Percutaneous transluminal coronary angioplasty: clinical and quality of life outcomes one year later

CABG and PTCA Patients' Expectations of Informational Support in Health-Related Quality of Life Themes and Adequacy of Information in 1-Year Follow-Up

The purpose of this study was to describe coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) patients' need for nursing informational support in health-related (HRQoL) items before and after coronary artery procedures. As well we present the adequacy of informational support from patients' viewpoint. The study sample (N=625) consisted of consecutive male (N=439) and female (N=176) patients with CAD who were treated with elective CABG or PTCA. The data were collected by structured interview before coronary artery procedures and by mailed questionnaires 6 and 12 months afterwards in 1999-2001. Patients in both groups reported needing the most information about recovery and psychosocial functioning before and after the treatments. Single HRQoL items identified that the expectations of women and men differed during the follow-up period. Women in the PTCA group needed more informational support than men before procedures, while men needed more support afterwards. Our results suggest that the content of informational support is different for male and female patients before and after the coronary artery procedures. The effects of nursing interventions and instruments for measuring change in patients' outcome resulting from nursing interventions should be developed further.

Physical activity and negative emotional response after percutaneous coronary intervention

BACKGROUND

The aims of this study were to investigate the association between negative emotional response (NER) and physical activity levels in percutaneous coronary intervention (PCI) patients, and to examine the extent to which physical activity levels were influenced by factors such as the patients' age, sex, and attendance at a cardiac rehabilitation (CR) programme.

METHODS

A consecutive series of 200 PCI patients [mean age 59.0 (+/-10.1) years] completed telephone interviews 2 weeks and 6 months after their procedure. NER was assessed using 12 items addressing patients' perceptions and concerns regarding symptoms, diagnosis and prognosis. Physical activity was assessed by asking four questions relating to the frequency and duration of walking and of moderate activity. CR attendance, medical history and sociodemographic data were also collected. Hierarchical linear regression was used to assess the association between NER and physical activity over time.

RESULTS

After controlling for baseline levels of moderate activity and other covariates, NER significantly predicted change in moderate activity over 6 months. Only baseline walking levels predicted the duration and frequency of walking at 6 months.

CONCLUSION

NER can be considered an inhibitive factor towards increased moderate activity uptake after PCI. Walking after PCI does not appear to be affected by NER. These findings highlight the need to focus on improving the emotional aspects of patients' recovery.

Sense of Coherence and Health-Related Quality of Life among Patients Undergoing Coronary Artery Bypass Grafting or Angioplasty

BACKGROUND

Every year, 4 million people die from cardiovascular disease (CAD) in Europe. As many as 800,000 of them die before they reach the age of 65. The ischemic heart disease is also the most common cause of death in Finland. The invasive treatments of the CAD, coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) relieve symptoms and increase patient's health-related quality of life (HRQoL) in most of the cases. In this paper sense of coherence is discussed as related to health-related quality of life among CABG and PTCA patients in a one-year follow-up.

SAMPLE

The study sample consisted of consecutive male (N=439) and female (N=176) patients who were treated with the elective CABG or PTCA. The baseline data before the interventions were collected by structured interviews, the follow-up data by mailed self-administered questionnaires six and twelve months afterwards.

MEASURES

The sense of coherence was studied by using a 13-item SOC scale. HRQoL was measured by the 15D. It is a generic, multidimensional, standardized, self-administered instrument, which has both a profile and single index score property. The differences in both groups were defined by using T-tests. Follow-up outcomes were analysed by using analyses of variance for repeated measures.

RESULTS

Health-related quality of life increased in both groups during the follow-up. There was a correlation between health-related quality of life and sense of coherence in CABG and PTCA patients' group at baseline. The mean score of the 15D was lower in moderate sense of coherence tertile than in strong sense of coherence tertile in both groups. After six and twelve months the similar tendency existed in health-related quality of life and sense of coherence; patients who had poor or moderate sense of coherence had lower health-related quality of life than the patients with strong sense of coherence.

