Gemma Randall

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.

Marital status, gender and cardiovascular mortality: Behavioural, psychological distress and metabolic explanations

The intermediate processes through which the various unmarried states can increase the risk of subsequent cardiovascular disease mortality are incompletely understood. An understanding of these processes and how they may vary by gender is important for understanding why marital status is strongly and robustly associated with subsequent cardiovascular disease. In a prospective study of 13,889 Scottish men and women (mean age 52.3, Standard Deviation: 11.8 yrs, range 35–95, 56.1% female) without a history of clinically diagnosed cardiovascular disease, we examined the extent to which health behaviours (smoking, alcohol, physical activity), psychological distress (General Health Questionnaire-12 item) and metabolic dysregulation (obesity levels, and the presence of hypertension and diabetes) account for the association between marital status and cardiovascular mortality. There were 258 cardiovascular deaths over an average follow up of 7.1 (Standard Deviation = 3.3) years. The risk of cardiovascular mortality was greatest in single, never married men and separated/divorced women compared with those that were married in gender stratified models that were adjusted for age and socio-economic group. In models that were separately adjusted, behavioural factors explained up to 33%, psychological distress explained up to 10% and metabolic dysregulation up to 16% of the relative change in the hazard ratios in the observed significant associations between marital status and cardiovascular mortality. Behavioural factors were particularly important in accounting for the relationship between being separated/divorced and cardiovascular mortality in both men and women (33% and 21% of the relative change in the hazard ratios, respectively). The findings suggest that health behaviour, psychological distress and metabolic dysregulation data have varying explanatory power for understanding the observed relationship between cardiovascular disease mortality and unmarried states.

Marital status and cardiac rehabilitation attendance: a meta-analysis.

Background Marital status has been clearly linked to subsequent health outcomes in those with established coronary heart disease (CHD). This robust association may be because of both pathophysiological and behavioural mechanisms. Design We employed meta-regression to examine the association between marital status and attendance at outpatient cardiac rehabilitation (CR) in published studies. Methods We searched electronic databases, for example, Medline and Science Citation Index, for published studies that reported an association between a measure of marital or partnered status and CR attendance in patients with diagnosed CHD. Results Eleven studies were identified which incorporated 6984 CHD patients. Being married/partnered was associated with significantly higher odds of attending CR. Using a fixed effects model, the pooled odds ratio of CR attendance was 1.72 [95% confidence interval (CI) 1.50–1.97] for those who were married/partnered. There was no evidence of heterogeneity of effects (P = 0.42) or publication bias (P = 0.12). Conclusion CHD patients who are married or have a partner are between 1.5–2 times more likely to attend CR. Associations between marital status and CR attendance may partly explain CHD outcomes.

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

The impact of an acute cardiac event on the partners of patients: a systematic review

Abstract Partner support facilitates successful recovery and adjustment following an acute cardiac event (myocardial infarction or coronary revascularisation), but there is limited research examining the partner experience after an acute cardiac event. A computerised literature search was conducted to identify quantitative research investigating the psychosocial impact of an acute cardiac event on the patients partner. The research base is limited, somewhat methodologically weak and outdated in relation to advances in cardiac care, and little attention has been paid to the experience of non-Caucasian couples, same sex couples or male partners. However, we found that partners are at significant risk of experiencing distress, anxiety and depression that may extend beyond the immediate recovery phase, and may contribute to adverse patient outcomes. Partners contend with significant disruption to their daily functioning and may engage in substantial caregiving responsibilities. Partners describe a lack of social support and information which may contribute to the high levels of distress. Marital and sexual functioning can also be adversely affected. Partner coping strategies and illness perceptions may contribute to adjustment. The findings of this review reveal that partner experience may play an important role in both partner and patient adjustment to an acute cardiac event and there is considerable scope for updating and extending current knowledge of partner experience.

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.

Marital Status and Heart Rate Variability in Patients with Suspected Coronary Artery Disease

BackgroundMarried individuals are at reduced risk of cardiovascular disease morbidity and mortality. Recent research indicates that impaired heart rate variability (HRV) may contribute to cardiovascular disease morbidity and mortality and has also been associated with social isolation.PurposeWe investigated associations between HRV and marital status in patients with suspected coronary artery disease (CAD).MethodsEighty-eight patients who were being investigated for suspected CAD (28 women, 60 men, mean age 61.6, 60% married) were recruited from three rapid access chest pain clinics in London. Heart rate variability was measured using 24-h electrocardiograms and analyzed using frequency and time-domain measures.ResultsUnmarried marital status was associated with reduced heart rate variability as indexed by both frequency and time-domain measures, independently of age, gender, beta-blocker use, depression ratings, and subsequent diagnosis of significant CAD.ConclusionThese findings suggest that reduced heart rate variability is associated with not being married and may contribute to the reliably observed relationship between marital status and cardiovascular disease morbidity and mortality.

