How gender affects psychological adjustment one year after coronary artery bypass graft surgery

Depression in Patients with Heart Diseases: Gender Differences and Association of Comorbidities, Optimism, and Spiritual Struggle

BACKGROUND

Depression is a well-established comorbidity of heart disease (HD) and is more prevalent in women than in men. Few studies have examined the gender effect on depression in patients with advanced heart disease prior to open heart surgery (OHS), controlling for cardiac indices. Previous studies indicated the health benefit of optimism but often lacked adjustment for medical confounders. This interdisciplinary study investigated gender differences in pre-OHS depression and the role of medical comorbidities and strength factors.

METHOD

Two waves of survey data were collected from 481 patients (mean age = 62, female 42%) along with medical indices in the Society of Thoracic Surgeon's (STS) national database used by all US cardiac surgeons.

RESULTS

A t test showed significantly higher levels of pre-OHS depressive symptoms in women than in men. In multivariate analyses, the gender effect on depression vanished after entry of other socio-demographics, medical comorbidities, objectively assessed cardiac indices in the STS database, and psychosocial strength factors. Depressive symptoms linked inversely with dispositional optimism and positively with medical comorbidities and religious/spiritual struggle, but not with any cardiac indices. A mediation analysis supported the role of comorbidities in the gender difference.

CONCLUSION

Women with heart disease were more depressed, but the gender difference may be partly explained by multiple comorbid conditions that could complicate disease burden. Reinforcing the literature, optimism, but not other strength factors, appeared to counteract depression after adjusting for health and cardiac conditions. The finding suggests that health providers should be more attentive to overall health of women with heart disease and to the positive expectations of OHS patients.

Does Gender Influence the Likelihood or Types of Complications Following Cardiac Surgery?

Over 410,000 cardiac surgeries are performed in American women each year. Women having coronary artery bypass graft (CABG) and valve surgery do so at an older age and with more cardiovascular risk factors than men. Women's smaller body size may also increase risk by increasing the technical difficulty of surgical procedures. Female CABG patients appear to have higher perioperative mortality and cardiac morbidity, although studies of neurologic outcomes in female CABG patients have produced equivocal findings. Women undergoing CABG tend to consume more hospital resources than men do in terms of blood transfusion, mechanical ventilation, and length of intensive care unit and overall hospital stay. With regard to valve surgery, women appear to have worse outcomes than men if the surgery is combined with a CABG operation. Women and men undergoing isolated aortic valve surgery have similar mortality, but little is known about gender differences in mitral and tricuspid valve surgery outcomes. Women who require heart transplantation tend to have idiopathic cardiomyopathy rather than the ischemic cardiomyopathy that is more common in male heart transplant candidates. Although female heart transplant recipients seem to have a stronger immunologic response after transplantation, which manifests in more frequent acute rejection episodes, it is not clear whether this increases women's mortality risk. Men appear to have a greater incidence of posttransplant vasculopathy than women. Further research is needed to identify risk factors for perioperative morbidity and mortality in women undergoing cardiac surgery and to develop medical interventions to mitigate these risks.

Recovery Symptoms and Mood States in Thai CABG patients

Recovery symptoms and related mood states during early recovery after coronary artery bypass graft surgery (CABG) have never been assessed in Thailand. This cross-sectional descriptive correlational study was to identify the relationships between frequency of recovery symptoms and mood states of a convenience sample of 91 Thai CABG patients during 2 weeks after discharge. Standardized tools/procedures were used to measure the variables of interest. The most common recovery symptoms were chest and leg incision pain, having trouble sleeping, and neck and shoulder or back discomfort. The most common mood states were confusion, anxiety, and anger, respectively. In addition, Thai CABG patients who had more frequent recovery symptoms also had greater negative mood disturbance. These findings provide a beginning explanation about the phenomena of recovery symptoms and mood states in a specific culture, Thai CABG patients.

Gender as a determinant of responses to a self-screening questionnaire on anxiety and depression by patients with coronary artery disease

BACKGROUND

Because patients with coronary artery disease (CAD) could benefit from interventions to decrease psychological distress, it is important to identify these individuals. Both salivary cortisol level and the Hospital Anxiety and Depression Scale (HADS) are recognized measures of stress/anxiety and depression.

OBJECTIVES

This study was designed to determine whether there is an association between anxiety and depression, as measured by the HADS, and salivary cortisol levels among patients with CAD, and whether this association is affected by gender.