CONCLUSIONS

Sense of coherence was more stable among CABG patients than PTCA patients. In PTCA patients' group sense of coherence decreased during the follow-up time. In both patients' group the health-related quality of life increased statistically significant by 6 months. No significant change in health-related quality of life took place in either group from 6 to 12 months.

Effect of Psychosocial Work Environment on Sickness Absence Among Patients Treated for Ischemic Heart Disease

INTRODUCTION

During the last decades mortality has declined in patients with coronary heart disease due to improvements in treatments and changes in life style, resulting in more people living with chronic heart disease. This implies that focus on rehabilitation and re-integration to the work-force becomes increasingly important. Previous studies among healthy workers suggest that the psychosocial working environment is associated with sickness absence. Whether the psychosocial working environment plays a role for patients with existing cardiovascular disease on return to work and sickness absence is less studied.

METHODS

A cohort of patients under 67 years and treated with percutaneous coronary intervention (PCI) was established in 2006. Three months after the procedure the patients (n = 625) answered a questionnaire about their psychosocial working environment. Patients were followed in registers for the following year. We examined the association between psychosocial working environment and sickness absence at 3 months, 1 year and new sick-listings during the first year with logistic regression.

RESULTS

A total of 528 patients had returned to work 3 months after the PCI, while 97 was still sick-listed. After 1 year one was dead, 465 were working and 85 were receiving health related benefits, while 74 had left the workforce permanently. A number of 106 patients were sick-listed during the whole first year or had left the workforce permanently. After the initial return to work, 90 experienced a new sickness absence during the first year while the remaining 429 did not. High work pace, low commitment to the workplace, low recognition (rewards) and low job control were associated with sickness absence at 3 months, but not after 1 year. Low job control as well as job strain (combination of high demands and low control) was associated with new sick-listings.

CONCLUSION

The psychosocial working environment was associated with sickness absence 3 months after the PCI, but not 1 year after.

Psychosocial Working Environment and Risk of Adverse Cardiac Events in Patients Treated for Coronary Heart Disease

INTRODUCTION

During the last decades a possible association between psychosocial working environment and increased risk of coronary heart disease (CHD) has been debated and moderate evidence supports that high psychological demands, lack of social support and iso-strain (the combination of high job strain and lack of social support) is associated with primary CHD. Whether psychosocial working environment plays a role as risk factor for new cardiac events and readmissions in patients with existing cardiovascular disease is less studied.

METHODS

A cohort of patients <67 years treated with percutaneous coronary intervention (PCI) was established in 2006. Three months after PCI patients answered a questionnaire about their psychosocial working environment. Patients were followed in the Danish National Patient Registry and the Danish Civil Registration System for 3+ years to identify adverse cardiac events and death. We analysed the association between psychosocial working environment and adverse cardiac events by Cox Regression.

RESULTS

A number of 528 patients had returned to work 12 weeks after PCI, while 97 were still sick-listed. We identified 12 deaths and 211 other events during follow-up. We found no statistically significant associations between psychosocial working environment and risk of adverse cardiac events and readmissions or mortality.

CONCLUSION

The psychosocial working environment was not associated with adverse cardiac events.

Return to work after percutaneous coronary intervention: the predictive value of self-reported health compared to clinical measures

AIMS

Coronary heart disease is prevalent in the working-age population. Traditional outcome measures like mortality and readmission are of importance to evaluate the prognosis but are hardly sufficient. Ability to work is an additional outcome of clinical and societal significance. We describe trends and predictors of Return To Work (RTW) after PCI and describe a possible benefit using patient-reported measures in risk stratification of RTW.

METHODS

A total of 1585 patients aged less than 67 years treated with PCI in 2006-2008 at the Aarhus University Hospital were enrolled. Clinical information was provided through the West Denmark Heart Registry, and 4 weeks after PCI we mailed a questionnaire regarding self-rated health (response rate 83.5%). RTW was defined at weekly basis using extensive register data on transfer payments. Predictors of RTW were analysed as time to event. ROC curves constructed by logistic regression of predicting variables were evaluated by the c-statistic.

