Anna Wikman

Fear of dying and inflammation following acute coronary syndrome

AIMS Many patients are afraid of dying during acute coronary syndrome (ACS), but the origins and biological correlates of these emotional responses are poorly understood. This study evaluated the prevalence of fear of dying, associations with inflammatory responses during ACS, and later heart rate variability (HRV) and cortisol secretion. METHODS AND RESULTS Two hundred and eight patients admitted with clinically verified ACS rated their fear of dying on interview in hospital. Plasma tumour necrosis factor (TNF)α was recorded on admission, and HRV and salivary cortisol were assessed 3 weeks later. Intense distress and fear of dying was experienced by 21.7%, with moderate levels in 66.1% patients. Fear of dying was more common in younger, lower socioeconomic status, and unmarried patients. It was positively associated with plasma TNFα on admission after controlling for sociodemographic factors, clinical risk, and pain intensity (adjusted odds = 4.67, 95% C.I. 1.66-12.65). TNFα was associated with reduced HRV 3 weeks later, adjusting for clinical and sociodemographic factors and medication (P = 0.019), while fear of dying was associated with reduced cortisol output (P = 0.004). CONCLUSIONS Intense distress and fear of dying and heightened inflammation may be related manifestations of an acute biobehavioural response to severe cardiac injury, and have implications for prognostically significant biological risk processes.

Quality of Life and Affective Well-Being in Middle-Aged and Older People with Chronic Medical Illnesses: A Cross-Sectional Population Based Study

Background There has been considerable research into the impact of chronic illness on health-related quality of life. However, few studies have assessed the impact of different chronic conditions on general quality of life (QOL). The objective of this paper was to compare general (rather than health-related) QOL and affective well-being in middle aged and older people across eight chronic illnesses. Methods and Findings This population-based, cross-sectional study involved 11,523 individuals aged 50 years and older, taking part in wave 1 of the English Longitudinal Study of Ageing. General QOL was assessed using the CASP-19, happiness was evaluated using two items drawn from the GHQ-12, and depression was measured with the CES-D. Analysis of covariance and logistic regression, adjusting for age, gender and wealth, were performed. General QOL was most impaired in people with stroke (mean 37.56, CI 36.73–38.39), and least in those reporting cancer (mean 41.78, CI 41.12–42.44, respectively), compared with no illness (mean 44.15, CI 43.92–44.39). Stroke (mean 3.65, CI 3.58–3.73) was also associated with the greatest reduction in positive well-being whereas diabetes (mean 3.81, CI 3.76–3.86) and cancer were least affected (3.85, CI 3.79–3.91), compared with no illness (mean 3.97, CI 3.95–4.00). Depression was significantly elevated in all conditions, but was most common in chronic lung disease (OR 3.04, CI 2.56–3.61), with more modest elevations in those with osteoarthritis (OR 2.08, CI 1.84–2.34) or cancer (OR 2.07, CI 1.69–2.54). Multiple co-morbidities were associated with greater decrements in QOL and affective well-being. Conclusion The presence of chronic illness is associated with impairments in broader aspects of QOL and affective well-being, but different conditions vary in their impact. Further longitudinal work is needed to establish the temporal links between chronic illness and impairments in QOL and affective well-being.

Persistence of Posttraumatic Stress Symptoms 12 and 36 Months After Acute Coronary Syndrome