METHODS

All adult residents of Alberta, Canada, undergoing their first cardiac catheterization for CAD (>or=50% occlusion of >or=2 coronary arteries) were eligible for participation in this study. A 14-question survey (the HADS) and 3 saliva-collection devices (a 1-day supply) were sent to the participants' home within 1 week of their initial cardiac catheterization. Participants were asked to take saliva samples for determination of cortisol levels on waking and at 30 and 60 minutes after waking, and then return the completed questionnaire and saliva samples using a prepaid express mailing envelope.

RESULTS

Seventy-one adults (52 men and 19 women) participated in the study. Mean (SD) ages were 68.4 (4.6) years for men and 69.1 (4.4) years for women. Among the women, significant negative correlations were found between the HADS anxiety score and the wake-up and 30-minute cortisol levels (higher HADS scores were associated with lower cortisol levels) (all, P < 0.05). Also among women, negative correlations were found between the HADS depression score and the salivary cortisol values, but the differences were not statistically significant. Conversely, among the men, nonsignificant positive correlations were found between the HADS anxiety scores and the salivary cortisol levels (higher HADS scores were associated with higher cortisol levels), and statistically significant positive correlations were observed between the HADS depression scores and all 3 salivary cortisol values (all, P < 0.05).

CONCLUSIONS

Our findings suggest that the HADS is an appropriate screening instrument for anxiety and depression in patients with CAD. In particular, the scale appears to be sensitive for measuring anxiety in women and depression in men. When the HADS is used clinically as a screening tool, it should be examined through a "gender-based lens.".

The effects of a symptom management intervention on symptom evaluation, physical functioning, and physical activity for women after coronary artery bypass surgery

The purpose of this subset analysis was to examine the effect of a symptom management (SM) intervention on postoperative symptom evaluation, physical functioning, and physical activity among the female participants (N = 40) of the larger parent study of coronary artery bypass graft patients aged 65 years and older. The intervention group (n = 23) had significantly lower fatigue scores at 6 weeks (Z = 1.96, P < .05) and higher levels of physical activity (Z = -1.71, P < .05) reflected in the expended kcal(-1) x kg x d(-1), as measured by the activity diary at 3 months after coronary artery bypass graft surgery. At 6 weeks and 3 months after surgery, there were significant correlations between cardiac surgery-related recovery symptoms (shortness of breath, fatigue, depression, incision pain, and sleep problems) and physical functioning (physical, vitality, and bodily pain functioning subscale scores), with correlations ranging from 0.31 to 0.46. Given that this was a subset analysis of a larger study, significant differences were not expected for all variables. Study findings support the need for a targeted (women-focused) and tailored (self-management recovery) intervention to assist females in recovering from coronary artery bypass graft surgery to improve symptom management, thereby enhancing physical functioning and physical activity outcomes.

Gender differences in recovery after coronary artery bypass graft surgery

This study examined the effect of gender on symptom evaluation, symptom response, and physical functioning following coronary artery bypass graft surgery. Symptom evaluation and symptom response were measured at baseline and 2, 4, and 6 weeks and 3 months following surgery, and physical functioning was measured at baseline, 6 weeks, and 3 months. The sample included 46 men and 19 women randomly assigned to the routine care group of a larger study examining symptom management intervention influence on recovery outcomes in elderly coronary artery bypass graft patients. No significant differences were found in symptom evaluation, symptom response, or physical functioning by gender over time. Women reported consistently higher symptom evaluation scores for shortness of breath, fatigue, depression, sleep disturbance, swelling, and anxiety and lower mean physical and vitality subscale scores than men at every time point. Gender-specific symptom management strategies should be developed and tested to address the differences in the reporting of symptoms by men and women.

Women with coronary artery disease report worse health-related quality of life outcomes compared to men

BACKGROUND

Although there have been substantial medical advances that improve the outcomes following cardiac ischemic events, gender differences in the treatment and course of recovery for patients with coronary artery disease (CAD) continue to exist. There is a general paucity of data comparing the health related quality of life (HRQOL) in men and women undergoing treatment for CAD. The purpose of this study was to compare HRQOL outcomes of men and women in Alberta, at one-year following initial catheterization, after adjustment for known demographic, co-morbid, and disease severity predictors of outcome.

METHOD

The HRQOL outcome data were collected by means of a self-reported questionnaire mailed to patients on or near the one-year anniversary of their initial cardiac catheterization. Using the Seattle Angina Questionnaire (SAQ), 5 dimensions of HRQOL were measured: exertional capacity, anginal stability, anginal frequency, quality of life and treatment satisfaction. Data from the APPROACH registry were used to risk-adjust the SAQ scale scores. Two analytical strategies were used including general least squares linear modeling, and proportional odds modeling sometimes referred to as the "ordinal logistic modeling".

