smoking cessation.

CONCLUSIONS

NNT analyses and evidence-based medicine recommendations provide surgeons with cardioprotective strategies to improve long-term outcomes following CABG surgery.

Perceived Cognitive Function and Emotional Distress Following Coronary Artery Bypass Surgery

Many patients experience decrements in cognitive function and emotional adjustment following coronary artery bypass graft (CABG) surgery. Moreover, cognitive decline and emotional distress are often positively related. This study evaluated the cross-sectional and prospective associations of emotional and subjective cognitive complaints, to assess the hypothesis that they would be mutually reinforcing. Participants were 76 CABG patients recruited from Akron General Medical Center. Depression and anxiety symptoms and perceived cognitive difficulties were evaluated at a baseline postsurgical visit and re-assessed 5 months later. Emotional symptoms and perceived cognitive difficulties were significantly related both within and across time. After controlling for numerous potential confounds, baseline perceived cognitive difficulties predicted a more negative course of emotional symptoms during follow-up. Baseline emotional symptoms did not predict the course of perceived cognitive difficulties. Perceptions of cognitive decline may contribute to emotional distress in patients post-CABG.

Swedish Council on Technology Assessment in Health Care (SBU). Chapter 8. Sick leave due to coronary artery disease or stroke

The assessment of the literature on sick-leave with cardiovascular diseases include only studies with sufficient scientific quality. These studies describe sick leave following stroke, myocardial infarction, coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI). We found limited scientific evidence for the following results: After stroke, more than half of the patients of working age returned to work (RTW) during the first year following onset (higher rate for the younger patients). The consequences of brain damage, e.g. impaired ADL ability or cognitive capacity, play an important role in this respect. Also after myocardial infarction most patients RTW. PCI is a milder coronary artery intervention than CABG and RTW is more rapid. However, in the long run there are no differences in sick leave. People at higher ages or with physically demanding jobs return to work to a lesser degree. An international comparison shows that the duration of sick leave due to these conditions in Sweden is longer than in other countries although there is no scientific evidence to support this practice. It appears that the interest in research on sick leave in patients with cardiovascular diseases has waned in recent years. Developments in acute cardiological care should inspire renewed scientific involvement in this area of research.

Depression and anxiety in coronary artery bypass grafting patients

PURPOSE

Heart surgery is a factor triggering off specific emotional and physiological responses of a patient. In spite of positive somatic effects of surgery, depression and anxiety can persist or appear for the first time after the operation worsening the patient's psychosocial functioning and quality of life. The aim of this study is to offer a prospective view on the incidence and course of self-reported depression and anxiety in coronary artery bypass graft (CABG) patients.

SUBJECT AND METHODS

After informed consent, 53 patients who submitted to CABG were examined a few days before and after the operation and 3 months after CABG. They completed the Spielberger Anxiety Questionnaire and Beck Depression Inventory.

RESULTS

Approximately 55% of the patients had high a level of anxiety preoperatively. Shortly after the surgery, 34% of patients and after 3 months 32% of them had clinically relevant level of anxiety. Thirty-two percent of patients before the surgery, 28% immediately after CABG and 26% at follow-up were depressed.

CONCLUSIONS

High preoperative depression, state and trait anxiety scores appear to be predictors of postoperative psychological outcome. Preoperative assessment can identify patients at risk for clinical levels of postoperative anxiety and depression. Psychological preventive counseling and psychiatric intervention can reduce patients' emotional distress, medical and economic costs.

Depression as a predictor of return to work in patients with coronary artery disease

The importance of depression in coronary artery disease (CAD) outcomes is being increasingly recognized. The aim of this study was to investigate the power of depression as a predictor of return to work, both at full time and at reduced working hours, within 12 months of participation in a behaviorally oriented rehabilitation program in Sweden. The sample comprised 198 employed patients who had recently experienced an acute myocardial infarction (AMI, n=85), or had been treated with coronary by-pass surgery (CABG, n=73) or coronary angioplasty (PTCA, n=40). The results showed that clinical depression before intervention (>or=16 as measured by the Beck Depression Inventory) exerted a great influence on work resumption both at full-time (odds ratio 9.43, CI=3.15-28.21) and at reduced working-hours (odds ratio 5.44, CI=1.60-18.53), while mild depression (BDI 10-15) influenced only work resumption at full-time (odds ratio 2.89, CI=1.08-7.70). Education and, at full-time hours, age also predicted work resumption. This highlights the importance of depressive symptoms in relation to return to work after a CAD event. More research is needed in order to elaborate the degree to which treatment of depression enhances work resumption rates.

Depression and anxiety and outcomes of coronary artery bypass surgery

Psychological and psychiatric disorders independently increase the risk of cardiovascular disease and worsen the prognosis in patients with established cardiovascular lesions. The objective of this literature review is to discuss recent data concerning the relationships between depression and anxiety and the outcomes of coronary artery bypass grafting. Pathophysiological hypotheses are put forward to explain observed links. We suggest recommendations aimed at improving the psychological evaluation and management of heart surgery candidates, as well as postbypass patients, in the hope of improving quality of life and cardiovascular outcomes in these patients.

Biological mechanisms in the relationship between depression and heart disease

Psychological depression is shown to be associated with several aspects of coronary artery disease (CAD), including arrhythmias, myocardial infarction, heart failure and sudden death. The physiological mechanisms accounting for this association are unclear. Hypothalamic-pituitary-adrenal dysregulation, diminished heart rate variability, altered blood platelet function and noncompliance with medial treatments have been proposed as mechanisms underlying depression and cardiovascular disease. Recent evidence also suggests that reduced baroreflex sensitivity, impaired immune function, chronic fatigue and the co-morbidity of depression and anxiety may be involved in the relationship between depression and cardiovascular dysregulation. An experimental strategy using animal models for investigating underlying physiological abnormalities in depression is presented. A key to understanding the bidirectional association between depression and heart disease is to determine whether there are common changes in brain systems that are associated with these conditions. Such approaches may hold promise for advancing our understanding of the interaction between this mood disorder and CAD.