Social and economic factors in patients with coronary disease.
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Emotions↗
Biomedical subjects
N Frasure-Smith
Publications and source records attributed to N Frasure-Smith.
Differential long-term impact of in-hospital symptoms of psychological stress after non-Q-wave and Q-wave acute myocardial infarction.
Because of their unstable pathophysiology, it was hypothesized that patients with non-Q-wave acute myocardial infarctions (AMI) would be more vulnerable to the negative effects of psychological stress than patients with Q-wave AMI, and thus would be more likely to benefit from programs aimed at relieving stress. This hypothesis was tested through secondary analysis of data from a 1-year randomized clinical trial of psychological stress monitoring and intervention after AMI. After discharge, treatment group patients were telephoned each month and asked to respond to an index of psychological stress symptoms (General Health Questionnaire GHQ-20). Those with high stress symptoms (GHQ greater than or equal to 5) received home nursing visits. Control group patients received usual care. The sample consisted of 461 men, aged 31 to 86 years, who responded to the GHQ-20 before hospital discharge. Patients were followed for 5 years using record data. There were 321 Q-wave AMIs, 112 non-Q-wave AMIs and 28 indeterminate electrocardiograms. Life-table analyses showed that among patients with non-Q-wave AMIs receiving usual care, high stress in the hospital (GHQ greater than or equal to 5) was associated with a 1-year relative risk (RR) of cardiac mortality of 5.49 +/- 1.39 (p = 0.01). In comparison, control patients with Q-wave MIs had no stress-related increase in risk (RR = 0.41 +/- 2.08, p = 0.40). In the treatment group, the patients with non-Q-wave AMIs did not experience an increase in risk associated with high stress (RR = 1.80 +/- 1.79, p = 0.52).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Report of the Canadian Cardiovascular Society's consensus conference on the Management of the Postmyocardial Infarction Patient.
In October 1989, the Canadian Cardiovascular Society announced a program to achieve consensus on important issues in the care of patients with cardiovascular disease. This report on the management of the postmyocardial infarction patient represents the first in a series of these consensus conferences. The process for establishing consensus recommendations involved several steps. A primary panel of 11 experts from various fields was selected to review the available clinical evidence and to make a list of recommendations about management decisions in the postmyocardial infarction period. The initial report was distributed to a secondary panel of 16 reviewers* representing allied health care constituencies from across Canada. On the basis of the critical reviews and feedback from these reviewers, a revised report was distributed to all members (over 800) of the Canadian Cardiovascular Society for further review and feedback. This iterative approach resulted in a penultimate report that was presented at a plenary session of the annual scientific meeting of the Canadian Cardiovascular Society on Oct. 18, 1990, in Halifax, NS. On the basis of discussion and feedback from this symposium, the consensus review was completed.
Canada↗
In-hospital symptoms of psychological stress as predictors of long-term outcome after acute myocardial infarction in men.
The impact of high levels of psychological stress symptoms in the hospital after an acute myocardial infarction (AMI) was examined over 5 years among 461 men who took part in a trial of psychological stress monitoring and intervention. Psychological stress was assessed using the 20-item General Health Questionnaire (GHQ) 1 to 2 days before hospital discharge. Once discharged, patients in the treatment group responded to the GHQ by telephone on a monthly basis and, when they reported high levels of stress symptoms (GHQ greater than or equal to 5), received visits from nurses to help them deal with their life problems. Control patients received routine medical care after discharge. Post-hoc subgroup analyses based on life-table methods showed that, for patients receiving routine care after discharge, high stress (GHQ greater than or equal to 5) was associated with a close to threefold increase in risk of cardiac mortality over 5 years (p = 0.0003) and an approximately 1.5-fold increase in risk of reinfarction over the same period (p = 0.09). In contrast, highly stressed patients who took part in the 1-year program of stress monitoring and intervention did not experience any significant long-term increase in risk. Although program impact was significant in terms of reduction of both cardiac mortality (p = 0.006) and AMI recurrences (p = 0.004) among highly stressed patients, there was little evidence of impact among patients with low levels of stress in the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)
Community Health Nursing↗
Levels of somatic awareness in relation to angiographic findings.
