Eficacia de la intervención psicológica en rehabilitación cardíaca / Effectiveness of psychological intervention in cardiac rehabilitation

OBJETIVO: El objetivo del presente estudio fue describir y analizar los resultados de la intervención cognitivo-conductual en los pacientes beneficiarios del programa multidisciplinar de rehabilitación cardíaca del Hospital General Universitario de Elche. MATERIAL Y MÉTODO: Para ello se dispuso de una muestra de 33 pacientes que habían tenido un infarto agudo de miocardio o que padecían angina de pecho inestable remitidos desde el Servicio de Cardiología para su inclusión en el Programa de Prevención y Rehabilitación Cardíaca durante los meses comprendidos en el período de septiembre de 2014 a octubre de 2015. Todos los participantes fueron evaluados mediante una batería de cuestionarios pre y postratamiento. RESULTADOS: Los resultados obtenidos mostraron una disminución estadísticamente significativa tras la intervención en gran parte de los factores de riesgo, como ansiedad (p < 0,001, d = 0,38), depresión (p < 0,005, d = 0,25) e ira (p < 0,005, d = 0,35). CONCLUSIONES: Este estudio constituye una nueva evidencia de la eficacia de la intervención psicológica en rehabilitación cardíaca

OBJECTIVE: The aim of this study was to describe and analyze the results of the cognitive-behavioral intervention in the patients beneficiaries of the multidisciplinary Cardiac Rehabilitation program of the Hospital General Universitario de Elche (Spain). MATERIAL AND METHOD: A sample that included 33 patients who had suffered an acute myocardial infarction or who suffer from unstable angina pectoris. These patients were referred from the Cardiology Department for inclusion in the Cardiac Prevention and Rehabilitation Program during the period from September 2014 to October 2015. All the patients were evaluated using a battery of pre- and post- treatment questionnaires. RESULTS: The results showed a statistically significant decrease in a large part of the risk factors after the intervention, such as anxiety (P < .001, d = 0.38), depression (P < .005, d = 0.25) and anger (P < .005, d = 0.35). CONCLUSIONS: This study provides new evidence of the effectiveness of psychological intervention in cardiac rehabilitation

[Effectiveness of psychological intervention in cardiac rehabilitation]. / Eficacia de la intervención psicológica en rehabilitación cardíaca.

OBJECTIVE: The aim of this study was to describe and analyze the results of the cognitive-behavioral intervention in the patients beneficiaries of the multidisciplinary Cardiac Rehabilitation program of the Hospital General Universitario de Elche (Spain). MATERIAL AND METHOD: A sample that included 33 patients who had suffered an acute myocardial infarction or who suffer from unstable angina pectoris. These patients were referred from the Cardiology Department for inclusion in the Cardiac Prevention and Rehabilitation Program during the period from September 2014 to October 2015. All the patients were evaluated using a battery of pre- and post- treatment questionnaires. RESULTS: The results showed a statistically significant decrease in a large part of the risk factors after the intervention, such as anxiety (P < .001, d = 0.38), depression (P < .005, d = 0.25) and anger (P < .005, d = 0.35). CONCLUSIONS: This study provides new evidence of the effectiveness of psychological intervention in cardiac rehabilitation.

Social Support, Unstable Angina, and Stroke as Predictors of Depression in Patients With Coronary Heart Disease.