Objectives: To assess the prevalence and predictors of posttraumatic stress symptoms in patients at 12 and 36 months post hospital admission for an acute coronary syndrome (ACS). There is increasing recognition that posttraumatic stress may develop in the aftermath of an acute cardiac event. However, there has been little research on the longer-term prevalence of posttraumatic stress disorder (PTSD). Methods: Posttraumatic stress symptoms were assessed at 12 months in 213 patients with ACS and in 179 patients at 36 months. Predictor variables included clinical, demographic, and emotional factors measured during hospital admission. Results: At 12 months post ACS, 26 (12.2%) patients qualified for a diagnosis of PTSD; 23 (12.8%) patients were identified with PTSD at 36 months. Posttraumatic symptoms at 12 months were associated with younger age, ethnic minority status, social deprivation, cardiac symptom recurrence, history of depression, depressed mood during admission, hostility, and Type D personality. In multiple regression, depressed mood during admission and recurrent cardiac symptoms were independent predictors of posttraumatic symptoms (R2 = 0.507, p < .001). At 36 months, posttraumatic stress symptoms were independently predicted by posttraumatic symptom levels at 12 months and depressed mood during admission (R2 = 0.635, p < .001). Conclusion: Posttraumatic stress symptoms persist for at least 3 years after an acute cardiac event. Early emotional responses are important in predicting longer-term posttraumatic stress. It is important to identify patients at risk for posttraumatic stress as they are more likely to experience reduced quality of life. ACS = acute coronary syndrome; BDI = Beck Depression Inventory; CHD = coronary heart disease; DSM = Diagnostic and Statistical Manual; GRACE = Global Registry of Acute Coronary Events; MI = myocardial infarction; NSTEMI = non-ST segment elevation myocardial infarction; PSS-SR = PTSD Symptom Scale-Self-Report; PTSD = posttraumatic stress disorder; STEMI = ST segment elevation myocardial infarction; UA = unstable angina.

Type D Personality, Self-Efficacy, and Medication Adherence Following an Acute Coronary Syndrome

Objective To assess the relationship among Type D personality, self-efficacy, and medication adherence in patients with coronary heart disease. Methods The study design was prospective and observational. Type D personality, self-efficacy for illness management behaviors, and medication adherence were measured 3 weeks after hospitalization for acute coronary syndrome in 165 patients (mean [standard deviation] age = 61.62 [10.61] years, 16% women). Self-reported medication adherence was measured 6 months later in 118 of these patients. Multiple linear regression and mediation analyses were used to address the study research questions. Results Using the original categorical classification, 30% of patients with acute coronary syndrome were classified as having Type D personality. Categorically defined patients with Type D personality had significantly poorer medication adherence at 6 months (r = −0.29, p < .01). Negative affectivity (NA; r = −0.25, p = .01) and social inhibition (r = −0.19, p = .04), the components of Type D personality, were associated with medication adherence 6 months after discharge in bivariate analyses. There was no evidence for the interaction of NA and social inhibition, that is, Type D personality, in the prediction of medication adherence 6 months after discharge in multivariate analysis. The observed association between NA and medication adherence 6 months after discharge could be partly explained by indirect effects through self-efficacy in mediation analysis (coefficient = −0.012; 95% bias-corrected and accelerated confidence interval = −0.036 to −0.001). Conclusions The present data suggest the primacy of NA over the Type D personality construct in predicting medication adherence. Lower levels of self-efficacy may be a mediator between higher levels of NA and poor adherence to medication in patients with coronary heart disease. Abbreviations ACS = acute coronary syndrome; SD = standard deviation

Emotional triggering and low socio-economic status as determinants of depression following acute coronary syndrome

BACKGROUND The determinants of depression following acute coronary syndrome (ACS) are poorly understood. Triggering of ACS by emotional stress and low socio-economic status (SES) are predictors of adverse outcomes. We therefore investigated whether emotional triggering and low SES predict depression and anxiety following ACS. METHOD This prospective observational clinical cohort study involved 298 patients with clinically verified ACS. Emotional stress was assessed for the 2 h before symptom onset and compared with the equivalent period 24 h earlier using case-crossover methods. SES was defined by household income and education. Depression was measured with the Beck Depression Inventory and the Hamilton Rating Scale for Depression and anxiety with the Hospital Anxiety and Depression Scale 3 weeks after ACS and again at 6 and 12 months. Age, gender, ethnicity, marital status, the Global Registry of Acute Coronary Events risk score, duration of hospital stay and history of depression were included as covariates. RESULTS Emotional stress during the 2-h hazard period was associated with increased risk of ACS (odds ratio 1.88, 95% confidence interval 1.01-3.61). Both low income and emotional triggering predicted depression and anxiety at 3 weeks and 6/12 months independently of covariates. The two factors interacted, with the greatest depression and anxiety in lower income patients who experienced acute emotional stress. Education was not related to depression. CONCLUSIONS Patients who experience acute emotional stress during their ACS and are lower SES as defined by current affluence and access to resources are particularly vulnerable to subsequent depression and anxiety.

