What's “Unstable” in Unstable Angina?

Cost-effectiveness analysis of fractional flow reserve versus angiography among patients with coronary artery disease undergoing borderline coronary lesions treatment in Iran

BACKGROUND

The present study aimed to examine the cost-effectiveness of fractional flow reserve (FFR) versus angiography in treating borderline coronary lesions in patients with coronary artery stenosis in Iran. Cardiovascular disease is a leading cause of morbidity, mortality, readmission and the most important cause of disability in many countries, including Iran.

METHODS

This was a cost-effectiveness study conducted from the perspective of the Ministry of Health in 2019. The effectiveness was determined using four indicators: Quality Adjusted Life Years (QALYs), major adverse cardiac events (MACE), angina, and number of used stents (mean). Only direct medical costs (DMC) were estimated. To evaluate the cost-effectiveness of FFR versus angiography, A decision tree model was built by patient's level data.To coping with uncertainty Probabilistic sensitivity analysis (PSA) was performed.

RESULTS

Totally, 98 cases of FFR and 238 cases of angiography were included in the analysis. The average of QALY in FFR and angiography were 0.853 and 0.787, respectively. The cost of these methods were $6128 and $8388, correspondingly. Therefore, FFR was dominant compared to angiography. Results of the scatter plots and acceptability curve showed that FFR was more cost-effective than angiography in 94% and 96% of simulations for a threshold lower than $11,000 PPP. The PSA analysis confirmed the robustness of the study results.

CONCLUSION

The results indicated that FFR was more cost-effective than angiography in the cases studied in Iran. Consequently, FFR can be used as a high-priority diagnostic method and it is recommendable to be included in insurance coverage.

[Influence of gender on protective and vulnerability factors, adherence and quality of life in patients with cardiovascular disease]

OBJECTIVES

To examine gender differences on specific protective factors (PF: acceptance and resilience), vulnerability factors (VF: anger, depression, and anxiety; adherence to treatment and quality of life (QoL) in cardiovascular patients, as well as to study separately the relationships of these factors with adherence and QoL in females and males.

DESIGN

Observational and cross-sectional.

SETTING

Two Primary Care Centres in Gran Canaria.

PARTICIPANTS

One hundred and ninety-eight cardiovascular patients (91 males and 107 females) participated.

MAIN MEASUREMENTS

Acceptance was assessed by the ICQ scale; resilience by the CD-RISC; depression by the PHQ-9; anxiety by the HADS; Anger-In and Anger-Out by the STAXI-2; QoL by the SF-36; and adherence by a self-reported scale.

RESULTS

Females exhibited higher anxiety (95% CI: 6.3-7.9) and adherence to reducing smoking (95% CI: 9.4-10.0) and drinking (95% CI: 9.6-10.1), and lower Anger-Out (95% CI: 8.9-10.0), mental QoL (95% CI: 47.0-51.3) and adherence to medication (95% CI: 22.2-23.3) compared to males. Acceptance was associated with better adherence only in women. There were more VF related to worse adherence in males. Anxiety had a negative impact on adherence, and QoL was positively associated with PF, and negatively with VF in both groups.

CONCLUSIONS

Gender differences in QoL, some VF, and adherence are observed, in addition to the beneficial role of Acceptance in women.

[Sleep disorders, anxiety and depressive symptoms and cardiovascular risk among black African hypertensive: cross-sectional study of 414 hypertensive followed as outpatients at the University Hospital of Ouagadougou (Burkina Faso)]

Introduction

Dans le but de déterminer la fréquence des troubles du sommeil, de l'anxiété et de la dépression, et de rechercher l'existence d'une relation entre ces troubles et le risque cardio-vasculaire global chez les hypertendus noirs africains, nous avons réalisé une étude transversale de mai 2010 à mars 2011 à l'unité de consultation externe du service de cardiologie du CHU-Yalgado Ouédraogo de Ouagadougou qui a inclut 414 hypertendus adultes suivis en ambulatoire. Après un examen clinique à la recherche des facteurs de risque cardio-vasculaire, deux auto-questionnaires ont été administrés.

Méthodes

Le questionnaire de l’«European Sleep Center » pour la recherche des troubles du sommeil et, l’échelle «Hospital Anxiety and Depression Scale » de Zigmond et Snaith pour la recherche de l'anxiété et la dépression. Le diagnostic du syndrome d'apnée du sommeil était clinique et basé sur la présence des 4 symptômes principaux: hypersomnolence diurne, éveils nocturnes fréquents avec nycturie, asthénie matinale avec ou sans céphalées et ronflements importants. Le risque cardio-vasculaire global était calculé grâce à l’équation d'Anderson tirée de l’étude de Framingham. L'analyse des données a été réalisée par le logiciel SPSS version 17. La comparaison des variables a été effectuée grâce au test de Khi 2 pour les variables qualitatives et au test «t» de Student pour les variables quantitatives. Le seuil de signification a été fixé à 5%.

