Health complaints and outcome assessment in coronary heart disease

The role of sex and gender in somatic complaints among patients with coronary heart disease: A longitudinal study on acute and long-term changes

BACKGROUND

Somatic complaints are persistently reported in patients with coronary heart disease (CHD). Sex and gender influence health and well-being in a variety of ways, but it is unknown how they affect somatic complaints over time after percutaneous coronary intervention (PCI). Therefore, we examined the association between sex and gender on somatic health complaints during the first month (acute) and the first two years (recovery) after PCI.

METHODS

514 patients (Mage = 64.2 ± 8.9, 84.2% male) completed the somatic scale of the Health Complaints Scale (including the subscales: cardiopulmonary complaints, fatigue, sleep problems) at baseline, one, 12-, and 24-months post-PCI. In a follow-up study, they filled in additional questionnaires to gauge gender norms, traits, and identity. Linear mixed modeling analyses were used to assess the influence of sex, gender, their interaction, and covariates on somatic complaints for the acute and recovery phases separately.

RESULTS

A general decline in somatic complaints over time was observed during the acute phase, followed by a stabilization in the recovery phase. Females and individuals with more feminine traits, norms, and identities reported increased somatic complaints. Males with more pronounced feminine norms and females with more masculine norms likewise reported more somatic, cardiopulmonary, and fatigue complaints. Furthermore, age, cardiac history, and comorbid diseases partly explained the associations with somatic complaints.

CONCLUSION

While somatic complaints improve post-PCI, there are still conspicuous sex and gender differences that need to be considered. Future research should further elaborate upon these discrepancies and incorporate sex and gender in prevention and develop tailored interventions to diminish somatic complaints.

Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management

Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.

Poor Sleep Quality Predicts Decline in Physical Health Functioning in Patients with Coronary Heart Disease and Moderating Role of Social Support

Although sleep problems are common among patients with coronary heart disease (CHD), there is a lack of prospective research examining its influence on health consequences over time. This study investigated whether poor sleep quality predicted patients' decline in physical health functioning over 6 months and whether social support buffered its detrimental effect. Participants were 185 patients with CHD, who completed measures of sleep, psychosocial characteristics, and physical health functioning at baseline and 6 months. Hierarchical regression analyses were conducted to examine whether global sleep index and its subscales, including sleep efficiency, perceived sleep quality, and daily disturbances (sleep disturbances and daytime dysfunction), predicted the decline of physical health functioning at 6 months. Social support was examined for its moderating effect in buffering the negative influence of poor sleep quality on physical health functioning over 6 months. Findings showed that poorer global sleep index, especially subscales of daily disturbances and lower sleep efficiency, significantly predicted greater decline of physical health functioning at 6 months, even after adjusting for covariates, including baseline functioning and depression. Moreover, social support was found to buffer the detrimental impact of poor sleep quality, especially low sleep efficiency, on 6-month physical health functioning. Findings suggest that improving sleep quality for patients with CHD may be promising to facilitate their long-term health maintenance.

Chronic stress exposure in men and women, and implications for the course of fatigue after percutaneous coronary intervention; the THORESCI study

BACKGROUND

Fatigue is a prevalent symptom in patients with coronary heart disease (CHD). Individual differences in chronic stress may affect the experience and persistence of fatigue, and this may vary between the sexes. Therefore, we studied the effect of chronic stress on the course of fatigue over a 2-year period after percutaneous coronary intervention (PCI), and examined the moderating effects of sex.

METHODS

1682 patients (78% men, age = 67.1 ± 10.6) were recruited and filled out multiple self-report questionnaires at baseline, one, 12, and 24 months post-PCI, including questions on demographics, fatigue (HCS). Multiple chronic stressors were assessed at baseline: work stress (ERI16), marital stress (MMQ-6), early life events (Life Events Questionnaire) and social stress. Latent class factor analysis (LatentGOLD) was used to construct a comprehensive chronic stress index. Linear mixed modeling examined the predictive quality of predictors and covariates.

RESULTS

Fatigue was found to substantially decrease over the first month post-PCI, then stabilized at a moderate level. Chronic stress impacted both the level and course of fatigue by increasing its level and delaying recovery. Overall and across time, women reported more fatigue than men. The level and course effects of chronic stress and sex were independent of demographic, health behavioral, and medical covariates.

CONCLUSIONS

Individual differences in chronic stress impact both the level and course of fatigue post-PCI, with women being affected most. Future research could further explain the mechanisms underlying the observed relationships. Developing and testing interventions focusing on exercise and stress-reduction could be used to alleviate fatigue.

Association between sleep quality and self-care in adults with heart failure: A systematic review

BACKGROUND

Sleep disturbance is one of the most common symptoms among heart failure patients. Sleep disturbance reduces quality of life and leads to higher rates of mortality. It may affect the ability of patients to perform adequate self-care. Although some research has evaluated the association between sleep quality and heart failure self-care, a synthesis of the most recent available evidence is lacking.

AIMS

This systematic review aimed to assess the association between sleep quality and self-care in adults with heart failure.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was used. Medline, CINAHL, PsycINFO and SCOPUS were searched. Observational, case-control and cohort studies were considered. The quality of the studies was evaluated with the Joanna Briggs Institute's Critical Appraisal Tools.

RESULTS

Six articles were included. Association between sleep quality and self-care was reported by three studies. One of these did not find an association between sleep disturbance and heart failure self-care, while the other two studies did. An association between sleep quality and medication adherence was reported by three studies. All three of these studies found associations between these two variables. Studies have measured similar but different constructs. Two studies assessed sleep quality, while four other studies measured excessive daytime sleepiness. Half of the studies examined self-care, while the other half measured medication adherence.