BACKGROUND: Depression is known to adversely affect coronary heart disease patients in western countries; however, no study of social support and depression has been conducted in the Chinese population. OBJECTIVE: The aim of this study was to investigate the predictors of depression in patients with coronary heart disease. METHODS: Between January and December 2015, a cross-sectional sample of 105 Taiwanese patients from cardiology units completed a demographic and clinical characteristics questionnaire, Enhancing Recovery in Coronary Heart Disease Social Support Inventory, and Patient Health Questionnaire-9. RESULTS: Thirty-nine percent of the participants reported low social support, and 61.0% had depression symptoms. Eight factors predicted depression. Social support was significantly and adversely correlated with depression (r = -.481, P < .01). The other 7 factors were positively correlated with depression: age (r = .212, P < .05), reported monthly income of less than US $600 (F = 4.98, P = .001), lack of exercise (F = 3.75, P = .027), history of stroke (t = -2.45, P = .016) and kidney disease (t = -2.41, P = .018), unstable angina (F = 3.56, P = .031), and groin puncture (F = 3.27, P = .042). A hierarchical regression model explained 43.7% of the variance in depression. CONCLUSION: Social support, unstable angina, and stroke may be important predictors of depression in patients with coronary heart disease. These findings help clinical staff to understand physical and mental health problems in cardiovascular patients. Thus, we suggest that early depression prediction and sufficient social support can help patients to face their disease and thus improve depression and health care quality.

Health-related quality of life in older patients with acute coronary syndrome randomised to an invasive or conservative strategy. The After Eighty randomised controlled trial.

Objective: in the After Eighty study (ClinicalTrials.gov.number, NCT01255540), patients aged 80 years or more, with non-ST-elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UAP), were randomised to either an invasive or conservative management approach. We sought to compare the effects of these management strategies on health related quality of life (HRQOL) after 1 year. Methods: the After Eighty study was a prospective randomised controlled multicenter trial. In total, 457 patients aged 80 or over, with NSTEMI or UAP, were randomised to either an invasive strategy (n = 229, mean age: 84.7 years), involving early coronary angiography, with immediate evaluation for percutaneous coronary intervention, coronary artery bypass graft, optimal medical therapy, or to a conservative strategy (n = 228, mean age: 84.9 years). The Short Form 36 health survey (SF-36) was used to assess HRQOL at baseline, and at the 1-year follow-up. Results: baseline SF-36 completion was achieved for 208 and 216 patients in the invasive and conservative groups, respectively. A total of 137 in the invasive group and 136 patients in the conservative group completed the SF-36 form at follow-up. When comparing the changes from follow-up to baseline (delta) no significant changes in quality-of-life scores were observed between the two strategies in any of the domains, expect for a small but statistically significant difference in bodily pain. This difference in only one of the SF-36 subscales may not necessarily be clinically significant. Conclusion: from baseline to the 1 year follow-up, only minor differences in change of HRQOL as measured by SF-36 were seen by comparing an invasive and conservative strategy. ClinicalTrials.gov identifier: NCT01255540.

Persistent psychological distress and mortality in patients with stable coronary artery disease.

BACKGROUND: A single assessment of psychological distress, which includes depression and anxiety, has been associated with increased mortality in patients with coronary heart disease, but the prognostic importance of persistence of distress symptoms is less certain. AIM: To determine whether intermittent and/or persistent psychological distress is associated with long-term cardiovascular (CV) and total mortality in patients with stable coronary artery disease. METHODS: 950 participants in the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) trial completed at least four General Health Questionnaires (GHQ-30) at baseline and after ½, 1, 2 and 4 years. In a landmark analysis from 4 years, Cox proportional hazards models evaluated the risk of CV and total mortality by increasing levels of psychological distress: never distressed, sometimes any severity (GHQ score >5), persistent mild (GHQ score >5 on three or more occasions) and persistent moderate distress (GHQ score >10) on three or more occasions, over a median of 12.1 (IQR 8.6-12.5) years. The models were both unadjusted and adjusted for known baseline risk factors. RESULTS: Persistent moderate or greater psychological stress was reported on three or more assessments by 35 (3.7%) subjects. These patients had a higher risk of both CV death (adjusted HR 3.94, 95% CI 2.05 to 7.56, p<0.001) and all-cause mortality (adjusted HR 2.85, 95% CI 1.74 to 4.66, p<0.001) compared with patients with no distress. In contrast, patients who reported persistent mild distress (n=73, 7.7%) on three or more visits, and those who met criteria for distress on only one or two assessments (n=255, 26.8%), did not have an increased risk of CV or all-cause mortality during follow-up. CONCLUSION: In patients with stable coronary artery disease, persistent psychological distress of at least moderate severity is associated with a substantial increase in CV and all-cause mortality.