One hundred and forty men, aged 32-75, were interviewed in hospital prior to cardiac catheterization. The interview included questions on activity limitations and events provoking chest symptoms, as well as measures of somatic awareness (MSPQ), psychological distress (GHQ) and social desirability response set (Marlowe-Crowne scale). On the basis of catheterization results patients were classified according to the number of vessels with 50% or more blockage. Stepwise discriminant function analysis identified six predictors (MSPQ score, age, previous MI status, two of 10 events provoking chest symptoms, and GHQ score) which correctly classified 57% of the patients according to their number of vessels blocked. MSPQ scores bore the greatest univariate relationship to blockage group, and examination of the group means for these scores showed that the more blockage, the lower the level of bodily awareness, particularly among patients with no previous infarction. In the context of MSPQ results with other samples, it is suggested that there may be an optimal level of somatic awareness. While patients who are catheterized with little blockage may be overly sensitive to bodily symptoms and sensations, those who are not catheterized until several blockages exist may have dangerously low levels of bodily awareness.
Adult↗
Interviewer effects in a telephone survey: a word to the wise.
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Adult↗
Life stress, denial and outcome in ischemic heart disease patients.
Goldberg's 20-item General Health Questionnaire was administered to 320 male ischemic heart disease patients prior to discharge from hospital. The relationship between GHQ scores and rehospitalization/death rates for the subsequent year was examined. Surprisingly, a curvilinear relationship emerged with both low and high scorers having better outcomes than patients scoring in the middle ranges. This relationship held regardless of physical risk factors reflecting severity of disease, and demographic factors failed to explain the curve. It was suggested that denial and compliance accounted for the good outcomes of the low and high scorers respectively, whereas the medium scoring patients were neither adequate deniers nor sufficiently enthusiastic about entering the sick role.
Adult↗
Memory problems after ischemic heart disease episodes: effects of stress, benzodiazepines and smoking.
Post-IHD episode memory problems and their correlates were investigated among 157 male ischemic heart disease patients under the age of 65. Twenty-five per cent of these patients reported memory difficulties originating during the year following admission to hospital. Of the wide variety of socio-demographic factors, measures of disease severity, and lifestyle variables evaluated, only three differentiated those patients with post-IHD episode memory problems from patients with no memory difficulties. These three were: quitting smoking during the year following hospitalization, using psychotropic drugs (benzodiazepines), and having high psychosocial stress levels one year after discharge. Further analysis revealed that stress was related to memory problems primarily because stressed patients were more likely to use psychotropic drugs. It was suggested that the relationship between quitting smoking and memory problems could be explained by reference to two contradictory effects of tobacco use: a short-acting memory facilitating effect due to nicotine and a longer lasting memory impairment due to smoking-related atherosclerosis which might persist long after giving up smoking.
Amnesia↗
General Health Questionnaire, stress and outcome after ischemic heart disease episodes.
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Adult↗
What makes a "good" nurse?
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Attitude to Health↗
Depression and health-care costs during the first year following myocardial infarction.
OBJECTIVE: Depression in the hospital after myocardial infarction (MI) has been associated with a substantial increase in the long-term risk of cardiac mortality, but little is known about other outcomes. This study uses Quebec Medicare data to examine the relationship between post-MI depression and physician costs, including both out-patient care and hospital readmissions. METHODS: The sample consists of 848 1-year survivors of an acute MI who had completed the Beck Depression Inventory (BDI) in hospital. Two hundred sixty subjects had BDI scores of >/=10 (30.7%), indicative of mild to moderate symptoms of depression. Quebec Medicare data during the index admission for an acute MI and during the year following discharge were compared for the patients with elevated BDI scores and those with normal scores. RESULTS: Total costs, in Canadian dollars (out-patient physician charges plus physician costs during admissions plus estimates of associated direct costs), were about 41% higher (p = 0.004) for patients with elevated BDI scores. The difference was primarily related to out-patient and emergency room visits and readmission costs associated with longer stays in hospital wards, and was not accounted for by use of psychiatric services or readmissions for revascularization. CONCLUSION: Results suggest that, in addition to the survival risks associated with post-MI depression, there are increased health care costs linked to both readmissions and out-patient contacts among depressed patients who survive the first post-MI year. The extent to which the increased use of health care may have reduced depression and enhanced survival remains unclear.