CONCLUSIONS

Although the evidence should be strengthened, sleep quality seems to affect self-care in heart failure patients. The mechanism underlying the effect of sleep quality on heart failure self-care remains unclear. Future longitudinal interaction analyses could be useful to clarify this mechanism.

Psychological factors and self-rated health: An observative study on cardiological patients

This study investigated the association of illness representations, awareness of bodily states and health complaints to self-rated health in N = 150 consecutive patients with heart disease (ischaemic disease, heart failure and heart valve disease) and explored differences between ‘health optimist’ and ‘health pessimist’ patients. After controlling for medical variables, health complaints accounted for 14.2 per cent of patients’ self-rated health, and illness representations contributed for another 16.2 per cent; body awareness was not associated with self-rated health. Also, ‘optimists’ tended to see less negative consequences from their illness and perceived greater control over illness treatment compared to ‘pessimists’. Targeting symptoms and illness representations may optimize rehabilitation outcomes.

Perceived Cognition after Percutaneous Coronary Intervention: Association with Quality of Life, Mood and Fatigue in the THORESCI Study

Purpose

Percutaneous coronary intervention (PCI) is a common invasive procedure for the treatment of coronary artery diseases. Long-term cognitive functioning after PCI and its association with health-related quality of life (HRQL) and psychological factors is relatively unknown. The aim of this study is to examine whether perceived cognitive functioning during the year after PCI is associated with HRQL over this time period, and whether mood, fatigue, and age are associated with changes in perceived cognition and HRQL.

Methods

Patients undergoing PCI (n = 384, 79% male, mean age = 63, SD = 10) were recruited in the observational Tilburg Health Outcome Registry of Emotional Stress after Coronary Intervention (THORESCI) cohort study. Perceived concentration and attention problems, HRQL, mood, and fatigue were assessed at baseline, at 1-month and 12-month follow-up.

Results

General linear mixed modeling analysis showed that across time, between- and within-subject differences in perceived concentration problems were associated with a reduced HRQL in all domains independent of clinical and demographic covariates. Only a part of this association could be explained by negative mood, fatigue, and older age. Similar findings were found for between-subject differences in perceived attention problems.

Conclusions

Between-subject differences and within-subject changes in perceived cognition in PCI patients were strongly associated with HRQL across time, such that poorer perceived cognition was associated with poorer HRQL, independent of demographic and clinical variables. Most of the associations were also independent of mood and fatigue. The results should increase the awareness of clinicians for the role of cognition in the cardiac rehabilitation and recovery post-PCI.

Validity of the European Society of Cardiology's Psychosocial Screening Interview in Patients With Coronary Artery Disease-The THORESCI Study

OBJECTIVE

The aim of the study was to examine the validity of the European Society of Cardiology (ESC) psychosocial screening instrument.

METHODS

A total of 508 acute (67%) or elective (33%) percutaneous coronary intervention patients (mean [standard deviation]age = 63 [10] years, 81% male) completed the ESC screening interview and established questionnaires for psychosocial risk markers, that is, depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder Questionnaire 7), type D personality (Type D Scale 14), hostility (Cook-Medley Hostility Scale 7), and marital/work stress (Maudsley Marital Quality Questionnaire 6, Effort-Reward Imbalance Scale) during or close after hospital admission. At 1-year follow-up, angina and cardiopulmonary symptoms were assessed.

RESULTS

Prevalence estimates of psychosocial factors based on the ESC screener were as follows: depression (18%), anxiety (33%), negative affectivity (11%), social inhibition (41%), work stress (17%), marital stress (2%), and hostility (38%). Analysis of correspondence with validated questionnaires revealed fair to moderate agreement (depression [κ = .39], anxiety [κ = .23], type D personality [κ = .21]), regardless of percutaneous coronary intervention indication. For work and marital stress, there was poor to fair performance (κ range = .04-.24); agreement for hostility was poor (κ = -.27). A positive ESC screen for depression, anxious tension, and type D personality was associated with more angina and cardiopulmonary symptoms at follow-up (odds ratios ranging between 1.85 (95% confidence interval = 0.84-4.08) and 8.01 (95% confidence interval = 2.35-27.35).

CONCLUSIONS

The ESC screener contributes to the search for a multidimensional and easy-to-use psychosocial screening instrument for cardiac patients. Although the screener, in its current form, may not be sufficiently valid to reliably detect all predefined psychosocial factors, screening scores for depression and anxiety might be useful in clinical practice. Our findings can be used for further refinement and validation of the screener.

Feasibility of a Cognitive-Behavioural Group Intervention for Men Experiencing Psychological Difficulties After Myocardial Infarction

Background: People experiencing psychological distress after a cardiac event may require special follow-up and targeted interventions in order to effectively decrease levels of distress. Aims: Men who were judged to be experiencing poor emotional adjustment post-myocardial infarction (MI) were invited to a cognitive behaviour therapy group. The current study examines the attendance at such a group and the consequent feasibility of such interventions. Method: The content of the group aimed to help men deal with the uncomfortable psychosocial issues that had arisen since having a MI. Results: Of the 26 men approached only 30% were interested in attending and only 11% actually completed the group. Two men who were committed to attending the group could not complete all the sessions, as heart bypass operations became available to them. Conclusion: Ways of involving men in interventions targeting psychological distress requires ongoing investigation.

Symptom clusters and health-related quality of life in people with chronic stable angina

AIM

This paper reports findings of a study to examine the independent contribution of chest pain, fatigue and dyspnoea to health-related quality of life in people with chronic stable angina.

BACKGROUND

People with chronic stable angina experience poorer quality of life in multiple areas including physical and emotional health. Emerging evidence suggests the presence of concomitant symptoms yet there are no systematic studies examining the impact of symptom clusters on quality of life in people with chronic angina.