FACTORS ASSOCIATED WITH DEPRESSIVE EPISODE IN PATIENTS HOSPITALIZED WITH ACUTE CORONARY EVENTS.

Severe infarction or its consequences are considered as triggering factors of incidental depression. The aim of our study was to reveal factors associated with depressive episode in patients hospitalized with acute coronary syndrome (acute myocardial infarction, unstable angina). The Beck Depression inventory (BDI) was used for assessment of depressive symptoms in patients with coronary disease in Emergency Cardiology Clinic Tbilisi, Georgia. The study sample included 84 patients. The clinical Information was collected from hospital recordings. The chi-square test was used for assessment the difference between groups. Independent t-test was used to compare means for numerical variable "age". A binary logistic regression was applied in order to assess a relationship between disease severity factors (ejection fraction and revascularization) and depressive episode. Study sample included 79% of men and 21% of women with a mean age 59 years. Coronary obstruction as well as cardiac risk factors was revealed in majority of participants. The mean depression score was 13.0, while BDI score > 16 was revealed in 28.6% of patients. In the binary regression model ejection fraction was inversely associated with depressive episode even after adjustment to the age, gender and coronary risk factors. When disease severity markers (ejection fraction, revascularization) together with classic risk factors were included into the model, they explained only 42% of depressive episodes. It may be concluded that disease severity markers together with classic cardiac risk factors explain only partially depressive episode in patients, hospitalized for acute coronary events. A multidisciplinary approach is needed in order to provide optimal care and improve prognosis of patients with acute coronary syndrome (ACS).

Factors related to the evolution of Health Related Quality of Life in coronary patients. A longitudinal approach using Weighted Generalized Estimating Equations with missing data.

BACKGROUND: The aim is to know the factors related to the evolution of Health Related Quality of Life (HRQL) in Coronary Patients (CP) from a longitudinal perspective using an appropriate method that handles missing data adequately when the mechanism of missingness is uncertain. METHODS: Prospective study with repeated measures at baseline, 3 and 6months. 250 patients with acute myocardial infarction or unstable angina were studied. Sociodemographic and clinical data were collected at baseline. Mental health (GHQ-28) and HRQL (SF-36v1) were assessed during the follow-up. The missingness mechanism was tested. Friedman test and partial eta-squared were used to analyse changes in SF-36 scores and WGEE were used to identify the predictors of the evolution of HRQL. RESULTS: 95 dropped out after 3months and 72 after 6months. The missingness was likely to be at random. All the dimensions of the SF-36 improved over time, except PF. The factors related to the evolution of HRQL were: being woman (B=-23.9 in RE; B=-6.9 in MCS), older age (B=-0.5 in BP; B=-0.3 in VT), being single/separated (B=-14.5 in GH; B=-14.1 in SF; B=-23.3 in MH) and widow(er) (B=-23.2 PF; B=-29.8 in SF), hypertensive (B=-19.8 in RP; B=-8.9 in VT), worse mental health (B=-3 in PF; B=-2.8 in RP; B=-3.1 in BP; B=-1.2 in PCS; B=-3.8 in VT; B=-2.6 in SF), previous history of CHD (B=-12.5 in PF; B=-5.2 in PCS), and performing heart-healthy physical activities (B=13.9 in PF). CONCLUSIONS: HRQL improves over time. A global approach, including age, marital status, performing physical activities or hypertension, is required to improve HRQL in CP.

Test-retest reliability of HeartQoL and its comparability to the MacNew heart disease health-related quality of life questionnaire.