Résultats

L’échantillon était composé de 414 patients dont 248 femmes (59,9%). L’âge moyen était de 54,6 ± 9,3 ans. Les troubles du sommeil étaient retrouvés dans 72,2% des cas. Ils étaient dominés par l'insomnie (49,2%), le syndrome d'apnée du sommeil (33,5%) et le syndrome des jambes sans repos (25,8%). L'anxiété était retrouvée dans 37,1% des cas et la dépression dans 16,6% des cas. Le risque cardio-vasculaire global était faible dans 21,0%, modéré dans 33,6%, élevé dans 24,4% et très élevé dans 21,0% des cas. Le syndrome d'apnée du sommeil (p=0,033), le syndrome des jambes sans repos (p=0,005), l'anxiété (p=0,0021) et la dépression (p=0,0001) étaient significativement associés à un risque cardio-vasculaire élevé à très élevé.

Conclusion

Les troubles du sommeil, l'anxiété et la dépression sont fréquents chez les hypertendus noirs africains. Ils sont liés à un niveau de risque cardio-vasculaire élevé. Leur dépistage devrait être intégré à la prise en charge des hypertendus.

Illness perceptions, mood and quality of life: a systematic review of coronary heart disease patients

OBJECTIVE

To examine published literature investigating the relationship between illness perceptions, mood and quality of life (QoL) in coronary heart disease (CHD) populations.

METHODS

Key databases were systematically searched (CINAHL, Medline, PsycINFO, Scopus and Web of Science) for studies matching the inclusion criteria between November 2011 and February 2012. References of included studies were examined and key authors contacted. Studies were subject to a quality control check.

RESULTS

21 studies met the inclusion criteria. A synthesis of the results found that illness perceptions were correlated to and predicted QoL and mood across CHD diagnoses. Specific illness perceptions (control, coherence and timeline) were found to be important for patients that had experienced an unexpected medical event, such as myocardial infarction.

CONCLUSION

The results of this study provide support that illness perceptions are related to outcomes across CHD populations and disease progression, however the results do not selectively support one particular model. Recommendations are consistent with cardiac rehabilitation guidelines. Further research should focus on the systemic impact of illness perceptions.

Depression and cardiac symptoms among AL amyloidosis patients: the mediating role of coping strategies

BACKGROUND

Amyloidosis is a rare disease group. AL amyloidosis represents the most common type of systemic amyloidosis and cardiac involvement determines prognosis. Although some studies have revealed that amyloidosis patients present high levels of depression, few data are available about depression-contributing factors. No investigations have been conducted about the coping strategies that AL amyloidosis patients use to face the disease and there is little research on patients with cardiac symptoms that are strongly related to the prognosis.

OBJECTIVES

to examine coping strategies (avoidance, social support seeking and problem-solving) as potential mediator in the relationship between cardiac symptom severity (independent variable) and depressive symptoms (dependent variable) in AL cardiologic patients.

METHOD

Thirty-four AL patients with cardiac-related symptoms were administered the Coping Strategy Indicator and the Centre for Epidemiological Study-Depression Scale. Clinical variables such as months since cardiac symptom onset and cardiac symptom severity were collected.

RESULTS

According to questionnaire normative values, all patients presented clinical depression. Moreover, out of the coping strategies, avoidance and social support seeking mediated the link between cardiac symptom severity and depressive symptoms. No mediational effect was found for problem-solving.

DISCUSSION

As cardiac symptoms have low severity, AL patients can avoid the disease. However, as cardiac symptoms proceed and interfere with daily activities, they can no longer ignore their signs thus perceiving the severity of their medical condition. This status makes individuals prone to seek less social support and thus to prefer social isolation. Results suggest the need for early psychological support on coping strategies for AL cardiologic patients.

An interactive model of pain and myocardial ischemia

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

Screening, diagnosis & monitoring of depression/distress in CHF patients

Objective and validated measures of depression/distress (anxiety and anger) are available and readily usable at the bedside or in clinic. Foremost among these is the Patient's Health Questionnaire--an adaptation of DSM IV criteria for Major Depressive Disorder that permits administration and scoring by nursing or physician personnel, and quantification of the intensity of depression. A score of 10 or greater indicates a need for evaluation/treatment. Because of patient denial/minimization/alexithymia, PHQ negatives should undergo further screening by having a spouse or friend complete a depression/distress rating scale. The only standardized, normed, and validated spouse/friend scale presently available is the Ketterer Stress Symptom Frequency Checklist, which is available by internet.

Empirically Derived Psychometric Screening for Emotional Distress in Coronary Artery Disease Patients

BACKGROUND AND RESEARCH OBJECTIVES

Multiple types of evidence implicate emotional distress as a cause of adverse outcomes in individuals with coronary artery disease. The present study was intended to determine the most accurate and user-friendly means of screening patients with coronary artery disease for emotional distress using age at initial diagnosis as the criterion.