METHOD

Outpatients (n = 134), recruited over a 16-month period in 2000 and 2001, with confirmed coronary heart disease and chronic angina completed reliable and valid questionnaires measuring chest pain frequency, fatigue, dyspnoea and quality of life. The data have contemporary relevance because despite changes in treatment of coronary heart disease, chronic angina remains prevalent worldwide. Hierarchical multiple linear regression was used to examine the symptom cluster of chest pain frequency, fatigue and dyspnoea in predicting quality of life.

RESULTS

The sample was predominantly white (74·6%), men (59·7%) with a mean age of 63·4 (sd 12·12) years. Controlling for age, gender, social status and co-morbidities, the symptom cluster of chest pain frequency, dyspnoea and fatigue accounted for a statistically significant increase in unadjusted R² (F of Δ, P < 0·05) for the models predicting physical limitation (R² Δ 24·1%), disease perception (R² Δ 24·6%), Short Form-36 Physical Component Score (R² Δ 24·3%) and Mental Component Score (R² Δ 07·0%).

CONCLUSION

Symptom assessment and management of people with chronic stable angina should involve multiple symptoms. Greater fatigue predicted poorer quality of life in multiple areas. As a possible indicator of depression, it warrants further assessment and follow-up.

Anhedonia is associated with poor health status and more somatic and cognitive symptoms in patients with coronary artery disease

Purpose

The effectiveness of cardiac rehabilitation (CR) in patients with coronary artery disease (CAD) is moderated by negative emotions and clinical factors, but no studies evaluated the role of positive emotions. This study examined whether anhedonia (i.e. the lack of positive affect) moderated the effectiveness of CR on health status and somatic and cognitive symptoms.

Methods

CAD patients (n = 368) filled out the Hospital Anxiety and Depression Scale (HADS) to assess anhedonia at the start of CR, and the Short-Form Health Survey (SF-36) and the Health Complaints Scale (HCS) at the start of CR and at 3 months to assess health status and somatic and cognitive symptoms, respectively.

Results

Adjusting for clinical and demographic factors, health status improved significantly during the follow-up (F(1,357) = 10.84, P = .001). Anhedonic patients reported poorer health status compared with non-anhedonic patients, with anhedonia exerting a stable effect over time (F(1,358) = 34.80, P < .001). Somatic and cognitive symptoms decreased over time (F(1,358) = 3.85, P = .05). Anhedonics experienced more benefits in terms of somatic and cognitive symptoms over time (F(1,358) = 13.00, P < .001).

Conclusion

Anhedonic patients reported poorer health status and higher levels of somatic and cognitive symptoms prior to and after CR. Somatic and cognitive symptoms differed as a function of anhedonia over time, but health status did not. Anhedonia might provide a new avenue for secondary prevention in CAD.

Beyond Type D personality: reduced positive affect (anhedonia) predicts impaired health status in chronic heart failure

Objective

Type D personality has been associated with impaired health status in chronic heart failure (CHF), but other psychological factors may also be important.

Aim

To determine whether non-Type D patients with low positive affect and Type D patients report lower health status, compared with non-Type D patients with high positive affect at 12-month follow-up in chronic heart failure.

Methods

Consecutive CHF outpatients (n = 276) filled out the Short Form-12 (health status) and Health Complaints Scale (disease-specific complaints) at inclusion and 12-month follow-up, and the DS14 (Type D personality) and positive affect (Global Mood Scale) at inclusion. Three groups were composed: non-Type D patients without anhedonia, non-Type D patients with anhedonia, and Type D patients.

Results

After controlling for demographic and clinical confounders, and scores at inclusion, anhedonic non-Type D patients reported lower mental health status (β = –.19, P < .004), and more feelings of disability (β = .10, P = .04), marginally lower physical health status (β = −.11, P = .07), and equal levels of cardiac symptoms (β = .04, P = .43), when compared with non-Type D’s without anhedonia. Type D patients reported lower levels of impaired mental health status, more cardiac symptoms and feelings of disability (−.31 < β < .17, all Ps < .05). A trend was shown for physical health status (β = −.11, P = .09).

Conclusion

Non-Type D patients low on positive affect and Type D patients report lower levels of health status in CHF, compared with non-Type D patients with high positive affect. Future studies need to determine whether lack of positive affect is associated with impaired clinical outcome.

Relationship of initial level of distress to changes in health-related quality of life during cardiac rehabilitation or usual care

OBJECTIVES

To assess the relationship between changes in health-related quality of life (HRQOL) and initial levels of distress in cardiac patients who received multidisciplinary cardiac rehabilitation (CR) or usual care. High rates of psychological distress have been reported in cardiac patients.

METHODS

Cardiac patients completed a questionnaire battery at the start and finish of a CR program (n = 131) or at equivalent times after hospital discharge in comparison hospitals where CR was not available (n = 185). The questionnaire battery comprised the Hospital Anxiety and Depression Scale, the Health Complaints Scale, and the Quality of Life Index Cardiac Version III (QLI CV-III).

RESULTS

Significant correlations between initial levels and subsequent changes in distress and HRQOL measures were found for both the CR and comparison groups. The CR program was associated with significant changes in both somatic and cognitive complaints for only those in distress. Changes in functional and psychological morbidity were greater in the CR group than in the comparison group.

CONCLUSIONS

Changes in HRQOL were significantly related to the initial levels of distress found in cardiac patients, regardless of CR attendance. The CR program had beneficial effects on levels of functional ability and on psychological morbidity reduction. Implications of the research for CR outcomes assessment are considered.

Symptoms of fatigue in chronic heart failure patients: Clinical and psychological predictors

OBJECTIVE

To examine the role of clinical and psychological characteristics as predictors of fatigue in CHF.

BACKGROUND

Little is known about predictors of fatigue in CHF. Next to heart failure characteristics, depressive symptoms and type-D personality may explain individual differences in fatigue.