OBJECTIVES: Heart Quality of Life (HeartQoL) is a new "hybrid" developed from the MacNew and two condition-specific questionnaires measuring health-related quality of life (HRQoL) in patients with ischemic heart disease (IHD). This study investigates test-retest reliability of HeartQoL (English version) according to international criteria (e.g., COSMIN, GRRAS). Findings on HeartQoL are compared to the published data on MacNew in view that both serve as the core IHD-specific HRQoL instrument. METHODS: Out of 105 patients with IHD, 76 completed self-administration of HeartQoL at the clinic followed by at home within a 2-week interval. In retest, patients responded using non-interview methods (phone messaging, email, fax, and post). Phone interviewing was reserved for non-respondents to reminder. RESULTS: Reliability of HeartQoL was good (intraclass correlation coefficients = 0.78-0.82), was supported in the Bland-Altman plot, and was comparable to five studies on MacNew of similar retest interval (MacNew-English = 0.70-0.75; translated MacNew = 0.72-0.91). Applicability of its standard error of measurement (0.20-0.25) and smallest detectable change (0.55-0.70) will depend on availability of normative data in future. CONCLUSION: The reliability of HeartQoL is comparable to its parent instrument, the MacNew. The HeartQoL is a potentially reliable core IHD-specific HRQoL instrument in measuring group change.

Neighborhood matters: the impact of Hispanic ethnic density on future depressive symptoms 1-year following an ACS event among Hispanic patients.

The Ethnic Density hypothesis posits that living around others from similar ethnic backgrounds reduces the risk of adverse mental health outcomes such as depression. Contrary to this hypothesis, previous work has shown that Hispanic ethnic density is cross-sectionally associated with increased depressive symptom severity among patients hospitalized with an acute coronary syndrome (ACS; myocardial infarction or unstable angina pectoris). To date, no study has examined the prospective association of Hispanic ethnic density on long-term depressive symptom severity following an acute medical event. We prospectively assessed the impact of Hispanic ethnic density on depressive symptoms, 1-year following an ACS event, among Hispanic adult patients. We tested the non-linear association between ethnic density and depressive symptoms to account for inconsistent findings on the ethnic density hypothesis. At the time of an index ACS event (i.e., baseline, N = 326) and 1-year later (N = 252), Hispanic patients from the Prescription Usage, Lifestyle, and Stress Evaluation prospective cohort study completed the Beck Depression Inventory as a measure of depressive symptom severity. Hispanic ethnic density was defined by the percentage of Hispanic residents within each patient's census tract using data extracted from the American Community Survey Census (2010-2013). Covariates included baseline demographic factors (age, gender, English fluency, education, nativity status), cardiovascular factors (Charlson comorbidity index, left ventricular ejection fraction, Global Registry of Acute Coronary Events 6-month prognostic risk score), and neighborhood factors (residential density, income, and percentage of households receiving public assistance). In an adjusted multivariable linear regression analysis there was a significant curvilinear association between Hispanic ethnic density and depressive symptom severity at 1 year. As Hispanic ethnic density increased from low to moderate density, there was an increase in depressive symptoms, but depressive symptoms slightly declined in census tracts with the highest density of Hispanics. Furthermore, gender significantly moderated the relation between Hispanic ethnic density and 1-year depressive symptom severity, such that Hispanic ethnic density was significantly associated with increased depressive symptom severity for female Hispanic patients with ACS, but not for male Hispanic patients. Previous research suggests that ethnic density may be protective against depression in Hispanic enclaves; however, our findings suggest a non-linear ethnic density effect and an overall more complex association between ethnic density and depression. These data add to a growing body of literature on the effects of sociodemographic and contextual factors on health.

Optimism and recovery after acute coronary syndrome: a clinical cohort study.