RESULTS

Four weeks before PCI 50% of the patients were working; the corresponding figures were 25% after 4 weeks, 36% after 12 weeks, and 43% after one year. The patients' self-rated health one month after the procedure was a significant better predictor of RTW compared to other variables including LVEF, both at short (12 weeks) and long (one year) term.

CONCLUSIONS

The patient's self-rated health four weeks after the procedure was a stronger predictor than left ventricular ejection fraction (LVEF), and consequently useful when patients seek medical advice with respect to RWT.

Sickness absence following coronary revascularisation. A national study of women and men of working age in Sweden 1994-2006

BACKGROUND

Evidence based and gender specific knowledge about sickness absence following coronary revascularisation is lacking. The objective was to investigate sickness absence after a first coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) among women and men in a national Swedish study.

MATERIALS AND METHODS

All patients 30-63 years of age, who underwent a first CABG (n = 22,985, 16% women) or PCI (40,891, 22% women) in Sweden between 1994 and 2006 were included. Information on sickness absence, co-morbidity, and other patient characteristics was obtained from national registers. Long-term sickness absence (LTSA) was defined as >180 and >90 sick-leave days in the first sick-leave spell following CABG and PCI, respectively. Prevalence ratio (PR) and 95% confidence interval (CI) of LTSA were calculated.

FINDINGS

LTSA followed the interventions in 41% and 36% for CABG and PCI patients, respectively. Women had more often LTSA compared with men, (CABG PR = 1.23: 95% CI 1.19-1.28 and PCI PR = 1.19; 95% CI 1.16-1.23). A history of sickness absence the year before the intervention increased the risk for LTSA after the intervention in both genders. Among women, older age, or being self employed or unemployed was associated with a lower risk for LTSA. Among men previous cardiovascular disease, diabetes and low socio-economic position increased the risk. During the observation period, there was no change in sickness absence rates among PCI patients but an increase among CABG patients adjusting for patient characteristics.

CONCLUSION

This national study covering a 13-year period shows that long-term sickness absence following coronary revascularisation is common in Sweden, especially among women, and is associated with socio-economic position, co-morbidity, and sickness absence during the year before the intervention. Gender specific scientific knowledge about use and effects of sickness absence following coronary revascularisation is warranted for the patients, the treating physicians, the healthcare sector, and the society.

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.

Does the ownership of the admitting hospital make a difference? Outcomes and process of care of Medicare beneficiaries admitted with acute myocardial infarction

BACKGROUND

Concerns have been expressed about quality of for-profit hospitals and their use of expensive technologies.

OBJECTIVE

To determine differences in mortality after admission for acute myocardial infarction (AMI) and in the use of low- and high-tech services for AMI among for-profit, public, and private nonprofit hospitals.

STUDY DESIGN, SETTING, AND PATIENTS

Cooperative Cardiovascular Project data for 129,092 Medicare patients admitted for AMI from 1994 to 1995.

MAIN OUTCOME MEASURES

Mortality at 30 days and 1 year postadmission; use of aspirin, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers at discharge, thrombolytic therapy, catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass graft (CABG) compared by ownership.

RESULTS

Mortality rates at 30 days and at 1 year at for-profit hospitals were no different from those at public and private nonprofit hospitals. Without patient illness variables, nonprofit hospitals had lower mortality rates at 30 days (relative risk [RR], 0.95; 95% confidence interval [CI], 0.91-0.99) and at 1 year (RR, 0.96; 95% CI, 0.93-0.99) than did for-profit hospitals, but there was no difference in mortality between public and for-profit hospitals. Beneficiaries at nonprofit hospitals were more likely to receive aspirin (RR, 1.04; 95% CI, 1.03-1.05) and ACE inhibitors (RR, 1.05; 95% CI, 1.02-1.08) than at for-profit hospitals, but had lower rates of PTCA (RR, 0.91; 95% CI, 0.86-0.96) and CABG (RR, 0.93; 95% CI, 0.86-1.00).