METHODS

At baseline, 136 CHF outpatients (age<or=80 years) completed a questionnaire to assess depressive symptoms, type-D personality and cardiac symptoms. At one-year follow-up, they completed the Dutch Exertion Fatigue Scale and the Fatigue Assessment Scale to assess symptoms of fatigue. Medical information was obtained from the patients' medical records.

RESULTS

Exertion fatigue and general fatigue were identified as different manifestations of fatigue. We found that exertion fatigue at 12-month follow-up was predicted by decreased exercise capacity (beta=-.35; p<.001), dyspnoea (beta=24; p=.002), hypertension (beta=.16; p=.03), and depressive symptoms (beta=.16; p=.05). In contrast, general fatigue at 12-month follow-up was predicted by dyspnoea (beta=.24; p=.003), depressive symptoms (beta=.27; p<.001), type-D personality (beta=17; p=.03), and sleep problems (beta=.20; p=.01). Together, these variables explained 32% and 37% of the variance, respectively.

CONCLUSION

The present study showed that fatigue was related to both clinical and psychological characteristics. The use of this knowledge may lead to a better understanding and treatment of the clinical manifestations of fatigue in CHF.

Effects of antidepressant treatment following myocardial infarction

BACKGROUND

Depression following myocardial infarction is associated with poor cardiac prognosis. It is unclear whether antidepressant treatment improves long-term depression status and cardiac prognosis.

AIMS

To evaluate the effects of antidepressant treatment compared with usual care in an effectiveness study.

METHOD

In a multicentre randomised controlled trial, 2177 myocardial infarction patients were evaluated for ICD-10 depression and randomised to intervention (n=209) or care as usual (n=122). Both arms were evaluated at 18 months post-myocardial infarction for long-term depression status and new cardiac events.

RESULTS

No differences were observed between intervention and control groups in mean scores on the Beck Depression Inventory (11.0, s.d.=7.5 v.10.2, s.d.=5.1, P=0.45) or presence of ICD-10 depression (30.5 v. 32.1%, P=0.68). The cardiac event rate was 14% among the intervention group and 13% among controls (OR=1.07, 95% CI 0.57-2.00).

CONCLUSIONS

Antidepressant treatment did not alter long-term depression post-myocardial infarction status or improve cardiac prognosis.

Failure to consult for symptoms of heart failure in patients with a type-D personality

BACKGROUND

Self-management and adequate consultation behaviour are essential for the successful treatment of chronic heart failure (CHF). Patients with a type-D personality, characterised by high social inhibition and negative affectivity, may delay medical consultation despite increased symptom levels and may be at an increased risk for adverse clinical outcomes.

AIM

To examine whether type-D personality predicts poor self-management and failure to consult for evident cardiac symptoms in patients with CHF. Design/methods/

PATIENTS

178 outpatients with CHF (aged < or =80 years) completed the type-D Personality Scale at baseline, and the Health Complaints Scale (symptoms) and European Heart Failure Self-care Behaviour Scale (self-management) at 2 months of follow-up. Medical information was obtained from the patients' medical records.

RESULTS

At follow-up, patients with a type-D personality experienced more cardiac symptoms (OR 6.4; 95% CI 2.5 to 16.3, p<0.001) and more often appraised these symptoms as worrisome (OR 2.9; 95% CI 1.3 to 6.6, p<0.01) compared with patients with a non-type-D personality. Paradoxically, patients with a type-D personality were less likely to report these symptoms to their cardiologist/nurse, as indicated by an increased risk for inadequate consultation behaviour (OR 2.7; 95% CI 1.2 to 6.0, p<0.05), adjusting for demographics, CHF severity/aetiology, time since diagnosis and medication. Accordingly, of 61 patients with CHF who failed to consult for evident cardiac symptoms, 43% had a type-D personality (n = 26). Of the remaining 108 patients with CHF, only 14% (n = 16) had a type-D personality.

CONCLUSION

Patients with CHF with a type-D personality display inadequate self-management. Failure to consult for increased symptom levels may partially explain the adverse effect of type-D personality on cardiac prognosis.

Depression after myocardial infarction is a risk factor for declining health related quality of life and increased disability and cardiac complaints at 12 months

OBJECTIVE

To study the prospective effects of post-myocardial infarction (MI) depressive disorder on health status, including self reported cardiac symptoms, disability, and health related quality of life, at 12 months after MI while controlling for cardiac condition and health status at three months after MI.

METHODS

Longitudinal study of a cohort of 468 adults with MI recruited from four hospitals in the north of The Netherlands between September 1997 and September 2000. Assessment of depressive disorder in the year after MI according to International classification of disease, 10th revision criteria. Assessment of health status at three and 12 months by the RAND 36 item health survey, the health complaints scale, self rated cardiac complaints, and disability.

RESULTS

Patients with post-MI depressive disorder were more likely than those without to have poor quality of life, more health complaints, more cardiac complaints, and more disability at 12 months' follow up. In multivariate analyses adjusted for cardiac condition, health status at three months, age, sex, and pre-MI depression, the prospective association of post-MI depression with poor health status remained for most of the indicators. Severity of the post-MI depression further contributed to aspects of poor health status.

CONCLUSIONS

In a prospective study design, post-MI depression had strong effects on poor health status exceeding the effects of cardiac condition and its short term consequences. Efforts to improve health status after MI should therefore include standard assessment and guideline based treatment of post-MI depressive disorder.