OBJECTIVE: Optimism is associated with reduced cardiovascular mortality, but its impact on recovery after acute coronary syndrome (ACS) is poorly understood. We hypothesized that greater optimism would lead to more effective physical and emotional adaptation after ACS and would buffer the impact of persistent depressive symptoms on clinical outcomes. METHODS: This prospective observational clinical study took place in an urban general hospital and involved 369 patients admitted with a documented ACS. Optimism was assessed with a standardized questionnaire. The main outcomes were physical health status, depressive symptoms, smoking, physical activity, and fruit and vegetable consumption measured 12 months after ACS, and composite major adverse cardiac events (cardiovascular death, readmission with reinfarction or unstable angina, and coronary artery bypass graft surgery) assessed over an average of 45.7 months. RESULTS: We found that optimism predicted better physical health status 12 months after ACS independently of baseline physical health, age, sex, ethnicity, social deprivation, and clinical risk factors (B = 0.65, 95% confidence interval [CI] = 0.10-1.20). Greater optimism also predicted reduced risk of depressive symptoms (odds ratio = 0.82, 95% CI = 0.74-0.90), more smoking cessation, and more fruit and vegetable consumption at 12 months. Persistent depressive symptoms 12 months after ACS predicted major adverse cardiac events over subsequent years (odds ratio = 2.56, 95% CI = 1.16-5.67), but only among individuals low in optimism (optimism × depression interaction; p = .014). CONCLUSIONS: Optimism predicts better physical and emotional health after ACS. Measuring optimism may help identify individuals at risk. Pessimistic outlooks can be modified, potentially leading to improved recovery after major cardiac events.

Age, job characteristics and coronary health.

BACKGROUND: Workplace demographics are changing in many European countries with a higher proportion of older workers in employment. Research has shown that there is an association between job strain and cardiovascular disease, but this relationship is unclear for the older worker. AIMS: To investigate the association between job strain and a coronary event comparing younger and older male workers. METHODS: Cases with a first-time coronary event were recruited from four coronary/intensive care units (1999-2001). Matched controls were recruited from the case's general practitioner surgery. Physical measurements were taken and self-administered questionnaires completed with questions on job characteristics, job demands and control. Unconditional logistic regression was carried out adjusting for classical cardiovascular risk factors. RESULTS: There were 227 cases and 277 matched controls. Age stratified analyses showed a clear difference between younger (<50 years) and older (≥50 years) workers with regard to the exposure of job strain (job demands and control) and the association between these factors and cardiovascular disease. Older workers who had a coronary event were four times as likely to have high job strain [OR = 4.09 (1.29-13.02)] and more likely to report low job control [OR = 0.83 (0.72-0.95)]. CONCLUSIONS: Job control emerged as a potential protective factor for heart disease and this evidence was stronger in the older male worker. Nevertheless, they were significantly more likely to have job strain. These results suggest that older workers may be more susceptible to job strain.

[C reactive protein in women with coronary heart disease and its association with depression]. / C-reaktives Protein bei Frauen mit koronarer Herzkrankheit und Zusammenhange mit Depressivitat.

OBJECTIVES: Depression is associated with increased risk and poor outcome of coronary heart disease (CHD), though the mechanisms are largely unknown. Low-grade inflammation offers a possible biological pathway, which has been confirmed in men but not in women. METHODS: We studied the association of C reactive protein (CRP), a biomarker of inflammation, with depressive symptoms in 292 women with CHD and 300 healthy age-matched controls, considering confounder variables (BMI, age, HDL cholesterol, triglycerides, menopausal status). CRP was measured by a high sensitivity assay. RESULTS: In the overall sample no significant association was found between depressive symptoms and CRP, whereas in the control group women with 2 or more versus 0-1 depressive symptoms showed heightened CRP (p = 0.005); there was no significant difference in CRP levels between CHD patients with 0-1 versus 2 or more depressive symptoms. Women with CHD had higher serum levels of CRP and more depressive symptoms than did controls. CONCLUSIONS: Contrary to men and healthy controls there was no link between CRP and depressive symptoms in women with CHD. More research is needed on how the harmful effects of depression are mediated, especially in women.

[Personality self-actualization: an independent additional risk factor of myocardial infarction and unstable angina].

It is shown for the first time that changes of self-actualization (SA) in patients with CHD are the main risk factor of myocardial infarction (MI) and unstable angina (UA). The clinical course and prognosis of MI correlate with SA prior to the development of an acute coronary event. Isolated correlations exist between CHD risk factors and results of SA questionnaire studies. SA personality peculiarities in patients with MI and UA account for more than 50% dispersion of the results of linear factor analysis.

