Psychoeducation for chronic cognitive impairment and reduced early readmissions amongst pulmonary inpatients

Patients with chronic pulmonary disease have been found to have among the highest rates of early (30 days) readmissions by the Center for Medicare and Medicaid Services. Proactive identification and psychoeducational intervention for the effect of chronic cognitive impairment on readmission have not been tested in this population. This is a pre-post quality improvement study for service-wide inpatient pulmonary readmission rates in chronic pulmonary disease. We examined the impact of screening patients for likely cognitive impairment and providing patients/families with psychoeducation regarding 'forgetfulness' on 30-day readmission rates on an inpatient pulmonary service. We observed a 50% decline in early readmissions (25.7% > 12.3%) for the inpatient pulmonary service after initiation of screening and psychoeducation of patients/families for improved adherence despite cognitive impairment (t = -2.53, df= 17, p = 0.011). A randomly assigned, controlled clinical trial is warranted.

Family Consultation to Reduce Early Hospital Readmissions among Patients with End Stage Kidney Disease: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

The US Centers for Medicare and Medicaid Services have mandated reducing early (30-day) hospital readmissions to improve patient care and reduce costs. Patients with ESKD have elevated early readmission rates, due in part to complex medical regimens but also cognitive impairment, literacy difficulties, low social support, and mood problems. We developed a brief family consultation intervention to address these risk factors and tested whether it would reduce early readmissions.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

One hundred twenty hospitalized adults with ESKD (mean age=58 years; 50% men; 86% black, 14% white) were recruited from an urban, inpatient nephrology unit. Patients were randomized to the family consultation (n=60) or treatment-as-usual control (n=60) condition. Family consultations, conducted before discharge at bedside or via telephone, educated the family about the patient's cognitive and behavioral risk factors for readmission, particularly cognitive impairment, and how to compensate for them. Blinded medical record reviews were conducted 30 days later to determine readmission status (primary outcome) and any hospital return visit (readmission, emergency department, or observation; secondary outcome). Logistic regressions tested the effects of the consultation versus control on these outcomes.

RESULTS

Primary analyses were intent-to-treat. The risk of a 30-day readmission after family consultation (n=12, 20%) was 0.54 compared with treatment-as-usual controls (n=19, 32%), although this effect was not statistically significant (odds ratio, 0.54; 95% confidence interval, 0.23 to 1.24; P=0.15). A similar magnitude, nonsignificant result was observed for any 30-day hospital return visit: family consultation (n=19, 32%) versus controls (n=28, 47%; odds ratio, 0.53; 95% confidence interval, 0.25 to 1.1; P=0.09). Per protocol analyses (excluding three patients who did not receive the assigned consultation) revealed similar results.

CONCLUSIONS

A brief consultation with family members about the patient's cognitive and psychosocial risk factors had no significant effect on 30-day hospital readmission in patients with ESKD.

Prospective correlates of early (30 day) readmissions on a Cardiothoracic Surgery Service

Known to vary widely among hospitals for unclear reasons, early readmissions are associated with higher mortality and are suspected to frequently be due to inadequate discharge preparation/planning. It has been previously documented that the strongest and most consistent predictor of early readmissions in CHF patients is chronic cognitive impairment, and compensatory assistance with adherence on discharge improves early readmission rates. Prospective observational study. The present investigation examined multiple putative perioperative predictors of early readmission in a hospitalized Cardiothoracic Surgery Service. A subtest of the Mini-Cog, Short Term Memory, was the strongestunivariate predictor of early readmissions (p < .001), but the overall Mini-Cog (p = .024), Age (p = .045), Number of Admissions over the Preceding Year (p = .036), an Anxiety Scale (p = .035), Years of Education (p = .055) and a Depression Scale (p = .056) also demonstrated covariation. In a Logistic Regression, only Short Term Memory survived as a predictor variable (p = .007), correctly classifying 76% of patients. Chronic cognitive impairment is a predictor of early readmissions in Cardiothoracic patients. A brief bedside exam interpreted in medical context may permit identification of patients requiring familial assistance for adherence on discharge.

Denial of Depression as an Independent Correlate of Coronary Artery Disease

A number of psychosocial measures were tested as correlates of coronary artery disease (CAD) in 122 males with positive coronary angiograms and 56 males with no manifest history of atherosclerotic disease who were selected to approximate the patients' age and socio economic status. Only denial of depression as indexed by spouse/friend-minus-self scores on the Ketterer Stress Symptom Frequency Checklist and number of unprovoked nocturnal awakenings were independently and positively related to CAD severity in multivariate regression analyses which controlled for jointly associated cardiac risk factors and commonly used cardiovascular medications. Denial of depression and unprovoked nocturnal awakening appear to be independent correlates of coronary artery disease.