Cognitive predictors of posttraumatic stress symptoms six months following acute coronary syndrome.

This study examined patients’ illness representations assessed shortly after an acute coronary syndrome (ACS) as predictors of posttraumatic stress symptoms six months later. Illness representations were assessed in ACS patients using standard measures at a home visit three weeks after discharge from hospital. Posttraumatic stress symptoms were assessed at the same time, and again six months later. Patients were aged 61 years on average, the majority being men (89.8%) of white European decent (89%). Greater posttraumatic symptoms at six months were associated with beliefs that the illness would last a long time (timeline), that it had an unpredictable time course (timeline – cyclical), greater consequences, less personal and treatment control, poorer illness coherence and stronger negative emotional representations (emotional upset relating to the illness; p < 0.05). In multiple regression analyses, controlling for demographic, clinical and psychological factors (age, gender, ethnicity, social deprivation, ACS severity, negative affectivity and cardiac symptom recurrence), more intense emotional representations (β = 0.146, p = 0.041) and reduced illness coherence (β = −0.133, p = 0.029), emerged as independent predictors of posttraumatic symptom severity at six months. There was a near significant effect for personal control (β = −0.113, p = 0.058). These results demonstrate the importance of illness representations of ACS in predicting longer-term posttraumatic stress symptoms.

Cortisol levels and history of depression in acute coronary syndrome patients

BACKGROUND Depressed mood following an acute coronary syndrome (ACS) is a risk factor for future cardiac morbidity. Hypothalamic-pituitary-adrenal (HPA) axis dysregulation is associated with depression, and may be a process through which depressive symptoms influence later cardiac health. Additionally, a history of depression predicts depressive symptoms in the weeks following ACS. The purpose of this study was to determine whether a history of depression and/or current depression are associated with the HPA axis dysregulation following ACS. METHOD A total of 152 cardiac patients completed a structured diagnostic interview, a standardized depression questionnaire and a cortisol profile over the day, 3 weeks after an ACS. Cortisol was analysed using: the cortisol awakening response (CAR), total cortisol output estimated using the area under the curve method, and the slope of cortisol decline over the day. RESULTS Total cortisol output was positively associated with history of depression, after adjustment for age, gender, marital status, ethnicity, smoking status, body mass index (BMI), Global Registry of Acute Cardiac Events (GRACE) risk score, days in hospital, medication with statins and antiplatelet compounds, and current depression score. Men with clinically diagnosed depression after ACS showed a blunted CAR, but the CAR was not related to a history of depression. CONCLUSIONS Patients with a history of depression showed increased total cortisol output, but this is unlikely to be responsible for associations between depression after ACS and later cardiac morbidity. However, the blunted CAR in patients with severe depression following ACS indicates that HPA dysregulation is present.

The psychosocial predictors of long-term distress in partners of patients with acute coronary syndrome

Objective: Partners of acute coronary syndrome (ACS) patients are at risk of experiencing long-term distress and the purpose of this study was to identify its predictors. Design: Using an observational design, 80 partners of ACS patients completed validated questionnaires at three time points. The predictor variables, marital satisfaction and optimism were assessed three weeks after patient hospital discharge (T1). The outcomes, depressive symptoms and physical health status (from a quality of life scale) were measured 6 (T2) and 12 (T3) months post-discharge, and scores were combined to indicate the long-term response. Main outcome measures: Depressive symptoms and physical health status. Results: Partner depressive symptoms increased and physical health status deteriorated over the months following the patients’ ACS. After controlling for demographics, clinical severity of ACS and T1 levels of the outcome variable, partners’ long-term depressive symptoms were predicted by poor marital satisfaction and low optimism at T1, and poor physical health status was predicted by low T1 optimism. Conclusion: Psychosocial factors are predictors of long-term distress for ACS partners. Partners in an unhappy marriage or with low optimism after ACS are at an increased risk of depression and low physical health status, and should be the target of additional support.