CONCLUSIONS

Although outcomes did not vary by ownership, for-profit hospitals were more likely to use expensive, high-tech procedures. This pattern appears to be the result of for-profit hospitals' propensity to locate in areas with demand for high-tech care for AMI.

Lifestyle pattern change in males following percutaneous transluminal coronary angioplasty/intracoronary stenting

Utilizing a naturalistic inquiry approach, a semi-structured interview schedule and non-probability purposive sampling, this study provided detail on the rationale and influences behind the decisions of four males participants to change or not change their lifestyle patterns 3 months after a percutaneous transluminal coronary angioplasty/intracoronary stent procedure. One of the participants made a noticeable lifestyle pattern change in this period. The remaining participants failed to exhibit any discernible lifestyle pattern change or had continued with their previous behaviours. Results suggest a new 'positive' psychological health perspective, family considerations, return-to-work issues and a reluctance to participate in cardiac rehabilitation as the major factors influencing lifestyle pattern change. Because nurses spend the greatest amount of time with percutaneous transluminal coronary angioplasty/intracoronary stent patients during hospitalization, they have the best opportunity to provide up-to-date and relevant information to patients that will enable them to then make decisions concerning cardiac healthy lifestyle changes.

Quality of life comparisons after coronary angioplasty and coronary artery bypass graft surgery

OBJECTIVE

To examine the differences in realization of expected benefits, complications, and quality of life (QOL) 3 months after percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery.

DESIGN

Nonexperimental, prospective, and comparative. Before discharge, participants listed benefits expected from the procedure, as well as comorbid health problems (Charlson Comorbidity Index) and complications. At 3 months, they quantified their realization of expected benefits, reported postdischarge complications, and completed Ferrans and Powers' Quality of Life Index-Cardiac Version III.

SAMPLE

36 patients who had PTCA; 38 patients who had CABG.

RESULTS

There were no differences between groups in realization of expected benefits or QOL. Patients who had CABG reported a greater number of complications after discharge, and a greater proportion of patients who had PTCA reported angina. Patients who had PTCA and then recurrent angina had significantly lower health QOL and psychologic and spiritual QOL.

CONCLUSIONS

Patients who undergo CABG need guidance regarding what complications to expect, and patients who undergo PTCA need to know that recurrent angina is possible and how to manage it.

Predictors of patient-reported physical and mental health 6 months after percutaneous coronary revascularization

BACKGROUND

There is interest in measuring and comparing outcomes of percutaneous transluminal coronary angioplasty (PTCA) other than death, but there are no accepted methods for adjusting these outcomes for preprocedure differences in populations. We sought to identify independent predictors of functional outcome after PTCA.

METHODS AND RESULTS

We developed multivariate risk adjustment models for the 6-month postprocedure physical and mental health summary scores of the MOS SF-36. Complete data were available on 1182 patients undergoing PTCA at 12 institutions. The mean physical component score (PCS) of the SF-36 rose from 36.6 before PTCA to 43. 4 at 6 months after PTCA (P <.0001). Independent predictors of follow-up PCS were baseline PCS, a composite index of comorbidities, prior coronary bypass surgery, baseline MOS SF-36 mental component score (MCS), age, and recent thrombolysis. The model had an adjusted R(2) value of 0.357. The mean MCS rose from 48.5 before PTCA to 50.5 at 6 months after PTCA (P <.0001). Independent predictors of postprocedure mental health were baseline MCS, age, and heart failure. The predictive model for MCS had an adjusted R(2) value of 0.235.

CONCLUSIONS

Preprocedure patient-reported functional status and select clinical variables are significantly associated with physical functioning and mental health 6 months after PTCA. The predictive power of these models, however, is probably insufficient to allow their use for comparisons among institutions or providers.