"Alert and Oriented × 3?" Correlates of Mini-Cog Performance in a Post/Nondelirious Intensive Care Unit Sample

BACKGROUND

Cognitive impairment has been found to be a predictor of adverse medical outcomes, including nonadherence, recurrent medical crises resulting in early readmissions, and death.

OBJECTIVE

The Mini-Cog has been proposed for bedside/clinic cognitive testing. Its validity as a measure of central nervous system (CNS) impairment has never been tested against measures of CNS-medical history, CNS scans, selected laboratory findings, observed in-hospital nondelirious memory impairment, or collateral history from family.

METHODS

We observed Mini-Cog performance in 107 post/nondelirious medical intensive care unit patients and tested its association with age, CNS-medical history, CNS scans, selected laboratory findings, and behavioral history (in-hospital observation of memory problems and collateral history from family or significant others).

RESULTS

The overall Mini-Cog covaried with age, various measures of CNS impairment, abnormal laboratory findings, and measures of preadmission "forgetfulness" per family and by in-hospital staff observation. Unique variance in predicting overall Mini-Cog scores included age, positive CNS scan, and behavioral history. Of 91 patients found to be "alert and oriented × 3," 76% were impaired in immediate memory, short-term memory, or clock drawing.

CONCLUSIONS

The Mini-Cog appears to be a brief, yet valid, measure of CNS dysfunction that significantly enhances sensitivity of evaluation at the bedside. Failure to evaluate patients with a formal examination like the Mini-Cog appears to miss up to 76% of patients with moderate cognitive impairment.

Psychological Correlates of Mental Stress-induced Ischemia in the Laboratory: The Psychophysiological Investigation of Myocardial Ischemia (PIMI) Study

Participants consisted of 184 patients (160 males, 24 females) with positive angiograms or prior myocardial infarctions who displayed at least 1 mm of ST segment depression on a standardized treadmill test. Mean scores on the Reward Dependence subscale of the Tridimensional Personality Questionnaire were higher in patients displaying ischemia during mental stress. Patients who reported higher levels of irritability/anger in response to the Speech stressor were also more likely to display ischemia. However, this result was primarily a result of the females in the sample whose ratings of interest and irritability were associated with ischemia during the Speech task. Psychometric measures previously found in prospective studies to predict acute cardiac events were unrelated to mental stress-induced ischemia in the laboratory.

Healthcare utilization and emotional distress in coronary artery disease patients

BACKGROUND

No studies to-date have examined the various types of emotional distress (ED) for their relative power at predicting costs in patients with coronary artery disease (CAD).

OBJECTIVE

The authors investigated the association between expenditure for CAD patients and various measures of emotional/psychological functioning.

METHOD

The authors assessed dollars spent in relation to dimensions of the Symptom Checklist 90-Revised and traditional risk factors in the year preceding referral of 164 CAD patients for stress management.

RESULTS

Total costs were associated with the Anxiety, Phobic Anxiety, and Psychoticism scales. Hypertension was also associated with increased costs.

CONCLUSIONS

Present results indicate an association of higher costs with anxiety. Because the symptoms of anxiety overlap with those of cardiac disease, increased vigilance by both patients and practitioners, resulting in more testing and longer hospital stays is not surprising. Results suggest that there is a potential for substantial cost savings with enhanced detection and treatment of anxiety-spectrum emotional distress.

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.

“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.

Do others really know us better? Predicting migraine activity from self- and other-ratings of negative emotion

OBJECTIVE

The validity of self-reported negative emotion to predict health status is limited by response biases, introspection limitations, and methodological confounds. The reports of significant others about the patients' negative emotion may circumvent these limitations. This study sought to compare the validity of self- versus other-reported negative emotion as a correlate of migraine headache activity.

METHODS

On 89 patients with migraine headache (74 women and 15 men), we correlated self-ratings and significant-other-ratings of patients' negative emotion with patients' report of migraine frequency and severity, which were assessed both cross-sectionally and prospectively, 3 months later.

RESULTS

Other-reported negative emotion correlated with migraine activity better than did self-reported negative emotion, both cross-sectionally and prospectively. Patterns were different for women and men, however. Among women, other-reported negative emotion was positively associated with migraine activity. Among men, other-reported negative emotion was inversely associated with migraine frequency and severity.

CONCLUSION

The results suggest that it may be valuable to obtain significant-other-ratings when assessing negative emotion in patients and that the genders may differ in how others' ratings are related to the patients' health.

What's “Unstable” in Unstable Angina?

