Kathleen B. King

Guide to preventive cardiology for women

Coronary heart disease (CHD) is the single leading cause of death and a significant cause of morbidity among American women.1 Risk factors for CHD in women are well documented.2 Compelling data from epidemiological studies and randomized clinical trials show that CHD is largely preventable. Assessment and management of several risk factors for CHD are cost-effective.3 Despite these facts, there are alarming trends in the prevalence and management of risk factors in women.2 Smoking rates are declining less for women than for men. The prevalence of obesity is increasing, and ≈25% of women report no regular sustained physical activity.4 Approximately 52% of women >45 years old have elevated blood pressure, and ≈40% of women >55 years old have elevated serum cholesterol.5 The purpose of this statement is to highlight risk factor management strategies that are appropriate for women with a broad range of CHD risk. A more detailed description, including the scientific basis for these recommendations, is available in the 1997 American Heart Association scientific statement “Cardiovascular Disease in Women.”2 Recently, the Centers for Disease Control and Prevention National Ambulatory Medical Care Survey6 showed clinicians are missing opportunities to prevent CHD. In this study of 29 273 routine office visits, women were counseled less often than men about exercise, nutrition, and weight reduction. In the multicenter Heart and Estrogen/progestin Replacement Study (HERS),7 only 10% of women enrolled with documented CHD had baseline LDL-cholesterol levels below a National Cholesterol Education Program (NCEP) target of 100 mg/dL. A recent national survey showed that women were significantly less likely than men to enroll in cardiac rehabilitation after an acute …

Social support and long-term recovery from coronary artery surgery: Effects on patients and spouses.

Using a longitudinal design, the effect of social support on recovery from coronary bypass surgery was examined in 155 patients and 103 of their spouses. Perception of the availability of 5 types of social support was relatively stable from preoperation to 1 year after surgery and was significantly related to emotional and functional outcomes. Of the 5 types of support measured, only esteem support was significantly and consistently related to outcomes for patients and spouses. This relationship was strongest within-time, and across-time relationships effects were weaker. Spouses perception of support was related to patient outcomes, controlling for patient perceptions of support. Results suggest that perception of esteem support may be the most salient type of support related to feelings of well-being during and after an acute health-care event. In addition, perception of social support may be characterized by stable individual differences.

Correlates of fatigue in older women with heart failure

OBJECTIVE To examine the relative contribution of psychologic factors and physical symptoms to the variance in fatigue in older women with heart failure. METHODS Eighty women who had been hospitalized in the previous 12 months for heart failure were interviewed. Fifty-seven women completed second interviews 18 months after the first interview. RESULTS Fatigue was the most frequently occurring physical symptom at both measurement times, and it significantly increased with time. Other physical symptoms contributed uniquely to the variance in fatigue at both measurement times, but psychologic factors did not. At time 1, sleep difficulties, chest pain, and weakness each explained unique variance in fatigue. At time 2, dyspnea was the only variable that explained unique variance in fatigue (9%). Dyspnea also explained a significant portion of the variance (7%) in time 2 fatigue, when time 1 fatigue was controlled. CONCLUSIONS Fatigue in older women with heart failure is related more to other physical symptoms than psychologic factors.

Patterns of referral and recovery in women and men undergoing coronary artery bypass grafting

This study compares women and men undergoing coronary artery bypass grafting. Factors before and after coronary surgery were examined to identify variables related to mortality and morbidity. The study population included 465 women and 465 men matched for age (mean age 64.2 years) who underwent first time isolated coronary artery bypass grafting between 1983 and 1988. There were higher incidences of systemic hypertension, diabetes mellitus, postmyocardial infarction angina, thyroid gland disease, arthritis (p less than 0.001 for all), acute myocardial infarction (p = 0.03), congestive heart failure (p = 0.03), and emergency surgery (p = 0.02) in women, whereas more men had peptic ulcer disease (p less than 0.001). The in-hospital death rate was not significantly different (women 4.3% vs men 3.7%). For all subjects, emergency surgery (p less than 0.001), significant left main narrowing (p less than 0.05) and renal disease (p less than 0.001) were related to death, whereas history of myocardial infarction (p less than 0.05) and diabetes (p less than 0.05) were related to death only in men. Age and body surface area were not related to death. After surgery men had a higher incidence of atrial arrhythmia (p less than 0.001), and women had a higher incidence of congestive heart failure (p less than 0.001). Although women did not have a higher mortality rate, the data suggest that women and men do not share all the same predictors of mortality after surgery.

Optimism, coping, and long‐term recovery from coronary artery surgery in women

Optimism, coping strategies, and psychological and functional outcomes were measured in 55 women undergoing coronary artery surgery. Data were collected in-hospital and at 1, 6, and 12 months after surgery. Optimism was related to positive moods and life satisfaction, and inversely related to negative moods. Few relationships were found between optimism and functional ability. Cognitive coping strategies accounted for a mediating effect between optimism and negative mood. Optimists were more likely to accept their situation, and less likely to use escapism. In turn, these coping strategies were inversely related to negative mood and mediated the relationship between optimism and this outcome. Optimism was not related to problem-focused coping strategies; this, these coping strategies cannot explain the relationship between optimism and outcomes.