Perceived health over 3 years after percutaneous coronary balloon angioplasty

The magnitude of the benefit of percutaneous transluminal coronary angioplasty (PTCA) in terms of quality of life depending on baseline and outcome clinical variables is not sufficiently understood because of the restrictive inclusion criteria of randomized clinical trials. The present study was designed to assess perceived health outcome at 3 years and its association with clinical variables after successful elective PTCA in a tertiary hospital throughout a prospective cohort study. Questionnaires were administered on the day before the procedure and 1 month and 3.4 years later (as mean follow-up) to 106 patients recruited during a 15-month period. Mean perceived health scores improved significantly for the population as a whole 1 month after PTCA, and improvement was maintained at the end of follow-up. The magnitude of the effect was different depending on clinical subgroups: (a) It was greatest in patients free from angina, myocardial infarction, or new revascularization procedures at the end of follow-up; (b) It was moderately reduced in patients with comorbidity; (c) Patients who reported to have dyspnea or angina at rest after the latest revascularization procedure did not improve, with poor final perceived health scores. Elective PTCA is associated with a significant improvement in perceived health, which varies depending on the clinical outcome. Comorbidity and initial perceived health influence outcome but do not preclude improvement.

Quality of life in coronary artery disease

BACKGROUND

Coronary artery disease (CAD) constitutes a considerable financial burden on society in Finland; it is the cause of death of approximately 7,500 men and 6,500 women annually in a population of 5 million.

OBJECTIVES

The purpose of this study was to assess the changes in the quality of life (QOL) of patients with CAD treated by medication, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass surgery (CABS) during 1 year.

METHOD

The study population consisted of 280 patients with CAD. One hundred patients had been referred to CABS and another 100 to PTCA, whereas 80 patients were on drug therapy. The patients assessed their health status and QOL in terms of functional capacity and aspects of distress using self-completed questionnaires with the Nottingham Health Profile (NHP) instrument before the operation and 6and 12 months afterwards.

RESULTS

The QOL of the patients who had undergone CABS and PTCA was significantly better on the dimensions of energy, pain, and mobility 1 year after the intervention. In the medication group, the only improvement took place on the dimension of social isolation, whereas both energy and mobility deteriorated.

CONCLUSIONS

The results on QOL obtained in this study support the notion that patients continue to have many problems even after medical treatment with a good outcome. The problems occur in different areas compared with the pretreatment situation as on the dimensions of social isolation and emotional reaction. The rehabilitation of CAD patients is therefore important because the new problems are manifested differently from those seen before the illness or the treatment. The patient's QOL and personal preference for a treatment modality should be important criteria in the choice of treatment.

Assessment of quality of life with the Nottingham Health Profile among women with coronary artery disease

OBJECTIVE

To examine the differences in the health-related quality of life (HRQOL) of Finnish women with coronary artery disease (CAD) (n = 91) in comparison with Finnish men with CAD (n = 189). Healthy women (n = 990) served as a control group.

DESIGN

Prospective, cross-sectional survey.

SETTING

Surgical and medical clinics at the University of Oulu, Finland.

PATIENTS

Twenty-one women underwent coronary artery bypass grafting (CABG), 40 women underwent percutaneous transluminal coronary angioplasty (PTCA), and 30 women received medication for treatment of CAD. The patients in the medication group were taking beta blockers (81%), long-acting nitrates (86%), calcium channel blockers (43%), aspirin (79%), and lipid-lowering drugs (18%).

OUTCOME MEASURES

The Nottingham Health Profile (NHP), which consists of six dimensions: energy, sleep, pain, emotional reactions, social isolation, and physical mobility. Higher mean indexes signify lower HRQOL.

INTERVENTION

The patients referred to CABG and PTCA procedures were interviewed and asked to fill in the questionnaire on the day before the operation. They were instructed to describe their HRQOL over the preceding 3 months. The patients in the medication group were mailed the NHP questionnaire.