The role of emotional distress (e.g., anger, depression, and anxiety) in anginal chest discomfort (ACD) may have been underestimated. The authors review the empirical studies in this area, which are inconsistent with the standard theory on the ischemia-angina relationship; summarize the substantial evidence indicating a strong and consistent cross-sectional/prospective epidemiological association of emotional distress and ischemia/ACD; review the distress-targeted, interventional evidence confirming a causal relationship (i.e., reduced chest discomfort and health system utilization), thus confirming clinical utility of such interventions; and explore the possible mechanisms that might account for the relationship between emotional distress and chest discomfort. Substantial clinical benefit may be achieved by aggressively detecting and treating emotional distress in ACD patients.

Familial Transmissability of Early Age at Initial Diagnosis in Coronary Heart Disease (CHD): Males Only, and Mediated by Psychosocial/Emotional Distress?

In equal sized samples, a strong association between a positive Family History of Early Coronary Heart Disease (FamHx) and early Age at Initial Diagnosis (AAID) was found only for males, and thus all further analyses were restricted to males. All three scales of the self-report version of the Ketterer Stress Symptom Frequency Checklist--Revised (KSSFCR)--"AIAI" (or aggravation, irritation, anger, and impatience), Depression, and Anxiety--were associated with both a positive FamHx and early AAID. A series of regression models was used to demonstrate that the KSSFCR scales may plausibly account for 22-32% of the variance in the relationship between a positive FamHx and early AAID. Because of previously documented denial in males, the analyses were repeated in a subgroup of males for whom Spouse/Friend KSSFCRs were obtained. Spouse/Friend-reported AIAI was related to both early FamHx and early AAID, and could account for 68% of the common variance.

Men deny and women cry, but who dies? Do the wages of "denial" include early ischemic coronary heart disease?

OBJECTIVES

In this study patients with documented ischemic coronary heart disease (ICHD; prior MI or CAD per catheterization) were tested for the association of various measures of emotional distress with Age at Initial Diagnosis.

METHODS

The measures were chosen because of a published track record at predicting mortality in this population. Females were oversampled to achieve equivalent numbers of each sex (n=50), and thus equivalent statistical power. In a subset of patients (38 males and 32 females), Spouse/Friend Ketterer Stress Symptom Frequency Checklists (KSSFCs) were received.

RESULTS

Females reported more depression and anxiety than males. However, spouses or friends reported more anger for males. Denial (spouse/friend minus self-ratings) was greater in males for all three scales of the KSSFC (Anger, P=.005; Depression, P=.024; Anxiety, P=.001). Although females showed the same trend, self and spouse or friend ratings of distress were significantly associated with Age at Initial Diagnosis only in males. When split at the sample mean on the Spouse/Friend KSSFC AIAI (Anger) scale, Age at Initial Diagnosis occurred 14.2 years earlier in males.

CONCLUSIONS

Use of a significant other in assessing psychosocial/emotional distress in males may confer greater accuracy, and therefore predictive power for clinical endpoints.

Health-related interactions and the self in marriage

This study investigated the association between self processes and married partners' (N = 59 couples) perspectives of their health-related social interactions. Findings revealed that wives' self processes were associated with their social behavior from the perspective of each partner. The wives' self processes differentially predicted wives' and husbands' perspectives of their interactions, however. These findings demonstrate that wives' future expectations for the health of their husband, as well as for their role in maintaining his future health, motivate their current social behavior to promote the positive health lifestyle behaviors of their husband.

Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study

BACKGROUND

Ischemia during laboratory mental stress tests has been linked to significantly higher rates of adverse cardiac events. Previous studies have not been designed to detect differences in mortality rates.

METHODS AND RESULTS

To determine whether mental stress-induced ischemia predicts death, we evaluated 196 patients from the Psychophysiological Investigations of Myocardial Ischemia (PIMI) study who had documented coronary artery disease and exercise-induced ischemia. Participants underwent bicycle exercise and psychological stress testing with radionuclide imaging. Cardiac function data and psychological test results were collected. Vital status was ascertained by telephone and by querying Social Security records 3.5+/-0.4 years and 5.2+/-0.4 years later. Of the 17 participants who had died, new or worsened wall motion abnormalities during the speech test were present in 40% compared with 19% of survivors (P=0.04) and significantly predicted death (rate ratio=3.0; 95% CI, 1.04 to 8.36; P=0.04). Ejection fraction changes during the speech test were similar in patients who died and in survivors (P=0.9) and did not predict death even after adjusting for resting ejection fraction (P=0.63), which was similar in both groups (mean, 56.4 versus 59.7; P=0.24). Other indicators of ischemia during the speech test (ST-segment depression, chest pain) did not predict death, nor did psychological traits, hemodynamic responses to the speech test, or markers of the presence and severity of ischemia during daily life and exercise.