Posttraumatic stress due to an acute coronary syndrome increases risk of 42-month major adverse cardiac events and all-cause mortality.

Approximately 15% of patients with acute coronary syndromes (ACS) develop posttraumatic stress disorder (PTSD) due to their ACS event. We assessed whether ACS-induced PTSD symptoms increase risk for major adverse cardiac events (MACE) and all-cause mortality (ACM) in an observational cohort study of 247 patients (aged 25-93 years; 45% women) hospitalized for an ACS at one of 3 academic medical centers in New York and Connecticut between November 2003 and June 2005. Within 1 week of admission, patient demographics, Global Registry of Acute Coronary Events risk score, Charlson comorbidity index, left ventricular ejection fraction, and depression status were obtained. At 1-month follow-up, ACS-induced PTSD symptoms were assessed with the Impact of Events Scale-Revised. The primary endpoint was combined MACE (hospitalization for myocardial infarction, unstable angina or urgent/emergency coronary revascularization procedures) and ACM, which were actively surveyed for 42 months after index event. Thirty-six (15%) patients had elevated intrusion symptoms, 32 (13%) elevated avoidance symptoms, and 21 (9%) elevated hyperarousal symptoms. Study physicians adjudicated 21 MACEs and 15 deaths during the follow-up period. In unadjusted Cox proportional hazards regression analyses, and analyses adjusted for sex, age, clinical characteristics and depression, high intrusion symptoms were associated with the primary endpoint (adjusted hazard ratio, 3.38; 95% confidence interval, 1.27-9.02; p = .015). Avoidance and hyperarousal symptoms were not associated with the primary endpoint. The presence of intrusion symptoms is a strong and independent predictor of elevated risk for MACE and ACM, and should be considered in the risk stratification of ACS patients.

Gender differences and determinants of health related quality of life in coronary patients: a follow-up study.

BACKGROUND: The role of gender differences in Health Related Quality Life (HRQL) in coronary patients is controversial, so understanding the specific determinants of HRQL in men and women might be of clinical importance. The aim of this study was to know the gender differences in the evolution of HRQL at 3 and 6 months after a coronary event, and to identify the key clinical, demographic and psychological characteristics of each gender associated with these changes. METHODS: A follow-up study was carried out, and 175 patients (112 men and 63 women) with acute myocardial infarction (AMI) or unstable angina were studied. The SF-36v1 health questionnaire was used to assess HRQL, and the GHQ-28 (General Health Questionnaire) to measure mental health during follow-up. To study the variables related to changes in HRQL, generalized estimating equation (GEE) models were performed. RESULTS: Follow-up data were available for 55 men and 25 women at 3 months, and for 35 men and 12 women at 6 months. Observations included: a) Revascularization was performed later in women. b) The frequency of rehospitalization between months 3 and 6 of follow-up was higher in women c) Women had lower baseline scores in the SF-36. d) Men had progressed favourably in most of the physical dimensions of the SF-36 at 6 months, while at the same time women's scores had only improved for Physical Component Summary, Role Physical and Social Functioning; e) the variables determining the decrease in HRQL in men were: worse mental health and angina frequency; and in women: worse mental health, history of the disease, revascularization, and angina frequency. CONCLUSIONS: There are differences in the evolution of HRQL, between men and women after a coronary attack. Mental health is the determinant most frequently associated with HRQL in both genders. However, other clinical determinants of HRQL differed with gender, emphasizing the importance of individualizing the intervention and the content of rehabilitation programs. Likewise, the recognition and treatment of mental disorders in these patients could be crucial.

Disparity in perceived illness intrusiveness and illness severity between cardiac patients and their spouses.

