Longitudinal course of depressive symptomatology after a cardiac event: effects of gender and cardiac rehabilitation.

OBJECTIVE: Recent research has linked depression to cardiac mortality, and shown a high burden of persistent depressive symptomatology among cardiac patients. The objective of this study was to longitudinally examine the prevalence and course of depressive symptomatology among women and men for 1 year after a cardiac event, and the effect of cardiac rehabilitation (CR) on this trajectory. METHODS: Nine hundred thirteen unstable angina (UA) and myocardial infarction patients from 12 coronary care units were recruited, and follow-up data were collected at 6 and 12 months. Measures included CR participation, medication usage, and the Beck Depression Inventory (BDI). The longitudinal analysis was conducted using SAS PROC MIXED. RESULTS: At baseline there were 277 (31.3%) participants with elevated depressive symptomatology (BDI > or = 10), 131 (25.2%) at 6 months, and 107 (21.7%) at 1 year. Overall, approximately 5% were taking an antidepressant medication, and 20% attended CR over their year of recovery. Participants with greater depressive symptomatology participated in significantly fewer CR exercise sessions (r = -0.19, p = .02), and minimal psychosocial interventions were offered. The longitudinal analysis revealed that all participants experienced reduced depressive symptomatology over their year of recovery (p = .04), and younger, UA participants with lower family income fared worst (ps < 0.001). CR did not have an effect on depressive symptomatology over time, but women who attended CR were significantly more depressed than men (p = .01). CONCLUSION: Depressed cardiac patients are undertreated and their symptomatology persists for up to 6 months. CR programs require greater resources to ensure that depressed participants adhere to exercise regimens, and are screened and treated for their elevated symptomatology.

Prospective examination of anxiety persistence and its relationship to cardiac symptoms and recurrent cardiac events.

BACKGROUND: The current study builds on previous research demonstrating a link between anxiety and inhospital recurrent ischemic and arrhythmic events, by examining the effects of persistent anxiety on recurrent events 1 year later. METHODS: 913 patients with unstable angina (UA) and myocardial infarction (MI) from 12 coronary care units were recruited, and follow-up data were collected at 6 and 12 months after the event. Measures included cardiac symptomatology, healthcare utilization, the anxiety subscale of the Primary Care Evaluation of Mental Disorders , the phobic anxiety subscale of the Middlesex Hospital Questionnaire, and the Beck Depression Inventory. RESULTS: Over one third of participants with UA and MI experienced elevated anxiety at the time of the ischemic event, and these symptoms persisted for 1 year in 50% of anxious participants. Although participants with anxiety reported more atypical cardiac symptomatology, the prevalence of typical cardiac symptoms such as chest pain did not differ based on anxiety. After controlling for the severity of the coronary event, family income, sex, diabetes, and smoking, the following variables were significantly predictive of self-reported recurrent cardiac events at 6 months or 1 year: older age, family history of cardiovascular disease, greater depressive symptomatology at baseline, and anxiety at 6 months. Only 38% of anxious patients were asked about such symptoms, indicating underutilization of effective psychotherapeutic treatment. CONCLUSIONS: Over and above the effects of depressive symptomatology (among other confounding variables), nonphobic anxiety appears to have a negative effect on self-reported outcome following an ischemic coronary event. Anxiety symptomatology is underrecognized and undertreated, and examination of effects of treatment on secondary prevention must be pursued.

Sex differences in predictors of illness intrusiveness 1 year after a cardiac event.

OBJECTIVE: This prospective study examined sex differences in illness intrusiveness and in baseline predictors of illness intrusiveness in cardiac patients' 1-year postcardiac event. METHODS: Patients diagnosed with a myocardial infarction (MI) or unstable angina (UA) completed a baseline questionnaire during their hospitalization (139 men and 104 women). Eighty-one men and 67 women completed the follow-up questionnaire 1-year postcardiac event. The questionnaire included measures of illness intrusiveness in three life domains, depressive symptomatology, social support, medical information, risk factors for heart disease, and sociodemographic information. RESULTS: A MANCOVA with the three Illness Intrusiveness subscales as dependent variables, sex as the between-group factor, and partnership status as a covariate found a sex effect for the Intimacy subscale, but not for the Instrumental and the Relationships/Personal Development subscales. Men reported more intrusiveness in the Intimacy domain of their life as compared to women. After controlling for sociodemographic factors and risk factors for heart disease, hierarchical regressions indicated sex differences in baseline predictors of 1-year follow-up illness intrusiveness in the three life domains. For men, being satisfied with support from partner at baseline was associated with less intrusiveness in the Instrumental Life domain 1 year after the cardiac event. For women, surprisingly, more satisfaction with support from their partner at baseline was associated with more intrusiveness in their intimate lives 1 year after their cardiac event. In addition, emotional symptoms of depression at baseline were predictive of increased illness intrusiveness in Relationship/Personal Development and Intimacy domains for men and in Instrumental and Intimacy domains for women. CONCLUSION: Support from partner may have a differential impact for men and women after a cardiac event. Depressive symptomatology during initial hospitalization, particularly emotional symptoms, is a prominent indicator of illness intrusiveness for both sexes 1 year after the cardiac event.