CONCLUSIONS

In patients with coronary artery disease and exercise-induced ischemia, the presence of mental stress-induced ischemia predicts subsequent death.

The big mush: psychometric measures are confounded and non-independent in their association with age at initial diagnosis of Ischaemic Coronary Heart Disease

The present study uses early diagnosis of ischaemic coronary heart disease (ICHD) as a proxy for disease malignancy in testing the statistical strength of association, and uniqueness/confounding, of several psychometric scales that have previously been found to prospectively predict death in cardiac samples (Beck Depression Inventory, Crown-Crisp Phobic Anxiety Scale, Type D Scale & Ketterer Stress Symptom Frequency Checklist). Eighty-three patients (no. of females = 35) with documented ICHD were assessed for traditional and psychometric risk factors. The psychometric risk factors were moderately to strongly intercorrelated, and strongly confounded in their relationship to age at initial diagnosis. In a stepwise multiple regression, only the AIAI (aggravation, irritation, anger and impatience) scale of the Ketterer Stress Symptom Frequency Checklist (KSSFC) survived as a predictor of age at initial diagnosis (P = 0.016). In a subgroup of the sample for whom the Spouse/Friend Version of the KSSFC was received (n = 58, or 70%), spouse/friend reported AIAI survived as the only predictor (P = 0.010). While present results need replication in a prospective study of diagnosed ICHD patients for all important clinical outcomes, only one psychometric screening instrument may be necessary to identify patients in need of treatment.

Sex differences in chest pain in patients with documented coronary artery disease and exercise-induced ischemia: Results from the PIMI study

BACKGROUND

Sex differences in the pathophysiologic course of coronary artery disease (CAD) are widely recognized, yet accurate diagnosis of coronary artery disease in women remains challenging.

METHODS

To determine sex differences in the clinical manifestation of CAD, we studied chest pain reported during daily activities, exercise, and mental stress in 170 men and 26 women. All patients had documented CAD (>50% narrowing in at least 1 major coronary artery or prior myocardial infarction) and all had 1-mm ST-segment depression on treadmill exercise. We collected psychologic test results, serum samples (potassium, epinephrine, norepinephrine, cortisol, b-endorphin, and glucose), and cardiac function, sensory threshold, and autonomic function data at specified times before, during, or after exercise and mental stress tests to assess measures of depression, anxiety, and neurohormonal and thermal pain perception.

RESULTS

Women reported chest pain more often than men during daily activities (P =.04) and during laboratory mental stressors (P =.01) but not during exercise. Men had lower scores than women on measures of depression, trait anxiety, harm avoidance, and reward dependence (P <.05 for all). Women had significantly lower plasma b-endorphin levels at rest (4.2 +/- 3.9 vs 5.0 +/- 2.5 pmol/L for men, P =.005) and at maximal mental stress (6.4 +/- 5.1 vs 7.4 +/- 3.5 pmol/L for men, P <.01). A higher proportion of women than men had marked pain sensitivity to graded heat stimuli applied to skin (hot pain threshold <41 degrees C, 33% vs 10%, P =.001).

CONCLUSIONS

Our results reflect sex differences in the affective and discriminative aspects of pain perception and may help explain sex-related differences in clinical presentations.

Psychosocial and traditional risk factors in early ischaemic heart disease: cross-sectional correlates

BACKGROUND

Psychosocial/emotional distress has been repeatedly found to be a correlate of the onset/aggravation of ischaemic heart disease.

METHODS

Eighty-three patients (63 men and 20 women) with known coronary artery disease who entered an aggressive lifestyle modification programme were administered a clinical/demographic history and the Symptom Checklist 90--Revised at baseline. Several measures of social isolation/alienation (shyness/self-consciousness, feeling lonely, feeling abused and overall) were derived from the the Symptom Checklist 90--Revised.

RESULTS

Univariate tests of the association of known cardiovascular risk factors and the Symptom Checklist 90--Revised scales with age at initial diagnosis yielded several significant results for history of hypercholesterolaemia (P = 0.018), history of hypertension (P = 0.030), somatization (P = 0.007), obsessive-compulsive (P = 0.009), depression (P = 0.006), anxiety (P = 0.021), hostility (P = 0.003), paranoia (P = 0.050), psychoticism (P = 0.029), the Global Severity Index (P = 0.007), the Positive Symptom Distress Index (P = 0.005), the Positive Symptom Total Score (P = 0.003) and feeling abused (P = 0.037). Only history of hypertension, history of hypercholesterolaemia and the hostility scale (overall F = 6.08 and P = 0.0009) emerged as unique correlates of age at initial diagnosis in a multiple regression using only the significant univariate predictors.