SUBJECTS AND METHODS

Two clinical databases consisting of patients with documented coronary artery disease, each contained multiple measures of emotional distress, were used. These databases were investigated by tests of covariation of the emotional distress measures with age at initial diagnosis. If these were statistically significant, sequential testing of cutpoints yielded the minimum score for positivity. Sensitivity, specificity, and positive predictive value calculations were made for the significant measures. Single-sex tests of covariation were also examined.

RESULTS AND CONCLUSIONS

The Patient Health Questionnaire was the only significant bedside measure of emotional distress (Pearson r = -0.149, P = .058), with a cutpoint of 10 or greater. The Beck Depression Inventory, Hospital Anxiety and Depression Scale, and Crown-Crisp Phobic Anxiety Scale failed to reach significance as covariates of age at initial diagnosis. Substantially greater sensitivity occurs with larger and more cumbersome measures of emotional distress. For example, the Ketterer Stress Symptom Frequency Checklist yielded consistent results with greater variance explained, particularly in men (Pearson r for self-ratings of anger = -0.339, P = .001; depression = -0.363, P = .005; anxiety = -0.273, P = .028). Brief bedside/clinic screening of emotional in populations with coronary artery disease is possible and necessary to improve quality of life, compliance (eg, smoking cessation), and possibly morbidity/mortality. Initial screening can and should occur at the bedside/clinic by cardiology or primary care personnel using the Patient Health Questionnaire.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Self-reported depression and cardiovascular risk factors in a community sample of women

The authors examined data collected from a randomly selected, representative sample of 755 women (ages 23-97 years) from southeastern Australia. Self-report questionnaires were utilized to determine lifetime rates of depression and cardiovascular risk factors within the study sample. A lifetime history of depression (LHx) was reported by 145 women (19.20%). There were no associations between indices of weight, cholesterol levels, hypertension, inactivity, diabetes, and LHx. However, a history of smoking increased the odds of reporting an LHx, whereas women with self-reported angina were more than four times more likely to report an age-adjusted LHx.

Post-MI psychiatric syndromes: six unanswered questions

Depression, anxiety, and other psychological variables following acute myocardial infarction (MI) have been the subject of intense study over the last two decades. Through selective literature review and editorial commentary, we address six vital, unanswered questions concerning these psychological variables and their impact on coronary outcome. The picture that emerges is complex. Despite all that has been learned about the nature, consequences, and management of post-MI depression and related disorders, there remain many open issues. First, the prevalence, phenomenology, medical impact, and method of diagnosis of post-MI depression and other psychiatric syndromes remain unclear. In addition, at least four pathophysiologic mechanisms have been proposed to explain the link between depression and cardiac disease, but evidence of causation remains elusive. There have been increasingly well-designed treatment studies of post-MI depression, but the optimal agents and timing of treatment have yet to be defined. Finally, few recent studies of post-MI anxiety have been conducted. To make further progress, large, multicenter trials that use optimized screening tools, obtain data at several time points, consider multiple psychosocial variables, and correct carefully for medical/cardiac severity are required.

Psychosomatic disorders in developing countries: current issues and future challenges

PURPOSE OF REVIEW

This paper focuses on understanding of the concept, recent advances, and challenges to be faced in the field of psychosomatic disorders by the developing countries.

RECENT FINDINGS

Changing health scenario in developing countries has led to imminent epidemic of noncommunicable diseases along with the unmet agenda of controlling infectious diseases. Psychosomatic medicine has a role to play in curtailing the upcoming epidemic. Research studies on psychosomatic disorders from developing countries are very few. Most of the publications are in nonpsychiatric medical journals covering explorative to intervention studies. Traditional, complementary, and alternative medicines such as ayurveda are already playing their role in the area of psychosomatic disorders in developing countries.

SUMMARY

The role and responsibility of the psychiatrist is changing from treating major mental disorders to preventing and treating psychosomatic disorders. In this regard, developing countries have to meet various challenges such as development of manpower, training of medical and paramedical staff, funding resources for clinical practice and research, coordinating with complementary and alternative medicines, and networking with policy makers in combating the imminent epidemic.

“Major” Depressive Disorder, Coronary Heart Disease, and the DSM–IV Threshold Problem

Seventy-seven patients with documented coronary heart disease (CHD) were evaluated for demographic/risk factor characteristics, Major Depressive Disorder (MDD) according to the Patient's Health Questionnaire (PHQ - Diagnostic and Statistical Manual IV criteria), and emotional distress by the Symptom Checklist 90-Revised (SCL-90-R). Early age at initial diagnosis for coronary heart disease (AAID) was used as a proxy for disease malignancy because early AAID is a known predictor of early mortality. MDD was unrelated to early AAID despite being strongly associated with all the scales of the SCL-90-R. Several of the SCL-90-R scales were significantly associated with early AAID in the sample as a whole (Depression, Interpersonal Sensitivity, Anxiety, Paranoia, and Psychoticism) and after removal of the patients meeting criteria for MDD (residual N = 54). Our results suggest a new criterion for determining whether depression, or any mental disorder, is "major": onset or aggravation of serious medical illness.