Responsiveness of health-related quality of life outcome measures in cardiac rehabilitation: comparison of cardiac rehabilitation outcome measures

Assessment instruments that are not responsive to change are unsuitable as outcome tools in cardiac rehabilitation because they underestimate the psychosocial benefits of program attendance. Nine questionnaires were assessed for responsiveness with the standardized response mean (SRM). Questionnaires were allocated into 3 batteries, and each battery was completed by cardiac rehabilitation and comparison participants at 2 time points (411 and 375 participants in total, respectively). There was a high degree of variability in the responsiveness of instrument subscales. The positive affect subscale of the Global Mood Scale (J. Denollet, 1993a) was the most responsive (SRM = 0.62). Further information on the comparative responsiveness of psychosocial scales is important to optimize instrument selection for outcome studies.

DS14: standard assessment of negative affectivity, social inhibition, and Type D personality

OBJECTIVE

Type D personality-a joint tendency toward negative affectivity (NA) and social inhibition (SI)-is related to poor cardiac prognosis, but there is no standard for assessing Type D. This study reports on the Type D Scale-14 (DS14) as a standard measure of NA, SI, and Type D.

METHODS

The study included 3813 participants (2508 from the general population, 573 cardiac patients, 732 hypertension patients). They all filled out the DS14, containing 7-item NA and SI subscales; 275 subjects also completed the NEO-FFI, and 121 patients filled out the DS14 twice.

RESULTS

Factor analysis of the DS14 yielded 2 dominant traits; all of the NA and SI items loaded between 0.62 to 0.82 on their corresponding factor (N = 3678). The NA scale covered dysphoria, worry, and irritability; the SI scale covered discomfort in social interactions, reticence, and lack of social poise. The NA and SI scales were internally consistent (alpha = 0.88/0.86; N = 3678), stable over a 3-month period (test-retest r = 0.72/0.82) and not dependent on mood and health status (N = 121). NA correlated positively with neuroticism (r = 0.68); SI correlated negatively with extraversion (r = -0.59/-0.65). Scale-level factor analysis confirmed the construct validity of the DS14 against the NEO-FFI. Using a cutoff of 10 (NA > or =10 and SI > or =10), 1027 subjects (28%) were classified as Type D, 21% in the general population versus 28% in coronary heart disease and 53% in hypertension (p < or = .001). Age, sex, and Type D (odds ratio, 3.98; 95% confidence interval, 3.2-4.6; p <.0001) were independently associated with cardiovascular morbidity.

CONCLUSION

The DS14 is a brief, psychometrically sound measure of negative affectivity and social inhibition that could readily be incorporated in epidemiologic and clinical research.

Occurrence of symptoms and depressive mood among working-aged coronary heart disease patients

BACKGROUND

The typical symptoms of coronary heart disease (CHD), chest pain and breathlessness, are well-known. They are considered quite dramatic, and can thus be fairly reliably mapped by a survey. However, people might have other clearly unpleasant symptoms impairing quality of life. The aim of this study is to evaluate the appearance of these complaints of working-aged people with self-reported CHD.

METHODS

The study consists of a postal questionnaire of randomly selected Finns in age groups 30-34, 40-44 and 50-54, a response rate of 39% (N = 15,477). The subjects were asked whether or not a doctor had told them that they had angina pectoris or had had myocardial infarction. Four randomly selected age and sex matched controls were chosen for every patient. The occurrence of self-reported dyspnoea, chest pain during anger or other kind of emotion, palpitation and perspiration without physical exercise, irregular heartbeats, flushing, trembling of hands and voice, jerking of muscles, depression and day-time sleepiness were examined. Odds ratios (OR) with 95% confidence intervals (CI), between occurrence of symptoms and CHD with and without heart infarction, were computed by multivariate logistic regression analysis.

RESULTS

The sample eventually comprised 319 CHD patients. Dyspnoea, chest pain during anger or other kind of emotion, palpitation, perspiration without physical exercise, irregular heartbeats daily or almost daily, trembling of hands and voice, and jerking of muscles occurred statistically significantly more frequently among CHD patients than among controls. The CHD patients also reported more depressive mood according to Beck's inventory scores and poorer sleep and more frequent day-time sleepiness than controls. In the multivariate logistic regression analysis chest pain during anger or other kind of emotion (ORs 4.12 and 3.61) and dyspnoea (ORs 2.33 and 3.81) were the symptoms most associated with CHD.

CONCLUSIONS

Working-aged people with self-reported coronary heart disease evince a number of symptoms limiting the quality of their every day life. This aspect should be paid attention to when evaluating functional capacity of these patients.

The effect of low social support on short-term prognosis in patients following a first myocardial infarction

The objectives of the current study were (1) to assess adjustment in patients following a first myocardial infarction (MI) at 9 months compared with 4-6 weeks post-MI, (2) to examine the availability of and satisfaction with social support over time, and (3) to determine separate baseline psychosocial predictors of recurrent cardiac events. A questionnaire assessing post-traumatic stress disorder, anxiety, depression, health complaints, and social support, was distributed to consecutive patients 4-6 weeks and 9 months post-MI. Prior to assessment at follow-up, 8 (7%) of 112 patients had dropped out, and two had died due to cardiac causes. Objective clinical measures were obtained from medical records. There was an improvement in somatic and cognitive symptoms at follow-up, but no change in symptoms of arousal, depression, and anxiety. Half of the patients were afraid of a recurrent MI. There was a significant decrease in social support between baseline and follow-up, and lower social support at baseline was associated with a 10% increased risk of recurrent cardiac events at follow-up (OR: 0.90; 95% CI: 0.84 to 0.97) adjusting for all other variables. Some patients still experienced difficulties with psychosocial adjustment 9 months post-MI despite a reduction in somatic and cognitive symptoms. Social support decreased over time, which may have serious prognostic implications; lower social support at baseline was an independent predictor of recurrent events at 9 months. An important step for future research will be to investigate how social support can be enhanced in patients at risk.