CONCLUSIONS

Psychosocial factors are sufficiently confounded with one another that they lose their predictive value once one is entered in the equation. High scores on the hostility scale were associated with a 5.7 year differential in age at initial diagnosis. The younger a patient is at initial diagnosis, the more likely he/she is to have high levels of emotional distress.

Chest pain and the treatment of psychosocial/emotional distress in CAD patients

Treatment of psychosocial/emotional distress as a strategy for diminishing chest pain in such patients remains entirely unutilized in standard care. Sixty-three patients with known or suspected CAD were entered in an aggressive lifestyle modification program. Patients completed the Symptom Checklist 90-Revised (SCL90R) at the diagnostic interview session, at 3 and at 12 months. Statistically significant drops were observed on multiple scales of the SCL90R at both 3 and 12 months. An item from the SCL90R was used as a proxy for angina. Multiple measures of emotional distress at baseline were found to correlate with chest pain at baseline, but not a number of traditional cardiovascular risk factors. The chest pain item displayed improvement at both 3 and 12 months. Improvement on all scales of the SCL90R correlated with improvement in chest pain. It may be possible to control chest pain in some CAD patients with psychosocial interventions.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

Cognitive/behavioral therapy of anxiety in the medically ill: cardiac settings

Anxiety appears to be a strong risk factor for ischemic heart disease (IHD) and specifically fatal IHD. However, no randomly assigned, controlled, clinical trial targeting anxiety yet exists demonstrating an impact on objective cardiac outcomes. Situational anxiety is frequent in cardiac populations and can diminish quality-of-life by increasing symptoms/disability and result in unnecessary medical system utilization. "Noncardiac" chest pain is common both in patients with objective coronary disease and in patients whose cardiac workup is negative. Both presentations of chest pain respond to cognitive/behavioral therapy, and imipramine has been found to be effective for chest pain unaccompanied by coronary disease. Because anxiety-like symptoms overlap with symptoms of IHD (eg, chest pain, dyspnea, dizziness, palpitations) and can be caused by organic factors, the diagnosis and treatment of anxiety in these populations require special considerations.

Five-year follow-up for adverse outcomes in males with at least minimally positive angiograms: importance of "denial" in assessing psychosocial risk factors

The purpose of this study was to test the role of "denial" (spouse/friend minus self-ratings on parallel versions of the same questionnaire) in diluting the predictive value of emotional distress for cardiac events (deaths, new MIs, and/or revascularizations). One hundred forty-four men with no history of prior revascularization who had at least minimally positive diagnostic coronary angiograms, and someone they selected as "someone who knows you well," completed parallel versions of the Ketterer Stress Symptom Frequency Checklist (KSSFC). They were followed up by phone an average of 59.7 months after recruitment. Length of follow-up, baseline cardiac risk factors, and a number of baseline-obtained psychosocial risk factors were tested as prospective predictors of combined events (death by any cause, new MIs, and/or revascularizations) and current anginal frequency. Only spouse/friend observed anxiety on the KSSFC predicted current anginal frequency (p = 0.001). On the self-report version of the KSSFC, patients with one or more events reported less anger (p = 0.031), depression (p = 0.008), and anxiety (p = 0.003). These results may be attributable to "denial" because there were no differences in spouse/friend ratings, and difference scores (spouse/friend minus patient) on the KSSFC scales, particularly anger, were also related to events: AIAI (p = 0.002); depression (p = 0.063); and anxiety (p = 0.010). Denial may be a major limiting factor in accurately assessing emotional distress in cardiac populations, and may help account for a number of the previous findings.

The Psychophysiological Investigations of Myocardial Ischemia (PIMI) study: objective, methods, and variability of measures

OBJECTIVE

This study evaluated physiological, neuroendocrine, and psychological status and functioning of patients with coronary artery disease in order to clarify their role in the expression of symptoms during myocardial ischemia (MI), and to establish repeatability of responses to mental stress. Design and methods of the study are presented.

METHODS

One hundred ninety-six coronary artery disease patients were examined during physical and mental stress tests in four hospitals. Eligibility criteria included narrowing of at least 50% in the diameter of at least one major coronary artery or verified history of myocardial infarction, and evidence of ischemia on an exercise treadmill test. Psychological, biochemical, and autonomic function data were obtained before, during, and after exposure to mental and exercise stressors during 2 or 3 half-days of testing. Ventricular function was assessed by radionuclide ventriculography, and daily ischemia by ambulatory electrocardiography. Sixty patients returned for a short-term mental stress repeatability study. Twenty-nine individuals presumed to be free of coronary disease were also examined to establish reference values for cardiac responses to mental stress.