Perceptions of patients with cardiovascular disease about the causes of coronary artery disease

This study was an examination of perceptions about the causes of coronary artery disease and the timeline of the disease among 105 patients hospitalized because of myocardial infarction or for coronary angiography and receiving the diagnosis of coronary artery disease. Although 79% of subjects named at least one of three modifiable risk factors (smoking, hypertension, elevated cholesterol), only 7% identified all three. Subjects known to have risk factors varied in their recognition of those risks as a cause of their coronary artery disease. Sixty-four percent of smokers recognized smoking as a personal cause of their coronary artery disease, whereas only 15% of subjects with hypertension recognized hypertension as a cause. The majority of subjects (55%) believed that coronary artery disease was a chronic disease. The other subjects were unsure (13%) or believed the situation would be short term (28%). Despite general knowledge about coronary artery disease, individuals with known risk factors continue to be largely ignorant of their personal risks and to some extent of the course of the disease.

Marriage and long-term survival after coronary artery bypass grafting.

OBJECTIVE To examine the effects of marital status and marital satisfaction on survival after coronary artery bypass grafting (CABG). METHODS Participants were 225 people who had CABG between 1987 and 1990. Marital status at the time of surgery and marital satisfaction 1 year after surgery were used to predict survival 15 years after surgery. RESULTS Married people were 2.5 times (p < .001) more likely to be alive 15 years after CABG than those who were not married. This finding was true for men and women, although the result for women was marginally significant adjusting for age. Those in high-satisfaction marriages were 3.2 times (p < .003) more likely to be alive 15 years after CABG compared with those reporting low marital satisfaction. Highly satisfied men were 2.7 times (p < .03) and highly satisfied women were 3.9 times (p < .15) more likely to be alive adjusting for age. Although the result was not significant for women, the effect size for marital satisfaction was actually larger for women than for men. CONCLUSIONS Being married, especially being in a highly satisfying marriage, offered a significant benefit to long-term survival after CABG. Why marital status and marital satisfaction have this effect on survival is surely mulitfactorial, most likely a combination of spousal support and survivor motivation to adopt a healthy lifestyle, along with the provision of emotional support to the survivor, which all could have the effect of modulating the physiologic mechanisms responsible for slowing the advancement of CVD.

Psychologic and social aspects of cardiovascular disease

In summarizing the evidence, it becomes apparent that several psychologic and social variables are related to coronary heart disease (CHD). Coronary prone behavior pattern, in particular the hostility component, appears to be related to the development and perhaps expression of CHD, whereas it is not reliably related to outcomes after CHD is manifest. Depression clearly has been shown to be related to outcomes after CHD has declared itself. Lack of social ties appears to be related to mortality, whereas emotional social support has been shown to be related to recovery from coronary events. It also seems apparent that there are subsets of vulnerable individuals who might be best served by targeted interventions. Interventions are proposed as suggested by the prevailing evidence. *** DIRECT SUPPORT *** A00FV011 00010

Symptom Clusters in Acute Myocardial Infarction: A Secondary Data Analysis

Background: Early recognition of acute myocardial infarction (AMI) symptoms and reduced time to treatment may reduce morbidity and mortality. People having AMI experience a constellation of symptoms, but the common constellations or clusters of symptoms have yet to be identified. Objectives: To identify clusters of symptoms that represent AMI. Methods: This was a secondary data analysis of nine descriptive, cross-sectional studies that included data from 1,073 people having AMI in the United States and England. Data were analyzed using latent class cluster analysis, an atheoretical method that uses only information contained in the data. Results: Five distinct clusters of symptoms were identified. Age, race, and sex were statistically significant in predicting cluster membership. None of the symptom clusters described in this analysis included all of the symptoms that are considered typical. In one cluster, subjects had only a moderate to low probability of experiencing any of the symptoms analyzed. Discussion: Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters identified in this study included all of the symptoms that are included typically as symptoms of AMI (chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness). These AMI symptom clusters must be communicated clearly to the public in a way that will assist them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior. Symptom clusters for AMI must also be communicated to the professional community in a way that will facilitate assessment and rapid intervention for AMI.

Montreal Cognitive Assessment and Mini-Mental Status Examination compared as cognitive screening tools in heart failure

BACKGROUND Heart failure (HF) patients run four times the risk of developing cognitive impairment than does the general population, yet cognitive screening is not routinely performed. METHODS This cross-sectional study enrolled 90 community-dwelling adults with HF aged 50 years and above. Participants took the Mini Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA), to measure cognitive function in persons with HF. Participants were predominately men (66%) and Caucasian (78%), aged 50-89 years (62 SD, 9 years), and 77% had an ejection fraction <40%. RESULTS Fifty-four percent of participants scored ≤26 on the MoCA, suggesting mild cognitive impairment (MCI), and 17% scored ≤22, suggesting moderate cognitive impairment, compared with 2.2% on the MMSE. The MoCA scores were lowest for visuospatial/executive domain, short-term memory, and delayed recall. These findings were similar to those in published reports. CONCLUSION These preliminary findings support the use of MoCA for cognitive screening in stable HF.