Catastrophic thinking about pain increases discomfort during internal atrial cardioversion

OBJECTIVES

This study investigated whether pain catastrophizing is associated with distress and perceived disability in patients with atrial fibrillation, whether pain catastrophizing predicts pain and fear during a medical procedure of atrial cardioversion, and whether pain catastrophizing influences the effects of an opioid analgesic during internal cardioversion.

METHODS

A secondary analysis is performed upon data from a double-blind placebo-controlled trial during which the effect of intranasal butorphanol tartrate (INB) was evaluated in patients with atrial fibrillation using a step-up internal atrial cardioversion protocol. Before the procedure, patients completed measures of pain catastrophizing, mood, distress and perceived disability. After each shock, patients completed measures of pain and fear.

RESULTS

We found that pain catastrophizing predicted the affective pain rating of the first shock, and the fear increase during subsequent shocks. There was no effect of INB. However, when controlling for the differences in pain catastrophizing, INB significantly reduced fear as compared to placebo. This suggests that the effects of INB during atrial cardioversion were overshadowed by the effects of pain catastrophizing.

CONCLUSIONS

It is recommended that in future atrial cardioversion trials, stratification based on pain catastrophizing be performed. Reducing catastrophizing thinking about pain through cognitive-behavioral techniques are likely to reduce levels of fear during internal atrial cardioversion and may increase the effectiveness of concomitant analgesics.

The role of personality variables and social support in distress and perceived health in patients following myocardial infarction

OBJECTIVES

(1) To investigate whether patients with low versus high social support and satisfaction with support report less distress and health complaints following a first myocardial infarction (MI). (2) To examine whether personality traits mediate social support and its effect on distress and health complaints.

METHODS

A questionnaire was distributed to 112 consecutive patients with a first MI 4-6 weeks postinfarction. Objective clinical measures were obtained from the patients' medical records.

RESULTS

Patients with low social support were at increased risk of depression and posttraumatic stress disorder (PTSD). Patients less satisfied with support were at increased risk of anxiety, depression, PTSD, and reported more health complaints. Generally, larger effect sizes were found for satisfaction with support compared with social support per se in relation to distress and health complaints. Neuroticism was identified as an independent predictor of all types of distress and health complaints when including both traits and social support variables in multivariable analyses, adjusted for demographic and clinical variables. Satisfaction with support only remained an independent predictor of depression.

CONCLUSION

These results suggest that personality traits may mediate social support and its effect on distress and health complaints. Hence, it may be important to include personality variables when investigating social support in relation to distress and health. In clinical practice, screening for particular personality traits could identify patients at risk of distress and recurrent cardiac events.

Perceived health following myocardial infarction: cross-validation of the Health Complaints Scale in Danish patients

With an ageing population and a decline in cardiac mortality rates, the number of patients with cardiac disease is increasing, which in turn poses a major challenge for secondary prevention. For this end, appropriate, sensitive, and validated instruments to assess health complaints and quality of life are required. The objectives of the current study were: (1) to cross-validate the Health Complaints Scale (HCS) in a Danish sample of patients with a first myocardial infarction (MI); and (2) to investigate whether perceived health, as measured by the HCS is related to cardiac disease severity. The HCS was originally developed in Belgian patients with coronary artery disease. One-hundred-and-twelve consecutive patients with a first myocardial infarction were assessed by means of a questionnaire four to six weeks post infarction. Clinical measures were sampled from medical records. The factor structure of the HCS and the internal consistency of the Somatic Complaints (alpha = 0.91) and Cognitive Complaints subscales (alpha = 0.94) were confirmed. The construct validity of the scale was confirmed against measures of psychopathology and personality. Patients scored significantly higher on the HCS Somatic and Cognitive scales as compared with self-reports of depression and anxiety (p < 0.0001). Health complaints were unrelated to severity of cardiac disease and rather reflected subjective perception of quality of life. These findings show that the HCS is a valid instrument that is equally applicable in Danish cardiac patients to monitor perceived health as a major component of quality of life.

A collaborative program for cardiovascular patient follow-up

Transitions from one health care system to another are common, but they can affect coordination of care and measurement of patient outcomes. In this project, a community hospital and a tertiary center collaborated to obtain follow-up information on patients 30 days after they underwent cardiac catheterization and revascularization. Results show that patients experienced similar physical and emotional concerns regardless of diagnosis or procedure. Although the intent was to gather information, nurses also provided education and arranged services for patients. This project has implications for the development of collaborative interventions to improve care for patients after undergoing coronary procedures.

Depression and myocardial infarction: relationship between heart and mind

There is a relationship between depression and Myocardial Infarction (MI) as higher levels of depression and severe depression (major vs minor) are associated with higher morbidity and mortality due to cardiac events, which are mainly caused by arrhythmia. Second, severity of MI is not or even inversely related to development of depression. Depression post-MI goes often unrecognized as only 10% of depressed MI patients are diagnosed as such. This underestimation of depression is attributed to its atypical profile, tendency of physicians to interpret depressive symptoms as a transient and 'natural' reaction to a life-threatening event, and the scarce knowledge of risk factors associated with development of post-MI depression. During the first 18 months following MI major depression occurs in 15-30% of patients. Depression should be assessed in an early stage as depression has the highest prevalence in hospital and in the first 6 months post-MI. Risk factors for developing post-MI depression include complications during hospitalization, prescription of benzodiazepines during hospitalisation, previous history of depression, and not being able to stop smoking. Selective Serotonin Reuptake Inhibitors (SSRIs) appear to be first choice treatment in post-MI depression. As yet there is no information on the efficacy and safety of Serotonin and Noradrenalin Reuptake Inhibitors (SNRIs).

Is there a relationship between cognitive dysfunction and systemic inflammatory response after cardiopulmonary bypass?

BACKGROUND

The systemic inflammatory reaction (SIR) is assumed to be one of the factors that causes cerebral dysfunction after cardiopulmonary bypass (CPB). The aim of the present study was to evaluate the relationship between the SIR and postoperative cognitive performance at 5 days and 3 months.