RESULTS

Study participants were 41 to 80 years of age; 83 (42%) had a history of MI, 6 (3%) of congestive heart failure, and 163 (83%) of chest pain; 170 (87%) were men; and 90 (46%) had ischemia accompanied by angina during exercise treadmill testing. Ischemia during ambulatory monitoring was found in 35 of 90 (39%) patients with and 48 of 106 (45%) patients without angina during exercise-provoked ischemia. Intraobserver variability of ejection fraction changes during bicycle exercise and two mental stress tests (Speech and Stroop) was good (kappa = 1.0, .90, and .76, respectively; percent agreement = 100, 97.5, and 93.8%, respectively). Variability of assessed wall motion abnormalities during bicycle exercise was better (kappa, agreement = 85%) than during Speech or Stroop kappa and .57, percent agreement = 70% and 82.5%, respectively).

CONCLUSIONS

Study design, quality control data, and baseline characteristics of patients enrolled for a clinical study of symptomatic and asymptomatic myocardial ischemia are described. Lower repeatability of reading wall motion abnormalities during mental stress than during exercise may be due to smaller effects on wall motion and lack of an indicator for peak mental stress.

Reproducibility of mental stress-induced myocardial ischemia in the Psychophysiological Investigations of Myocardial Ischemia (PIMI)

OBJECTIVE

Many patients with coronary artery disease (CAD) develop myocardial ischemia in response to mental stress. This has been documented both in the natural environment and in the laboratory. However, the reproducibility of laboratory mental stress-induced ischemia has not been investigated.

METHOD

Sixty patients with documented CAD and a positive exercise stress test discontinued cardiac medications and underwent two standardized mental stress tests (a timed Stroop Color-Word test and a public speaking task) in a nuclear cardiology laboratory (Visit 1), and repeated this procedure between 2 and 8 weeks later (Visit 2). Measurements of cardiovascular function and neurohormonal responses were obtained throughout testing, and mood state was assessed before and after testing.

RESULTS

Sixty-eight percent of the 56 patients with detailed radionuclide data from both visits had consistent responses (ie, ischemia either present during both sessions or absent during both) to the Stroop task (kappa = .29, p = .03), 61% had consistent responses to the speech task (kappa = .20, p = .12), and 60% had consistent responses when ischemia was considered present if it occurred during either the Stroop test, the speech task, or both, and absent if it did not occur during either task (kappa = .22, p = .07). Hemodynamic and neuroendocrine responses to the tests were moderately reproducible.

CONCLUSIONS

We conclude that two popular laboratory tests for mental stress-induced myocardial ischemia are modestly reproducible. The relatively low reproducibility is probably influenced by uncertainties in detecting relatively small changes in wall motion, habituation of the patient to repeated exposure to psychological stressors, and physiological differences in threshold for ischemia on different days of testing.

Silent versus symptomatic myocardial ischemia: the role of psychological and medical factors

This study examined the relationship of psychological, cardiac, and general medical history factors to asymptomatic (silent) versus symptomatic myocardial ischemia among 102 patients who underwent treadmill exercise testing and had perfusion imaging indicative of ischemia. During exercise, 68 patients exhibited silent ischemia, and 34 experienced chest pain. Patients with silent ischemia rated higher than symptomatic patients on anger control, externally oriented thinking, and somatosensory amplification, but did not differ on depression or global alexithymia. Anger control and externally oriented thinking remained independent correlates in multivariate analysis, controlling for demographic and cardiac factors. Groups did not differ on general medical or cardiac variables. Thus, this study suggests that affective and cognitive factors, but not biomedical factors, are associated with silent, as opposed to symptomatic, ischemia during exercise testing.

Psychosocial factors related to noncardiac chest pain during treadmill exercise

The authors examined historical, concurrent, and potentially secondary psychosocial problems related to noncardiac chest pain during exercise. The patients reporting chest pain during treadmill testing but who lacked cardiac ischemia (determined via nuclear scanning) were compared with the patients having both ischemia and chest pain, and with patients having neither ischemia nor chest pain. The noncardiac chest pain patients had the highest levels of 1) parental divorce and personal psychiatric treatment; 2) current depression, somatic awareness, and anger control; and 3) negative attitudes toward the health care system. The findings suggest that psychosocial problems predate, coexist with, and may result from noncardiac chest pain.