RESULTS

3392 (78.1%) patients responded to the follow-up survey. The adjusted proportional odds ratios for men relative to women (PORs > 1 = better) indicated that men reported significantly better HRQOL on all 5 SAQ dimensions as compared to women. (PORs: Exertional Capacity 3.38 (2.75-4.15), Anginal Stability 1.23 (1.03-1.47), Anginal Frequency 1.70 (1.43-2.01), Treatment Satisfaction 1.27 (1.07-1.50), and QOL 1.74 (1.48-2.04).

CONCLUSIONS

Women with CAD consistently reported worse HRQOL at one year follow-up compared to men. These findings underline the fact that conclusions based on research performed on men with CAD may not be valid for women and that more gender-related research is needed. Future studies are needed to further examine gender differences in psychosocial adjustment following treatment for CAD, as adjustment for traditional clinical variables fails to explain sex differences in health related quality of life outcomes.

Barriers and facilitators of self-reported physical activity in cardiac patients

The purpose of this study was to examine the relationships of personal factors (age and gender), barriers (symptom distress and negative well-being), and facilitators (self-efficacy to exercise and positive well-being) with self-reported physical activity in cardiac patients. Sixty-four participants (50 men, 14 women) 6-12 months post-cardiac event participated in this study. We found that age and gender accounted for 14.7% of the variance, symptom distress and negative well-being accounted for an additional 21.6% of the variance, and self-efficacy accounted for the remaining 7.6% of the variance for a total of 44% of the variance in physical activity levels explained. These results suggest that personal factors and barriers are central variables, in addition to self-efficacy, in understanding the levels of physical activity achieved by patients after a cardiac event.

Depression and anxiety in coronary artery bypass grafting patients

PURPOSE

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

SUBJECT AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cardiac rehabilitation I: review of psychosocial factors

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. There are gender differences in recovery from coronary events, which may be due physiological, sociodemographic, or psychosocial factors. Cardiac rehabilitation programs have beneficial effects on coronary recovery. The following presents a review of the literature from MedLine (1997-2001) and PsychInfo (1984-2001) on gender differences in participation in cardiac rehabilitation programs, with a focus on depression, anxiety, self-efficacy and social support. A critical analysis of gaps in the literature as well as areas for future research are presented.

Emotional and functional outcomes in women with coronary heart disease

Instruments used to measure emotional and functional outcomes of coronary heart disease show a fairly high level of consistency. Scores on depression scales are typically higher in women than men, yet this finding must be balanced with data showing that mean scores for depression are low. Both sexes report moderate levels of anxiety after a cardiac event; however, global mental health is rated as relatively high. Women report lower levels of physical activity and higher levels of disruption in functional activities than men. Women also report resuming household activities early in their recovery, a finding most likely reflective of traditional role responsibilities. Last, for both sexes, emotional distress and functional disability decrease over time and appear to be stable by 6 months after the event.

Stable pessimistic attributions interact with socioeconomic status to influence blood pressure and vulnerability to hypertension

We investigated the relationship of pessimistic attributional style (specifically, stable attributions for negative events) and socioeconomic status (SES) to cardiovascular and catecholamine profiles in a biracial sample of 37 postmenopausal women (aged 39-64 years) not taking hormone replacement therapy (HRT). Blood pressure (BP) variation in response to the demands of daily life was assessed by 24-hour ambulatory monitoring on a typical workday. Subjects were classified into groups by stable pessimistic attributions (high vs. low pessimism) and by SES (high vs. low). Significant SES x pessimism interactions were found. Low SES/high pessimism women demonstrated higher systolic BP (SBP) during the day, evening, and sleep periods of 24-hour ambulatory monitoring compared with the other three groups. A greater proportion of this group was in the hypertensive range (> or = 140/90 mm Hg) compared with the other groups (57% vs. 8%-29%). Low SES/high pessimism women also reported reduced available social support compared with the other three groups.

Gender-linked personality traits predict mental health and functional status following a first coronary event

Three gender-linked traits were examined with respect to adjustment to a coronary event: agency, a focus on the self; communion, a focus on others; and unmitigated communion, an extreme focus on others to the exclusion of the self. Participants (n = 65) were interviewed 1 week and 4 months after a 1st coronary event. Hypotheses were that agency should predict improved health, communion should be unrelated to health, and unmitigated communion should predict worse health over time. Outcomes included depression, anxiety, and well-being (as measured by the Profile of Mood States; D. McNair, M. Lorr, & L. Droppleman, 1971); mental and physical functioning (SF-36; J. E. Ware, K. K. Snow, M. Kosinski, & B. Gandek, 1993); and cardiac symptoms. Results confirmed hypotheses. In addition, unmitigated communion was linked with poor health behavior and negative social interactions, which partly explained the link of unmitigated communion with depression and cardiac symptoms.