Adult↗
Depression in patients with cardiac disease: a practical review.
Some degree of depression affects at least 30% of hospitalized patients with coronary artery disease (CAD), and is associated with increased risks of mortality and continuing depression over at least the first year following hospital discharge. Despite its consequences for prognosis and quality of life, depression is underrecognized and undertreated in cardiac patients. The diagnosis of depression is complicated in patients with medical illness. Their symptoms can reflect physical as well as psychological complaints. Many CAD patients resist the idea of additional medications, and drug interactions can be problematic for those willing to accept antidepressant treatment. Finally, depression tends to recur. Its successful treatment requires a long-term commitment from both physician and patient. This article examines the special challenges involved in diagnosing depression in patients with CAD, outlines available psychotherapeutic and pharmacological treatments, and considers the issues involved in deciding which patients to treat, with what approach, and for how long.
Coronary Disease↗
Uncertainty and psychologic stress after coronary angioplasty and coronary bypass surgery.
OBJECTIVE: To examine the trajectory of uncertainty and symptoms of psychologic stress during the first 3 months after coronary angioplasty and coronary bypass surgery and to study the impact of social support on uncertainty and psychologic stress in these patient populations. DESIGN: Descriptive, correlative. SETTING: Urban community, at-home interviews. PATIENTS: Male patients with angioplasty (n = 22) and bypass (n = 25) at 1 and 3 months after treatment. Age range was 39 to 75 years (mean 58 years). OUTCOME MEASURES: Mishel Uncertainty in Illness scores, General Health Questionnaire scores, and Perceived Social Support Scale scores. INTERVENTION: Patients underwent either percutaneous transluminal coronary angioplasty or coronary artery bypass grafting as treatment for coronary artery disease. RESULTS: Data were analyzed with repeated measures analysis of variance and Pearson correlation coefficients. Results showed that at both time periods angioplasty patients were more uncertain than bypass patients (p < 0.05), and that regardless of procedure, patients reported fewer symptoms of psychologic stress at 3 months than at 1 month (p < 0.01). Patients with high social support had less uncertainty and psychologic stress than patients with low support (p < 0.05). Analysis of the social support and treatment group interaction showed that angioplasty patients with low perceived social support had significantly more psychologic stress than angioplasty patients with high support (p < 0.01). Analysis of the correlations between uncertainty and psychologic stress in the angioplasty and bypass grafting procedure groups after control for social support revealed that social support was a significant mediator of the relationship between uncertainty and stress only among patients undergoing percutaneous transluminal coronary angioplasty. There was little evidence of a mediating role for social support in the coronary artery bypass grafting group. CONCLUSIONS: These results suggest that angioplasty patients may be in particular need of interventions aimed at reducing uncertainty, and that interventions that increase social support could be important in achieving this reduction.
Adult↗
The ischemic heart disease life stress monitoring program: impact on mortality.
Based on evidence that life stress is a precursor of ischemic heart disease episodes, a randomized control trial of a stress monitoring and intervention program was instituted involving 453 male myocardial infarction patients. Program patients were monitored monthly by telephone for 1 year using the General Health Questionnaire. Whenever a patient's score rose above a critical level, he received a variety of interventions aimed at stress reduction. Results showed that the treated group registered a greater decline in stress scores than controls and, although rehospitalizations and their durations did not differ, there were significantly fewer deaths in the monitored group. It is suggested that stress-relieving programs may have a greater impact in reducing cardiac deaths than in preventing nonlethal coronary episodes.
Humans↗
Long-term follow-up of the Ischemic Heart Disease Life Stress Monitoring Program.