METHODS

One hundred patients undergoing coronary artery bypass grafting were studied. Inflammatory markers and markers of coagulation and fibrinolysis were determined at several time points during and after the operation. Correlation analysis between maximum levels of the different markers and early and late performance was performed.

RESULTS

No overall association was found between the maximum levels of the inflammatory markers and early and late function.

CONCLUSIONS

Notwithstanding limitations of statistical power established markers of systemic inflammatory reaction showed no relationship with outcome at 5-day or 3-month follow-up in this subset of patients.

Inadequate response to treatment in coronary heart disease : adverse effects of type D personality and younger age on 5-year prognosis and quality of life

BACKGROUND

Improvement in treatment of patients with coronary heart disease (CHD) has caused longer survival but also an increase in the number of patients at risk for subsequent cardiac events and impaired quality of life (QOL). We hypothesized that chronic emotional distress confers an increased risk of poor outcome despite appropriate treatment.

METHODS AND RESULTS

This prospective study examined the 5-year prognosis of 319 patients with CHD. Baseline assessment included symptoms of depression/anxiety and distressed personality type (type D-ie, high negative affectivity and social inhibition). The main end points were cardiac death or nonfatal myocardial infarction and impaired QOL. There were 22 cardiac events (16 nonfatal); they were related to left ventricular ejection fraction (LVEF) </=50%, poor exercise tolerance, age </=55 years, symptoms of depression, and type D personality. Multivariate analysis yielded LVEF </=50% (OR, 3.9; P=0.009), type D personality (OR, 8.9; P=0.0001), and age </=55 years (OR, 2.6; P=0.05) as independent predictors of cardiac events. Convergence of these risk factors predicted the absence of the expected therapeutic response that was observed in 10% of the patients. When 2 or 3 risk factors occurred together, the rate of poor outcome was 4-fold higher (P=0. 0001). Estimates of medical costs increased progressively with an increasing number of risk factors. Smoking, symptoms of depression, and type D personality were independent predictors of impaired QOL.

CONCLUSIONS

Decreased LVEF, type D personality, and younger age increase the risk of cardiac events; convergence of these factors predicts nonresponse to treatment. Emotionally stressed and younger patients with CHD represent high-risk groups deserving of special study.

Is there a relationship between serum S-100beta protein and neuropsychologic dysfunction after cardiopulmonary bypass?

OBJECTIVES

Over the past decade, the glial protein S-100beta has been used to detect cerebral injury in a number of clinical settings including cardiac surgery. Previous investigations suggest that S-100beta is capable of identifying patients with cerebral dysfunction after cardiopulmonary bypass. Whether detection of elevated levels S-100beta reflects long-term cognitive impairment remains to be shown. The present study evaluated whether perioperative release of S-100beta after coronary artery operations with cardiopulmonary bypass could predict early or late neuropsychologic impairment.

METHODS

A total of 100 patients undergoing elective coronary bypass without a previous history of neurologic events were prospectively studied. To exclude noncerebral sources of S-100beta, we did not use cardiotomy suction or retransfusion of shed mediastinal blood. Serial perioperative measurements of S-100beta were performed with the use of a new sensitive immunoluminometric assay up to 8 hours after the operation. Patients underwent cognitive testing on a battery of 11 tests before the operation, before discharge from the hospital, and 3 months later.

RESULTS

No significant correlation was found between S-100beta release and neuropsychologic measures either 5 days or 3 months after the operation.

CONCLUSION

Despite using a sensitive immunoluminometric assay of S-100beta, we found no evidence to support the suggestion that early release of S-100beta may reflect long-term neurologic injury capable of producing cognitive impairment.

Psychosocial outcome assessments for use in cardiac rehabilitation service evaluation: a 10-year systematic review

A variety of measures are currently used to assess psychosocial outcome (quality of life) in cardiac rehabilitation programmes. However, there is no consensus on the most appropriate instruments to use. Instruments that are not sufficiently responsive to change in cardiac populations are unsuitable as audit tools as they underrepresent the benefits of programme attendance. To identify the most responsive instruments in cardiac rehabilitation populations a systematic overview of studies for the 10-year period 1986-1995 was conducted. The following databases were searched: Medline, Psychlit, Cinahl and Sociofile and 32 relevant studies were identified. The effect size statistic (a comparison of the magnitude of change to the variability in baseline scores) was used to determine those instruments most responsive to change. The following instruments were identified as being responsive in more than one study: Beck Depression Inventory, Global Mood Scale, Health Complaints Checklist, Heart Patients Psychological Questionnaire and Speilberger State Anxiety Inventory. There is little consensus on psychosocial evaluation instrument use in the cardiac rehabilitation literature. A number of measures show significant potential for routine outcome assessment. Formal assessment of these instruments is recommended to inform final recommendations about instrument selection for audit and evaluation purposes in cardiac rehabilitation.

Quality of life in patients with complete heart block and paroxysmal atrial tachyarrhythmias: a comparison of permanent DDIR versus DDDR pacing with mode switch to DDIR

A prospective double-blind randomized crossover study was done in 15 patients with complete heart block and intermittent ATs. The pacemaker was randomly programmed to dual chamber inhibited rate responsive pacing (DDIR) and to DDDR with mode switch, for 1 month each. An event recorder was given to the patients and after each period, a QOL questionnaire was obtained. Based on telemetric data, all but two patients had AT during follow-up. The duration and frequency of these episodes were not related to mode settings. AV synchrony was better preserved in DDDR (P < 0.05). Most symptom-related event recordings during DDIR showed loss of AV synchrony; DDDR with mode switch caused symptoms due to tracking of ST. Overall the QOL score was not different between the modes. Fewer somatic complaints were noted during DDDR pacing than during baseline. DDIR stimulation showed no difference. Twelve patients preferred the period of DDDR pacing; one experienced severe symptoms during DDIR. In conclusion, patients with paroxysmal AT, DDDR with mode switch, and DDIR had no influence on the occurrence, nor on the duration of AT episodes. AV synchrony was better preserved in DDDR, which was also associated with fewer somatic complaints compared to the baseline. In DDDR, symptoms were observed when ST was tracked. QOL was comparable, although more patients preferred DDDR.