Gender differences in health information needs and decisional preferences in patients recovering from an acute ischemic coronary event.

OBJECTIVE: This study examined gender differences in health information needs and decisional preferences after an acute ischemic coronary event (ICE). METHODS: Patients with ICE, recruited in 12 coronary intensive care units, completed a questionnaire on demographic, disease-related, and psychosocial topics. Six and 12 months later, they completed mailed follow-up questionnaires. RESULTS: Nine hundred six patients completed the baseline questionnaire, 541 (69%) completed the 6-month questionnaire, and 522 (64%) completed the 12-month questionnaire after hospital discharge. Men reported significantly more information received and greater satisfaction with healthcare practitioners meeting their information needs. Women wanted more information than men concerning angina and hypertension. Men wanted more information about sexual function and reported receiving more information about the role of each doctor, test results, treatments, cardiac rehabilitation, and how their families could support their lifestyle changes. Patients who reported receiving more information reported less depressive symptomatology and greater self-efficacy, healthcare satisfaction, and preventive health behaviors. Although most patients of both sexes preferred a shared decision-making role with their physician, the majority felt their doctor had made the main decisions. CONCLUSIONS: Patients after ICE, especially women, reported receiving much less information than they wanted from all health professionals. Most patients wanted a shared or autonomous treatment decision-making role with their doctor, but only a minority experienced this. Clinicians must do better, because meeting patients' information needs and respecting their decisional preferences are shown to be associated with better self-efficacy, satisfaction, and health-promoting behavior.

Presentation, delay, and contraindication to thrombolytic treatment in females and males with myocardial infarction.

BACKGROUND: This study seeks to explore gender-relevant factors of medical history, sociodemographics, symptom presentation, and delay on thrombolysis administration (or recorded contraindication) in a sample of men and women with confirmed myocardial infarction (MI). METHODS: Cross-sectional examination of self and nurse-report data collected in the coronary care unit (CCU) from 12 hospitals across south-central Ontario, Canada. A total of 482 MI patients (347 males, 135 females; 63% response rate) were recruited. MAIN FINDINGS: There was no gender difference in the report of chest pain (chi(2)(1) = 3.78, p =.052), or in prehospital delay time (median = 96.5 minutes). Thrombolysis was administered in 158 males (68.4%) and 50 females (50.0%) without reported contraindication. Females (median = 27 minutes) had a significantly longer interval between diagnostic electrocardiogram (ECG) and administration of a thrombolytic than males (median = 22, U = 3,056). No contraindication was indicated for not administering a thrombolytic (i.e., too late, risk of bleed) in approximately 40% of females. In accordance with clinical practice guidelines, thrombolysis was more often administered in participants with a shorter time interval between symptom onset and hospital arrival. For females, thrombolysis was more often administered in younger participants (Kruskal Wallis = 5.88). CONCLUSIONS: Reducing gender, age, and socioeconomic disparities in access to thrombolysis treatment is imperative. Hospital delays with female cardiac patients may be precluding thrombolysis administration.

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.

Cardiac rehabilitation II: referral and participation.

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. Substantial health risks continue following ischemic coronary events (ICEs), but secondary prevention efforts, including cardiac rehabilitation (CR), have beneficial effects on both early and late mortality and morbidity. This prospective study examined the relationship among psychosocial factors and CR referral and participation patterns in 906 (586 men, 320 women) patients from the coronary intensive care unit (CICU) over the course of six months. Only 30% of participants were referred to CR programs, with significantly fewer women being referred. A logistic regression analysis was used to determine whether depression, anxiety, self-efficacy, or social support predicted CR participation six months following an ICE, while controlling for sociodemographic factors. Results show that higher family income, greater anxiety symptomatology, and higher self-efficacy were significantly predictive of CR participation at six months. Implications for women's recovery from an ICE are discussed.