This study examines patient outcomes up to seven years after a one-year, post-myocardial infarction (MI) stress monitoring and management program. A previous randomized controlled trial involving 461 male patients demonstrated that the program lowered stress scores and reduced one-year cardiac deaths by almost 50%, but made no difference in readmission rates or durations. The present study used medical records to assess the durability of these outcomes. Results indicated that the difference in cardiac deaths was primarily due to out-of-hospital deaths (that is, those that were more likely to have been sudden deaths) and persisted for six months beyond the end of the program, after which the mortality curves began to approach one another. In addition, although during the program year MI recurrences occurred at the same rate in the two groups, during the years after the program there were fewer MI recurrences among the treated patients. Over the full follow-up period the group difference in MI recurrences was statistically significant (p = 0.043). Results are considered in terms of methodological limitations of the study, including the timing of randomization, sample selection requirements, and group differences on baseline variables. Findings are also discussed in relation to the outcomes of other programs producing long-term reductions in recurrences or deaths from ischemic heart disease. It is suggested that, regardless of their approach, all such programs may share a common therapeutic mechanism: the provision of emotional support during a period of high vulnerability to stress.
Adult↗
Major depression before and after myocardial infarction: its nature and consequences.
The prevalence and prognostic impact of previous depression, depression in the hospital, and depression after discharge were studied in 222 patients admitted for acute myocardial infarction (MI). Patients were interviewed 1 week, 6 months, and 12 months after the index MI using a modified version of the Diagnostic Interview Schedule (DIS); patients also completed the Beck Depression Inventory (BDI). Patients or family members were recontacted at 18 months to determine survival. Some 27.5% of patients had at least one episode of major depression before their MI, but only 7.7% were depressed at some point during the year preceding the infarct. Overall, 31.5% of patients experienced depression in the hospital or during the year postdischarge. Some 35 patients were depressed in the hospital, 30 became depressed between discharge and 6 months, and five more between 6 and 12 months after the MI. History of depression increased the risk of depression in the hospital and after discharge. Depression in the hospital was associated with an increased risk of mortality over 18 months. Patients who experienced a recurrent depression in the hospital were at particularly high risk. Although patients who became depressed after discharge differed from those who remained depression-free in terms of age, history of depression, BDI scores, and the number of depression symptoms on the DIS in the hospital, a model including these variables identified only 14.7% of the patients who became depressed after returning home. Post-MI depression is common and largely unrelated to medical and psychosocial factors.
Adult↗
The seduction of death.
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Cardiovascular Diseases↗
Gender, depression, and one-year prognosis after myocardial infarction.
OBJECTIVE: The purpose of this study was to assess gender differences in the impact of depression on 1-year cardiac mortality in patients hospitalized for an acute myocardial infarction (MI). METHODS: Secondary analysis was performed on data from two studies that used the Beck Depression Inventory (BDI) to assess depression symptoms during hospitalization: a prospective study of post-MI risk and a randomized trial of psychosocial intervention (control group only). The sample included 896 patients (283 women) who survived to discharge and received usual posthospital care. Multivariate logistic regression analysis was used to assess the risk of 1-year cardiac mortality associated with baseline BDI scores. RESULTS: There were 290 patients (133 women) with BDI scores > or =10 (at least mild to moderate symptoms of depression); 8.3% of the depressed women died of cardiac causes in contrast to 2.7% of the nondepressed. For depressed men, the rate of cardiac death was 7.0% in contrast to 2.4% of the nondepressed. Increased BDI scores were significantly related to cardiac mortality for both genders [the odds ratio for women was 3.29 (95% confidence interval (CI) = 1.02-10.59); for men, the odds ratio was 3.05 (95% CI = 1.29-7.17)]. Control for other multivariate predictors of mortality in the data set (age, Killip class, the interactions of gender by non-Q wave MI, gender by left ventricular ejection fraction, and gender by smoking) did not change the impact of the BDI for either gender. CONCLUSIONS: Depression in hospital after MI is a significant predictor of 1-year cardiac mortality for women as well as for men, and its impact is largely independent of other post-MI risks.
Aged↗