BACKGROUND: Recovery following a cardiac event is a complex physiological and psychological process that seldom occurs in isolation. The interdependence of a marital relationship may result in the spouse influencing the patient's overall recovery and the psychological well-being of both. The aim of the study was to assess whether perceived illness intrusiveness and illness severity differed between cardiac patients and their spouses and whether their perceptions were modified by treatment received. A thematic analysis of written feedback from patients and spouses informed the interpretation of the quantitative results. METHODS: Sixty-two male cardiac patients and their female spouses completed the Illness Intrusiveness Rating Scale and Perceived Severity of Illness Scale. Participants also provided written comments about anticipated life changes. A 2-way mixed-model analysis of variance was used to compare patient and spouse scores. RESULTS: There were no differences in terms of perceived illness intrusiveness. A statistically significant higher level of perceived illness severity was reported by spouses whose husbands had cardiac surgery (difference = 48.8 points, F1,59 = 23.2, P = .001). Five themes emerged from the written responses of the patients: anticipated lifestyle change, change in self-perception, reprioritization, enhanced quality of life, and uncertainty. Four themes emerged from the spouses: taking on responsibility, uncertainty, enhanced quality of life, and getting back to normal. CONCLUSIONS: Spouses of cardiac surgery patients had different perceptions about illness than their patient-partner. Future research should be directed toward a better understanding of how divergent illness beliefs develop during the recovery period, and how they impact physical and psychological well-being.

Anxiety in patients undergoing percutaneous coronary interventions.

OBJECTIVE: Many patients undergoing percutaneous coronary intervention (PCI) experience symptoms of anxiety; however, it is unclear whether anxiety is an issue in the early recovery period and the types of factors and patient concerns that are associated. This study set out to determine the patterns of anxiety and concerns experienced by patients undergoing PCI and the contributing factors in the time period surrounding PCI. METHODS: A convenience sample of patients undergoing PCI (n = 100) were recruited, and anxiety was measured using the Spielberger State Anxiety Inventory immediately before the PCI, the first day postprocedure, and 1 week postdischarge. Patients were also asked to identify their most important concern at each time. Independent predictors of anxiety at each time were determined by multiple regression analysis. RESULTS: Anxiety scores were highest pre-procedure (35.72, standard deviation [SD] 11.75), decreasing significantly by the postprocedure time (31.8, SD 10.20) and further still by the postdischarge time (28.79, SD 9.78) (repeated-measures analysis of variance: F = 39.72, P < .001). The concerns patients identified most frequently as most important were the outcome of the PCI and the possibility of surgery pre-procedure (37%) and postdischarge (31%), and the limitations and discomfort arising from the access site wound and immobility postprocedure (25%). The predictor of anxiety at the pre-procedure time was taking medication for anxiety and depression (b = 7.12). The predictors of anxiety at the postprocedure time were undergoing first-time PCI (b = 4.44), experiencing chest pain (b = 7.63), and experiencing pre-procedural anxiety (b = .49). The predictors of anxiety at the postdischarge time were reporting their most important concern as the future progression of CAD (b = 7.51) and pre-procedural anxiety (b = .37). CONCLUSION: Symptoms of anxiety were common, particularly before PCI. These symptoms are important to detect and treat because pre-procedural anxiety is predictive of anxiety on subsequent occasions. Patients who have had chest pain or their first PCI should be targeted for intervention during the early recovery period after PCI, and information on CAD should be provided postdischarge.

Identifying symptom profiles of depression and anxiety in patients with an acute coronary syndrome using latent class and latent transition analysis.

OBJECTIVE: To identify symptom profiles of depression and anxiety in patients with an acute coronary syndrome (ACS), to examine changes in symptom profiles over time, and finally, to examine the effects of age and sex on patients' symptom profiles. METHODS: One hundred ACS patients with mild to severe symptoms of depression and/or anxiety at 1 month post-hospital discharge were enrolled in a randomized trial of cognitive behavioral therapy. Latent class and latent transition analyses were used to identify symptom profiles and describe change over the time in profile membership. RESULTS: A two-class solution was selected to describe depression and anxiety symptom profiles. Class I (76% of patients at baseline) was labeled "depression and some anxiety symptoms." Class II (24% of patients at baseline) was labeled "anxiety and some depression symptoms." Approximately 25% of patients in the treatment condition transitioned from the depression and some anxiety symptoms class to the anxiety and some depression symptoms class at follow-up compared to 10% of patients in the control condition at follow-up; nearly 50% of patients in the control condition showed worsening of symptoms as compared to 28% in the treatment condition. Results suggested age differences in the probabilities of transitioning between the classes; older patients were more likely to continue having depression and some anxiety symptoms at the time of follow-up. CONCLUSIONS: Identifying symptom profiles of depression and anxiety in patients with an ACS may improve diagnostic practices and help to design tailored interventions.