Correlates of unrecognized acute myocardial infarction detected via perfusion imaging

Research using the electrocardiogram (ECG) indicates that about 1/3 of acute myocardial infarctions (AMIs) are unrecognized. To date, no studies of unrecognized AMIs have employed perfusion imaging, although it is more sensitive than the ECG and provides more information about infarct characteristics, such as size and location. In this study, 82 of 258 consecutive patients (31.8%) undergoing exercise testing with technetium-99m sestamibi perfusion imaging had fixed, nonartifactual perfusion defects, suggesting AMI. These patients were interviewed regarding their recognition of AMI; 27 patients (32.9%) had unrecognized AMI. Unrecognized AMI was significantly associated with (1) smaller infarcts, (2) infarcts not in the apical or septal regions, (3) diabetes mellitus, (4) lack of angina, (5) a negative family history for cardiac disease, and (6) being African-American. Many of these variables were significantly intercorrelated, and in multivariate analysis, unrecognized AMI remained significantly predicted by a smaller infarct and lack of angina. This study suggests that the incidence of unrecognized AMI detected via perfusion imaging on a clinic population is similar to that detected via electrocardiographic studies on community samples. This study also replicates prior findings of the medical history and demographic correlates of unrecognized AMI, and indicates that infarct size and location are also associated with unrecognized AMI.

Silent versus symptomatic myocardial ischemia: the role of psychological and medical factors

This study examined the relationship of psychological, cardiac, and general medical history factors to asymptomatic (silent) versus symptomatic myocardial ischemia among 102 patients who underwent treadmill exercise testing and had perfusion imaging indicative of ischemia. During exercise, 68 patients exhibited silent ischemia, and 34 experienced chest pain. Patients with silent ischemia rated higher than symptomatic patients on anger control, externally oriented thinking, and somatosensory amplification, but did not differ on depression or global alexithymia. Anger control and externally oriented thinking remained independent correlates in multivariate analysis, controlling for demographic and cardiac factors. Groups did not differ on general medical or cardiac variables. Thus, this study suggests that affective and cognitive factors, but not biomedical factors, are associated with silent, as opposed to symptomatic, ischemia during exercise testing.

Ischemic, hemodynamic, and neurohormonal responses to mental and exercise stress. Experience from the Psychophysiological Investigations of Myocardial Ischemia Study (PIMI)

BACKGROUND

The pathophysiology of mental stress-induced myocardial ischemia, which occurs at lower heart rates than during physical stress, is not well understood.

METHODS AND RESULTS

The Psychophysiological Investigations of Myocardial Ischemia Study (PIMI) evaluated the physiological and neuroendocrine functioning in unmedicated patients with stable coronary artery disease and exercise-induced ischemia. Hemodynamic and neurohormonal responses to bicycle exercise, public speaking, and the Stroop test were measured by radionuclide ventriculography, ECG, and blood pressure and catecholamine monitoring. With mental stress, there were increases in heart rate, systolic blood pressure, cardiac output, and systemic vascular resistance that were correlated with increases in plasma epinephrine. During exercise, systemic vascular resistance fell, and there was no relationship between the hemodynamic changes and epinephrine levels. The fall in ejection fraction was greater with mental stress than exercise. During mental stress, the changes in ejection fraction were inversely correlated with the changes in systemic vascular resistance. Evidence for myocardial ischemia was present in 92% of patients during bicycle exercise and in 58% of patients during mental stress. Greater increases in plasma epinephrine and norepinephrine occurred with ischemia during exercise, and greater increases in systemic vascular resistance occurred with ischemia during mental stress.

CONCLUSIONS

Mental stress-induced myocardial ischemia is associated with a significant increase in systemic vascular resistance and a relatively minor increase in heart rate and rate-pressure product compared with ischemia induced by exercise. These hemodynamic responses to mental stress can be mediated by the adrenal secretion of epinephrine. The pathophysiological mechanism involved are important in the understanding of the etiology of myocardial ischemia and perhaps in the selection of appropriate anti-ischemic therapy.

Emotional distress among males with "syndrome X"

The present study examined traditional risk factors and various indices of emotional distress in males with positive angiograms (N = 122), "syndrome X" males with negative or nominal results on angiogram (N = 53), and age- and socioeconomic status-matched males with no manifest history of otherosclerotic disease (N = 56). Syndrome X patients reported more depression on the Ketterer Stress Symptom Frequency Checklist (KSSFC) than positive angiographic patients. And compared with healthy controls, they were more likely to be perceived by a spouse/friend as depressed and anxious on the KSSFC, scored higher on the Framingham Type A Scale, and reported more unprovoked nocturnal awakening. Syndrome X patients generally appear to be similar to patients with positive angiograms with regard to traditional risk factor history but are more distressed than healthy controls. This becomes most evident when denial is circumvented by discussion with significant others or inquiries are "framed" appropriately.