Ventricular remodelling and revascularization in severe left ventricular dysfunction

OBJECTIVE

To evaluate the role of surgical revascularization in the presence of severe, global impairment of left ventricular function without discrete aneurysm formation or mitral regurgitation. The high mortality and morbidity associated with this group, together with the limited benefits tend to prompt referral for cardiac transplantation.

METHODS

Fifty-three patients initially referred for transplantation, in addition to coronary revascularization, underwent mitral annuloplasty (group A = 23), free wall remodelling by endoaneurysmorrhaphy (group B = 17) or mitral annuloplasty and free wall reconstruction (group C = 13). The mean ages were 59, 56 and 57 years for groups A, B and C, respectively. Detailed assessment of pre- and post-operative physical and psychological status were carried out.

RESULTS

Follow-up was for a mean period of 22-26 months. All patients reported substantial improvement in quality of life, both physical and psychological parameters and in NYHA functional class status. Objective evidence of improvement in ejection fraction was seen in all three groups but especially in group A. There were five early deaths, four were due to inadequate revascularization due to the poor quality of target vessels. There were three late deaths and one patient that required transplantation.

CONCLUSION

We conclude that patients with severe left ventricular dysfunction can be candidates for surgical revascularization and optimization of ventricular geometry with acceptable mortality. The importance of achieving complete revascularization is emphasized in this series.

[Transmyocardial laser revascularization and rehabilitation]

Transmyocardial laser revascularization (TMLR) is a new technique for patients with CAD or heart attack to revascularize ischemic areas of the myocardium in which the localisation or the condition of the vessels does not allow bypass grafting. This study shows the results in observation of patients before and during the first 3 months after TMLR. Of 110 patients operated on from 1994 to 1996, 86 were evaluated for well being (quality of life), using NYHA- and CCS-classification, stress test and nitril-scintigraphy at rest and under stress conditions. 51 patients, of whom 11 were females, underwent TMLR combined with coronary artery bypass graft (CABG). 35 male patients were treated singularly with TMLR. The average age in both groups was 59 years (+/- 23). All patients were subject to phase I rehabilitation in specialised institutions after being mobilised in the operating hospital. The evaluations took place on the day of admission to the hospital prior to surgery, within 10 days after surgery and 3 months following. The average stay in the rehabilitation-institution was between 4 and 6 weeks. Our findings demonstrate that both groups profited from the procedures, while the TMLR/CABG group showed a faster recovery and a better outcome. In comparison to 57% of the TMLR group, 85% of the patients in the TMLR/CABG group reported an improvement ranging from good to significant in quality of life assessments. The TMLR/CABG rated from an average of initially 3.4 (+/- 0.6) to 2.1 (+/- 0.8) after 3 months at NYHA- and 3.3 (+/- 0.7) to 1.7 (+/- 0.8) at CCS-classification. The TMLR group rated from 3.6 (+/- 0.5) to 2.4 (+/- 0.8) in NHYA- and from 3.4 (+/- 0.5) to 1.9 (+/- 0.7) on the CSS-scales. A remarkable improvement was noted in the stress test with an increase in power and endurance from 21 to 89 watts for the combined group and 8 to 81 watts for the TMLR treated patients, who generally recovered more slowly. The perfusion scan showed the same tendencies as previously reported but in some cases the results were not congruent with other findings. Overall, our findings indicate that there is a benefit for terminally symptomatic CAD patients after TMLR, but an observation period of 3 months does not allow for final conclusions on this matter. Rehabilitation seems to be of value for TMLR-patients since they have shown a markedly better performance following 3-month treatment, but further data from clinical randomised trials are needed to determine the influence of TMLR with short- and long-term rehabilitation on the prognosis of the disease.

Personality and mortality after myocardial infarction

Previous research showed: a) emotional distress is a risk factor for mortality after myocardial infarction (MI) and b) emotional distress is linked to stable personality traits. In this study, we examined the role of these personality traits in mortality after MI. Subjects were 105 men, 45 to 60 years of age, who survived a recent MI. Baseline assessment included biomedical and psychosocial risk factors, as well as each patient's personality type. After 2 to 5 (mean, 3.8) years of follow-up, 15 patients (14%) had died. Rate of death for patients with a distressed personality type (11/28 = 39%) was significantly greater than that for patients with other personality types (4/77 = 5%) (p < .0001). Patients with this personality type tend simultaneously to experience distress and inhibit expression of emotions. Low exercise tolerance, previous MI (p < .005), anterior MI, smoking, and age (p < .05) were also associated with mortality. A logistic regression model including these biomedical factors had a sensitivity for mortality of only 27%. The addition of distressed personality type in this model more than doubled its sensitivity. Of note, among patients with poor physical health, those with a distressed personality type had a five-fold mortality risk (p < .005). Consistent with the findings of other investigators, depression (p < .005), life stress, use of benzodiazepines (p < .01), and somatization (p < .05) were also related to post-MI mortality. These psychosocial risk factors were more prevalent in the distressed personality type than in the other personality types (p < .001-.05). Multiple logistic regression indicated that these psychosocial factors did not add to the predictive value of the distressed personality type. Hence, an important personality effect was observed despite the low power. This suggests that personality traits may play a role in the detrimental effect of emotional distress in MI patients.