Intentional and unintentional non-adherence to medications following an acute coronary syndrome: A longitudinal study

Objective Non-adherence to medication is common among coronary heart disease patients. Non-adherence to medication may be either intentional or unintentional. In this analysis we provide estimates of intentional and unintentional non-adherence in the year following an acute coronary syndrome (ACS). Method In this descriptive prospective observational study of patients with confirmed ACS medication adherence measures were derived from responses to the Medication Adherence Report Scale at approximately 2 weeks (n = 223), 6 months (n = 139) and 12 months (n = 136) following discharge from acute treatment for ACS. Results Total medication non-adherence was 20%, 54% and 53% at each of these time points respectively. The corresponding figures for intentional non-adherence were 8%, 15% and 15% and 15%, 52% and 53% for unintentional non-adherence. There were significant increases in the levels of medication non-adherence between the immediate discharge period (2 weeks) and 6 months that appeared to stabilize between 6 and 12 months after acute treatment for ACS. Conclusion Unintentional non-adherence to medications may be the primary form of non-adherence in the year following ACS. Interventions delivered early in the post-discharge period may prevent the relatively high levels of non-adherence that appear to become established by 6 months following an ACS.

Presence of symptom clusters in surgically treated patients with esophageal cancer: Implications for survival

It is not known whether symptoms cluster together after esophageal cancer surgery or whether such symptom clusters are associated with survival in patients with esophageal cancer who are treated surgically.

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.

Anaemia and the development of depressive symptoms following acute coronary syndrome: longitudinal clinical observational study

Objective Depressive symptoms are common following acute coronary syndrome (ACS) and predict subsequent cardiovascular morbidity. Depression in acute cardiac patients appears to be independent of clinical disease severity and other cardiovascular measures. One factor that has not been considered previously is anaemia, which is associated with fatigue and adverse cardiac outcomes. This study assessed the relationship between anaemia on admission and depressive symptoms following ACS. Design Longitudinal clinical observational study. Setting Coronary care unit. Patients 223 patients with documented ACS. Main outcome measures Depressive symptoms measured with the Beck Depression Inventory 3 weeks after admission. Results Anaemia was defined with WHO criteria and was present in 30 (13.5%) patients. Anaemia predicted raised depression scores 3 weeks later independently of age, gender, marital status, educational attainment, smoking, Global Registry of Acute Cardiac Events (GRACE) risk scores, negative mood in hospital and history of depression (p=0.003). The odds of a Beck Depression Inventory score ≥10 among anaemic patients were 4.03 (95% CIs 1.48 to 11.00), adjusted for covariates. Sensitivity analyses indicated that effects were also present when haemoglobin was analysed as a continuous measure. Anaemia also predicted major adverse cardiac events over the subsequent 12 months. Conclusions Anaemia appears to contribute to depression following ACS and is associated with future cardiac morbidity. Studies evaluating the effects of anaemia management will help delineate the role of this pathway more precisely.

The long-term effects of acute triggers of acute coronary syndromes on adaptation and quality of life

BACKGROUND A proportion of acute coronary syndromes (ACS) are thought to be triggered acutely by physical exertion, emotional stress and other stimuli. We assessed the consequences of triggering for long-term adaptation following ACS. METHODS We assessed mental and physical health status in 150 male and 44 female ACS survivors 12 and 36 months after cardiac events using standardised questionnaire measures. Triggers were assessed by interview an average of 2.56 days after hospital admission. Emotional triggers were defined as moderate or intense anger, stress or sadness/depressed mood in the 2 h before symptom onset, while vigorous physical exertion was defined as activity >/=6 metabolic equivalents in the hour before symptom onset. Clinical characteristics, psychiatric history, health behaviours and the Global Registry of Acute Coronary Events (Grace) risk algorithm were also assessed. RESULTS Emotional triggers predicted elevated anxiety and poor mental health status at 12 months independently of age, gender, socioeconomic status, ACS presentation, Grace risk scores, pre-admission medication, anxiety in hospital, depression history and symptom recurrence (p<0.001). Effects persisted at 36 months. Emotional triggers were not related to physical health status at follow up. By contrast, impaired physical health status was predicted by vigorous exertion during the trigger period independently of covariates (p=0.019). CONCLUSIONS ACS triggering has a long-term impact on adaptation and quality of life, with differential effects of physical and emotional triggers.