Is aspirin, as used for antithrombosis, an emotion-modulating agent?

Antiplatelet substances, generally aspirin, have become widely used for secondary prevention of ischemic heart disease. Used in relatively small doses, it is generally assumed that aspirin has no psychoactive effect. The present study took advantage of a sample of 174 males undergoing coronary angiography to see if regular aspirin use as prophylactic therapy for ischemic heart disease was associated with one or more of a number of measures of emotional distress. Aspirin use was found to be associated with less depression and anxiety or worry, as reported by the patient and as perceived by a significant other. Despite a significant association of aspirin use with the presence of documented coronary artery disease, the association of aspirin use and diminished distress could not be accounted for by the previously observed high prevalence of depressed/anxious individuals among patients with negative or nominal results on angiography, or by a number of other demographic or clinical variables such as age and socioeconomic status. Although only correlational in nature, present results raise the question of whether aspirin may have a beneficial mood-modulating effect.

Psychosocial factors related to unrecognized acute myocardial infarction

Acute myocardial infarction (AMI) often is unrecognized (i.e., a patient fails to notice or report the event to the physician, or the physician fails to diagnose it). Psychosocial differences between patients with recognized and unrecognized AMI have not been examined. We compared 40 patients who sought treatment for a documented AMI with 30 patients who were found on routine electrocardiogram to have had an AMI for which they did not seek medical care. Patients with unrecognized AMI showed greater "alexithymia," or deficient psychologic awareness (p = 0.04; Alexithymia Provoked Response Interview), and a greater belief that chance factors determine their health (p = 0.004; Multidimensional Health Locus of Control Scale). Patients with unrecognized AMI were less likely to have angina, yet did not differ from those with recognized AMI with regard to demographics, smoking, systemic hypertension, diabetes mellitus, AMI location, depression, or hypochondriasis. We hypothesize that deficient psychologic awareness may impede AMI symptom perception or recognition, and that the belief in chance or fate as determining health may inhibit treatment-seeking.

Snoring and the severity of coronary artery disease in men

Previous studies have found associations between snoring, or polysomnographic documented sleep apnea, and hypertension, cerebral vascular disease, and myocardial infarction. The present study examined the relationship of coronary artery disease (CAD) and snoring. One hundred and twenty-two males with positive angiographic studies were compared with fifty-six men, matched in age and socioeconomic status, who had no known history of coronary heart, or other atherosclerotic, disease. The percentage of subjects reporting that they snore "usually" or "always/loudly" increased across the four CAD severity groupings (nonpatient controls = 19.6%, 1 vessel = 44.4%, 2 vessel = 41.9%, 3 vessel = 56.0%) with a p value of .005. Hypertension, body mass index, and pack years of smoking were found to be associated with both coronary artery disease severity and snoring. When these variables were controlled in a multiple regression analysis, the relationship of snoring and CAD severity remained significant at p = .050.

Secondary prevention of ischemic heart disease. The case for aggressive behavioral monitoring and intervention

The hierarchy of evidence for arguing causality of a disease by any factor consists of epidemiological and, ultimately, treatment studies. The application of these criteria to chronic negative emotion as a risk factor for ischemic heart disease (IHD) is relatively new. However, controlled prospective evidence now indicates that anger, depression, and anxiety may play a major role in the genesis of IHD. And the strongest form of evidence, a controlled clinical trial that used randomly assigned subjects, exists, implicating anger as a strong predictor in the development of IHD. Resistance to the utility of this avenue of care is not based on evidence alone because widely accepted risk factors and/or treatment modalities often have less persuasive evidence, or less powerful effects, than do the emotional factors. Rather, such resistance is largely due to "paradigmatic scotomata"--conceptual difficulties for those not familiar with biopsychosocial research. Routine psychometric screening of IHD patients may provide a cost-effective means of alerting cardiologists and internists to the relatively high levels of distress among their patients.

Denial specific to Friedman's pathogenic emotions in Jenkins Activity Survey Type A and angiography-referred males

A pilot study of 27 firemen yielded a number of significant positive partial correlations between Type A Scale scores on the Jenkins Activity Survey and the spouse-or friend-reported frequency of items indicative of aggravation, irritation, anger, and impatience (AIAI), while controlling for subject self-reported frequency. A second study then assessed AIAI, depression, and anxiety with identical subjective (self-reported) and objective (spouse- or friend-reported) measures in 100 male angiography patients. Analysis of variance indicated that 1) angiographically normal or subclinical patients are psychologically distressed; 2) denial (as defined by diminished self-report vs. spouse- or friend-report) is specific to AIAI in this population; and 3) denial is observed with about equal intensity in both occluded and nonoccluded groups.