What predicts depression in cardiac patients: sociodemographic factors, disease severity or theoretical vulnerabilities?

Depression is associated with increased cardiovascular risk in acute coronary syndrome (ACS) patients, but some argue that elevated depression is actually a marker of cardiovascular disease severity. Therefore, disease indices should better predict depression than established theoretical causes of depression (interpersonal life events, reinforcing events, cognitive distortions, type D personality). However, little theory-based research has been conducted in this area. In a cross-sectional design, ACS patients (n = 336) completed questionnaires assessing depression and psychosocial vulnerabilities. Nested logistic regression assessed the relative contribution of demographic or vulnerability factors, or disease indices or vulnerabilities to depression. In multivariate analysis, all vulnerabilities were independent significant predictors of depression (scoring above threshold on any scale, 48%). Demographic variables accounted for <1% of the variance of depression status, with vulnerabilities accounting for significantly more (pseudo R² = 0.16, χ²(change) = 150.9, df = 4, p < 0.001). Disease indices accounted for 7% of the variance in depression (pseudo R² = 0.07, χ² = 137.9, p < 0.001). However, adding the vulnerabilities increased the overall variance explained to 22% (pseudo R² = 0.22, χ² = 58.6, df = 4, p < 0.001). Theoretical vulnerabilities predicted depression status better than did either demographic or disease indices. The presence of these proximal causes of depression suggests that depression in ACS patients is not simply a result of cardiovascular disease severity.

[Patient satisfaction in acute coronary syndrome. Improvement through the establishment of a chest pain unit]. / Patientenzufriedenheit beim akuten Koronarsyndrom. Verbesserung durch die Etablierung einer Chest-Pain-Unit.

BACKGROUND AND PURPOSE: Chest pain units (CPUs) were established primarily in the United States with the aim of reducing hospital admissions and costs, whilst improving quality of life and patient care. Clinical trials have shown that these units are safe and practical; however, there was a need to investigate to what extent patients are satisfied with the care in CPUs. The aim of this study is to evaluate the experiences of patients receiving CPU care and routine emergency department (ED) treatment for acute chest pain. PATIENTS AND METHODS: Patients presenting with acute chest pain at the ED between May 2004 and June 2005 and at the CPU between July 2005 and May 2006 were evaluated in this retrospective analysis. Standardized data collection using all available clinical data as well as telephone follow-up was carried out. Evaluation was carried out on a school-mark basis and a quality assessment was performed. RESULTS: Of the total population, 479 patients (323 male, 156 female) were treated in the ED, whereas 1176 (743 male, 433 female) in the CPU. In the ED, 26 patients (5.4%) were diagnosed as ST segment elevation myocardial infarction (STEMI), 39 (8.1%) as non-ST segment elevation myocardial infarction (NSTEMI) and 16 (3.3%) as unstable angina pectoris (UAP). In 398 patients (83.1%) acute coronary syndrome (ACS) could be ruled out. In the CPU, the incidence of STEMI was 74 (6.3%), of NSTEMI 141 (12%) and of UAP 153 (13%). ACS was excluded in 808 patients (68.7%). Data on satisfaction with in-hospital treatment was available in 78.5% of cases. In the CPU, 92.2% of the patients judged their treatment as excellent/good, 5.9% as appropriate and 1.9% as poor. The distribution of satisfaction in the ED was significantly lower with 78.6% excellent/good, 18.5% appropriate and 2.9% poor. CONCLUSION: The establishment of a CPU at the University Medical Center of Mainz demonstrated a higher level of patient satisfaction compared to the treatment of patients with acute chest pain in the general ED.