RESULTS

Women with CAD reported significantly poorer HRQOL than age-matched women in the healthy sample, as measured by the following dimensions of the NHP: energy, sleep, pain, emotional reactions, and physical mobility. This indicates the NHP dimensions affected by CAD among women. HRQOL for women with CAD was lower than that of men with CAD. The mean indexes of four of the six NHP dimensions, energy, sleep, emotional reactions, and physical mobility were higher for women with CAD than men with CAD in the two youngest age groups. Social isolation was most common in the youngest age group among both women and men with CAD. In women with CAD, emotional reactions and social isolation were most clearly related to demographic characteristics such as traumatic life experiences, depression, financial situation, and smoking.

CONCLUSIONS

These findings suggest that the subjective HRQOL should be considered along with the clinical severity of the disease in the evaluation of CAD. The findings further shed light on the HRQOL of especially young women with CAD, the female and male patients' referral for treatment, and the use of the NHP instrument among patients with CAD.

Assessment of quality of life with the Nottingham Health Profile among patients with coronary heart disease

The aim was to describe the quality of life of people suffering from coronary artery disease. The patients had been treated with medication (n = 80), percutaneous transluminal coronary angioplasty (n = 100) and coronary artery bypass surgery (n = 100). Of the 280 patients, 189 were men and 91 women. The patients who participated in this study were seriously ill, as nearly half of them had three or more stenosed coronary arteries. Male patients were most numerous in the bypass surgery group and female patients in the angioplasty group. The quality of life was evaluated using the Nottingham Health Profile (NHP) instrument relation to an age- and sex-matched general population, the background factors and the severity of the coronary disease. The NHP questionnaire consists of 38 statements on health problems, making up six dimensions of subjective health: physical mobility, pain, sleep, energy, emotional reactions and social isolation. The health-related quality of life of coronary patients before the invasive procedures was significantly poorer on all the six dimensions than the quality of life in an age- and sex-matched general population. The most obvious differences were seen on the following dimensions: energy, pain, emotional reactions, sleep and physical mobility. The smallest differences occurred in social isolation. Both males and females had the lowest value for energy and social isolation in the youngest age group (35-54 years). The index values of emotional reactions in the two youngest groups were significantly higher among females than males, which reflects poor quality of life. The women in the age group of 35-54 years found the manifestation of a serious disease extremely hard to face. Our findings clearly suggest that while choosing the mode of treatment, the patient's quality of life should be considered along with the clinical severity of the disease, especially in the case of young women. From the societal and social points of view, the patient's symptoms and quality of life are even more important than the objective medical outcome. In clinical decision-making, the goal is to integrate the results of health-related quality of life assessments with clinical decisions, and this underlines the need to evaluate whether the treatment given is congruent with the patient's quality of life. On the basis of the present findings, the NHP instrument seems to be applicable to quality of life measurements among coronary patients. It does not, however, necessarily give an accurate and profound view of an individual's overall quality of life.

Coronary risk factor status after percutaneous transluminal coronary angioplasty

OBJECTIVE

To determine whether patients modify their risk factors after undergoing percutaneous transluminal coronary angioplasty (PTCA).

DESIGN

One-group, pretest-posttest. Pretest data were collected on the day before PTCA, and posttest data were collected at a mean follow-up of 11 months after PTCA. Data were collected from medical records and by patient self-report.

SETTING

University-affiliated, metropolitan public and private hospitals.

PATIENTS

Two hundred nine patients undergoing PTCA.

OUTCOME MEASURES

Patients' smoking and exercise habits were assessed by self-report. Serum cholesterol level and body mass index were determined from entries in medical charts.

RESULTS

All measured risk factors, with the exception of smoking, underwent favorable change (p < 0.001) after PTCA. The number of current smokers, however, increased significantly (p < 0.001), as did the number of cigarettes these patients smoked per day (p < 0.05).

CONCLUSION

Evaluation of the effect of intervention strategies on reducing patients' smoking behavior after PTCA is required.